AANA past president looks at survival of private practice

“Can the private practice of orthopaedics survive the 21st century?” asked Jack M. Bert, MD, 2008–2009 president of the Arthroscopy Association of North America (AANA). His answer is a qualified “yes” but only if orthopaedists understand their interdependence and begin to build large practices.

In his address at the 2009 AANA Annual Meeting, Dr. Bert said, “I feel very strongly that to save the private practice of orthopaedic surgery, we simply cannot get along by ourselves as soloists or even as small group practices in the future.” To deal with both external forces (such as managed care plans, hospital systems, federal and state health plans, and private insurance) and internal problems (ourselves), Dr. Bert outlined five goals.

Never let a single payor control your patient source
According to Dr. Bert, in many areas, managed healthcare plans own hospitals, offer insurance plans, and employ physicians, thus creating a monopoly for themselves in the local market. He also believes that these “same factions that are attempting to control the marketplace have done a fantastic job of conveying to the public, to Congress, and to state and local governments that doctors are greedy, self-serving individuals who want to derive income from the services normally provided by a hospital system or radiology group and keep this income for themselves.”

The truth, however, says Dr. Bert, is that when physicians own and control ancillary services, the cost of providing care actually decreases. He noted that an internal audit of a large managed care organization’s health insurer found that 44 cents of every premium dollar collected was spent on claims management, profit for the insurer, and dividends to stockholders, while the cost of administering a Medicare claim is less than 10 cents on the dollar. “As long as third-party insurers continue to capture the majority of healthcare customers with their unwieldy administrative expenses, it will be impossible to significantly decrease the cost of medical care,” said Dr. Bert, leading into his second goal.

Get involved in state politics According to Dr. Bert, legislators are unaware of the real source of medical care costs. He advises selecting someone from each practice to be “the politician” and charging that person with interacting with state legislators. When confronted by legislators or administrators, physicians must raise the question: Who knows better how to order tests and render care to that patient than the physician who is caring for that patient?

“Our mission as physicians is to render high-quality patient care,” said Dr. Bert. “If you want to stay independent, you must become more active, and even if it’s not in your nature to do so, become more aggressive politically, or choose someone in your group who has those personality characteristics to do so.”

This step is crucial, said Dr. Bert, because insurers, hospital administrators, managed care executives, claims managers, and government employees can exert so much control over physicians. “Jobs become stressful if they combine high demands with no power or authority to alter the situation,” he said, noting that most physicians have limited power to alter their working conditions.

“We tend to be obsessively committed to perfection … inflexible … and to show dogged persistence and often an inability to relax,” he said. “Why, then, do we so easily give in when we are unable to solve a political, hospital, physician personality, or business issue?”

Get bigger and develop ancillaries
For physicians to regain control over their environment and address the imbalance between demand and control, Dr. Bert advised practices to “get as big as you can in your marketplace” without establishing a monopoly. “The other orthopods in your community are not your enemies!” he said. “Most everyone else, however, is!”

He pointed out that ancillary service revenues can offset decreasing reimbursements, and physician ownership of those services is needed to control the type and quality of care delivered.

“You don’t have to be social with your colleagues, you only have to work with them toward a common goal, and that is to exert influence in your community that will allow you to achieve some sense of control of your environment with the payors!” emphasized Dr. Bert. “Your colleagues are not your enemies!”

Don’t ignore your family and partners
According to Dr. Bert, a productive surgeon must be happy with himself (herself) and have a strong family structure.

“We will all have bad days, complications that will confound and depress us, and almost all of us will get sued, and many of us have to go to court and be told we are the worst doctor in the country by someone who makes his or her living testifying against other physicians,” he said. “The people who are most important to you will always be your family members, and they will give you the strength to get through the most difficult times of your career.”

Instead of taking out your frustration on your family, Dr. Bert advised telling—and showing—them how much you care about them.

Don’t ever forget who you are
Finally, Dr. Bert advised his audience to remember “you are all gifted physicians, or you wouldn’t be sitting in this room. You have taken the time out of your busy schedule to attend a meeting to improve your clinical and surgical skills … to learn from the best and the brightest.”

Read Dr. Bert's entire speech

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org