Although a great deal of media attention has focused on federal healthcare reform, orthopaedic surgeons know that what happens on the state level is just as—if not more—important. State politics may actually have more impact and influence on our practices than federal politics. State laws affect every aspect of orthopaedic care. State legislatures introduce thousands of bills each legislative session, and an increasing percentage of these relate to health care.
Many state laws—such as those related to managed care and contracting, prompt payment, licensure, and liability—apply to all medical specialties. Other bills may have more relevance for orthopaedic surgery, such as those dealing with scope of practice, imaging, ownership of surgery centers, self-referral practices, and consulting. As the number of bills grows and the practice of medicine becomes more challenging and complex, the importance of advocacy on a state level increases.
Although the American Association of Orthopaedic Surgeons (AAOS) has staff dedicated to state legislative activities, it behooves state orthopaedic societies and their members to be ever vigilant about new legislation. It is in our own vested interest as orthopaedic surgeons to be knowledgeable about the state legislative process and become active in state politics.
How a bill becomes law is different in every state. It is a complex process, but knowing the sequence of steps enables the prepared orthopaedic activist to intervene appropriately. Unfortunately, many orthopaedic surgeons only become active in government relations when a new law is proposed that they see as threatening to their patients and practices.
Although any activism on behalf of the orthopaedic profession is admirable, the ideal is to develop a relationship with legislators over time—not just when a crisis erupts. This would enable legislators to know us (orthopaedic surgeons) as small business owners, employers, constituents, maybe even as friends. It would also give us the opportunity to explain our issues to legislators on a more personal basis.
Join your state society
Each state orthopaedic society has its own dues collection, not connected to AAOS dues. Joining your state orthopaedic society is important, not only because your membership furthers orthopaedic volunteer activism and supplements the financial resources of the state society, but also because state societies are really the most appropriate venues for state political activism.
State societies vary considerably in the ways that they approach state government relations and in the resources that they have at their disposal. Many state orthopaedic societies have robust governmental relations, both at the organization level and at the individual member level. Unfortunately, others have minimal involvement and/or minimal resources. Some have a committee that reports on state legislative activities at their annual meeting, but not enough really discuss the legislative priorities or the direction that they can take to influence the process.
Ideally, all state orthopaedic societies would have regular strategy sessions before, during, and after legislative sessions. Additionally, state orthopaedic society representatives should be involved in regulatory matters at the state level through, for example, seats on regulatory and advisory committees and on medical boards. Members should be available to testify at legislative and regulatory hearings and be ready to submit comments on proposed rules and bills.
An effective legislative program needs accurate and timely information, which can only be achieved through proactive monitoring and assessment. Furthermore, knowledge of the political process and of the important players in the state government is also necessary.
What about lobbyists?
Some state societies hire a legislative consultant or lobbyist to assist the volunteer members of the committees. The lobbyist can provide direction to appropriate venues for achieving goals, such as using the regulatory process rather than the legislative process. Lobbyists are also more likely to know who the key figures are on the committees that will influence the issue at hand. They are also likely to know and understand the individual legislator’s voting record and previous positions on issues.
If legislation is introduced that affects orthopaedic surgery, the need for surveillance action intensifies. Professional lobbyists are experts in legislative strategy and techniques, and they can facilitate navigating the entire legislative process, identifying points of leverage and helping avoid pitfalls. They are also more likely to respond quickly to any issues that may arise and can help state societies in providing appropriate communication to key legislators and regulators.
Some state orthopaedic societies have contracted with their state medical societies to provide monitoring services. This may be problematic in two ways: the state medical society may not have adequate knowledge about the breadth of issues related to orthopaedic surgery or recognize the relevance of a proposed bill or regulation in relation to orthopaedic surgery, and it may create a conflict of interest for the state medical society.
It’s still up to you
Success in advocacy is about credibility, familiarity, and, most importantly, continuity. The more legislators know and trust you (or your lobbyist), the more effective you can be in influencing the legislative process. Therefore, a state orthopaedic society’s relationship with a lobbyist is best if it is a long-term one. This familiarity enables the lobbyist to learn more about orthopaedic surgery, the local society, and its concerns.
A lobbyist, however, is no substitute for local members getting to know and establishing long-term relationships with their legislators. Local members should encourage both legislators and lobbyists to visit local hospitals and orthopaedic practices. As surgeons spend face-to-face time with their legislators and potential regulators (state commissioners), their credibility will increase, and with credibility comes influence.
It takes time, but it is never too late to start cultivating these relationships. State laws and regulations govern most of what orthopaedic surgeons do on a day-to-day basis in their practices. Quality, safety, and reimbursement affect all of us. The AAOS and state orthopaedic societies can have a significant impact in representing orthopaedic surgeons, but the most important factor is still the individual orthopaedic surgeon who takes the time (and money) to advocate on behalf of his or her profession at the local, state, and national levels.
Scott F.M. Duncan, MD, MPH, is a member of the Advocacy Resource Committee and the Leadership Fellows Program. He can be reached at firstname.lastname@example.org