Orthopaedists from across the country gathered in Washington, D.C., April 28–May 1, 2010, for the National Orthopaedic Leadership Conference (NOLC). It was an opportunity for many to meet with their congressional representatives and press for action on issues such as the Medicare physician payment formula, the Access to America’s Orthopaedic Services (AAOS) Act, and the Health Information Technology (HITECH) Act.

It was also an opportunity to hear about how the recently passed healthcare reform legislation would affect the physician community in general and, more specifically, the medical specialty community. Peter J. Mandell, MD, chair of the AAOS Council on Advocacy, moderated a roundtable discussion that included the following participants:

• Cynthia A. Brown, vice president of government affairs for the American Medical Association (AMA)
• Kristen Hedstrom, assistant director of legislative affairs for the American College of Surgeons (ACS)
• Ted Burnes, director of the American College of Radiology (ACR) political action committee (RADPAC) and political education
• Karen J. Collishaw, deputy executive director of the American Academy of Dermatology (AAD)
• Lucia DiVenere, director of the department of government affairs for the American Congress of Obstetricians and Gynecologists (ACOG)

In introducing the panel, Dr. Mandell noted that “these are the people we hire to protect us from the people we elect.” During the discussion, and the question-and-answer period that followed, a wide range of issues were covered—from medical liability reform and the independent payment advisory board (IPAB) provisions in the healthcare reform act to workforce issues and strategies for the future—as the following excerpts show.

Dr. Mandell: What do your organizations think about the provisions in the healthcare reform law regarding medical liability reform?

Ms. Hedstrom (ACS): Although the bill is woefully inadequate in terms of protecting surgeons against medical liability, it does provide more funding for medical liability demonstration projects than ever before. We will continue to make liability reform a top priority and push Congress to provide alternatives, but it’s a tough, uphill challenge.

Ms. Brown (AMA): Liability reform has been a top priority for the AMA, and I think people under-estimate the symbolism of its inclusion in healthcare reform. For the first time, Democrats are acknowledging that the problem is real and contributes to cost. Although the programs are small, they are not without value.

We still have a way to go; it has to remain a top priority. Congress must realize that if physicians are required to follow guidelines and deal with “cost-effective care,” they need some protections when they do so.

Mr. Burnes (ACR): Radiology—particularly mammography—is one of the most litigated services provided to patients. We’ve seen a trend to reform in the states, which puts pressure on the federal level, making it more difficult for “Blue Dog Democrats” to ignore tort reform at that level. Developing data at the state level to support change at the federal level will help our efforts.

Dr. Mandell: Let’s talk about the independent payment advisory board (IPAB). What worries your organizations about IPAB and what can we do about it?

Ms. Hedstrom (ACS): One of the challenges that we face is that it doesn’t go into effect until 2014, and we could have a new president by then. We’re concerned about stability, because the commissioners are appointed by the president, and there’s very little congressional oversight. We’re looking at ways to engage Congress and give them more oversight on what the IPAB might implement. We’re also concerned about the broad discretion given to the Secretary of Health and Human Services.

Ms. Collishaw (AAD): We see IPAB as a usurpation of both legislative and administrative authority, taking a lot of power and vesting it in a small group. Many legislators think this is key to containing costs, and it is popular with both Democrats and Republicans, although not with the members of the committees that currently make those decisions.

Ms. Brown (AMA): One opportunity we do have is that the leadership in the House hates IPAB. I think there is an opportunity to change it, but not this year. There will be a corrections bill and we hope to address both IPAB and the Cantwell value-based index, which would give every physician a payment modifier, based on the health of the population served, the quality of care provided, and the cost-effectiveness provided.

The problem is that these measures do not exist; we can’t do the risk adjustment, and it’s beyond the capacity of the Centers for Medicare & Medicaid Services (CMS) to manage it. It might have gone away in conference if we hadn’t lost the opportunity to get a bill through the Senate again.

Dr. Mandell: Is there any middle ground? What if the IPAB has more doctors on it or better congressional oversight or if it’s easier to overturn rulings?

Ms. Brown (AMA): Not having that supermajority in both houses would be a major step.

Mr. Burnes (ACR): If members of Congress want to take a step back and remove themselves from the process, creating this board to determine reimbursements won’t eliminate the politics. The politics will still be there, just expressed differently.

Remember the uproar last November, when the recommendations came out on mammography screening? There wasn’t a single breast cancer surgeon or radiologist on the panel. So many people were surprised and alarmed at the recommendations, and IPAB does the same thing on a bigger scale. I think that argument will resonate to the point where we can change things.

Dr. Mandell: What could we have done better?

Ms. DiVenere (ACOG): We had worked on a plan of “healthcare for women, healthcare for all” that covered both physicians’ issues and women’s health issues. We saw it as an integrated package. The women’s health issues were included in the healthcare reform package, but not the physician issues. I don’t think we erred in allowing thoseissues to progress on different tracks; we have to pursue opportunities where we find them. But we need to explain this to our members and show exactly how it affects them.

Ms. Hedstrom (ACS): As an umbrella organization, the ACS was in an interesting position because some issues helped general surgeons and others polarized specialists. I think it’s a challenge we’ll continue to face. Our other challenge is educating members on what law means to them.

Ms. Collishaw (AAD): Medicine needs to be more unified, and we weren’t. The culture is to be autonomous and make autonomous decisions; it’s difficult to subsume individual interests for the betterment of the whole, and really difficult to keep everyone focused on a few key points.

Ms. Brown (AMA): Implementation of this bill will be a nightmare. We will need more smart regulatory people and will have to combine forces. A lot of what went wrong was process, and how programs will proceed gives us an opportunity to work together.

Mr. Burnes (ACR): We don’t use data at the micro or macro levels well enough. We need to say how the rules will impact a practice, and make it meaningful for regulators. The perception is that doctors are still doing pretty well and can handle the reimbursement cuts. We need to show that the cuts will mean jobs lost in the community.

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

Getting involved
All of the panelists agreed that greater involvement by the physician community in advocacy is needed.

Ms. Collishaw (AAD): In certain professions, political contributions are just a part of doing business. Teachers give more than doctors do. We’re just starting to get there.

Ms. Hedstrom (ACS): Out of 50,000 members in the ACS, only 2,000 contribute to the political action committee (PAC). Most physicians will give to their specialty PAC first, before they give to their broader umbrella organization.

Ms. Brown (AMA): Lawyers treat political contributions very differently than doctors. They see political contributions as a business expense and make personal contributions. Physicians may contribute to their PAC, but that doesn’t raise the same kind of money that attending a fundraiser does.

Ms. DiVenere (ACOG): A PAC is the ultimate focus group; you can really tell what issues people care about because they have to write a check. This year, 47 physicians are running for Congress. We want to get them elected. We also need to make it easier for doctors to make contributions, perhaps by using a mechanism similar to the debit accounts that attorneys have.

Mr. Burnes (ACR): Physicians can establish a noncorporate drawing account. Large practices can set up a separate bank account and use payroll deduction to make deposits to that account, which is then used to support the PAC. But the president of the group needs to make this the “culture” of the organization.

Ms. Brown (AMA): In any poll, physicians have the most influence over the public when it comes to healthcare reform. The people trust physicians to do the right thing. There is a role for physicians; doctors are so integral to the system, but the divisions by geography and by specialty create problems. Unlike lawyers who focus on one thing at a time, we’re very divided; we have multiple issues.