The passage of the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010, marked a landmark shift in the delivery of health care in the United States. Response to the reform bill has largely been mixed, with supporters claiming that the bill will improve coverage and reduce costs, while critics claim that the savings estimates are unrealistic and predict that the changes wrought by PPACA will increase pressure to scale back the delivery of quality health care.

At the “Healthcare Reform Bill: Past, Present and Future” symposium, held during the 2011 Annual Meeting, Stuart L. Weinstein, MD, chair of the American Association of Orthopaedic Surgeons (AAOS) Orthopaedic Political Action Committee, admitted as much to the assembled crowd.

“All of us in this audience, both as consumers and providers, may see it in a different light,” he said.

Dr. Weinstein explained that some of the dichotomy comes from different perceptions of what healthcare reform was supposed to accomplish. Some experts viewed it as an opportunity to improve quality and reduce costs, but President Obama’s primary stated goal was to improve coverage.

“It’s clear the president got his wish, which was to expand coverage,” he said. “But it’s really questionable whether the cost and quality issues have been addressed at all.”

Speaking from the audience, Douglas M. Murphy, MD, asked the panelists about the AAOS position on access.

“Insurance companies compete by disproportionately preselecting healthy people,” he said. “One of the reasons President Obama picked access as his issue is that it’s one of the most fundamental corrupters of the current system. With the AAOS exposed to so many issues of access to specialty care, I think the AAOS should clearly be in favor of universal access.”

“Patient access to musculoskeletal care is our number one issue,” responded 2010 President John J. Callaghan, MD.

“One of our position statements does call for coverage for all Americans,” agreed Council on Advocacy Chair Peter J. Mandell, MD. “We are in favor of that…we just need to see it done right and not in such a way that folks who require musculoskeletal care are second- class patients.”

Contact with Congress
Given that the AAOS opposed many aspects of the law, Dr. Callaghan explained that it must now decide whether to continue its opposition and support its repeal, or to work alongside legislators as the rules and regulations are put in place to ensure quality delivery of care.

“So far, we’ve nominated more than 70 orthopaedic surgeons to various commissions, institutes, and committees relating to the law,” said Dr. Callaghan. “We’re trying to stay actively involved and get a seat at the table if we can. It’s a tough process, but we’re not going to give up on it.”

“I think the new healthcare reform law provides a lot of challenges for us on the advocacy front,” said Dr. Weinstein, “and a lot of opportunities for the AAOS as we move forward, to take advantage of things that are in the healthcare bill that we can affect as a professional association.”

William R. Martin III, MD, medical director and director of the AAOS office of government relations, explained that Project 535—an Association initiative to link an AAOS fellow with every one of the 535 members of the U.S. Congress—is a good step toward improving the influence of orthopaedists among legislators.

“We define the program by having an AAOS fellow just a phone call away from a member of Congress,” said Dr. Martin. “We would certainly love to get more input; if you or anyone you know of has those personal relationships, please contact us so we can add you to our database.”

“Legal castration”
Michael P. Connair, MD, of North Haven, Conn., asked the panelists about the so-called Campbell/Conyers Bill, which, if enacted, would allow physicians to collectively bargain without violating antitrust laws.

“One of the glaring omissions of the PPACA was the failure to address the rights of physicians to collectively bargain with payers,” he said. “All of the other countries that have a hybrid or socialized system accept the right of physicians to have input as to the terms of their employment, their reimbursement, and the care that patients receive. The contracts that we have with private payers and Medicare regulate not only our fees, but access and quality as well. We are legally castrated from protecting our patients’ care, because we don’t have the right to bargain collectively.”

In his response, Dr. Weinstein took the opportunity to emphasize the importance of building relationships with legislators.

“Obviously, joining a political action committee (PAC) is a choice, not an obligation,” said Dr. Weinstein. “Mr. Conyers doesn’t support our other issues and supporting him was a difficult decision. But in this one area, he is obviously a champion, and we made a conscious decision that this was a high priority. The only way to do that is through the use of PACs to augment your opportunity to meet the legislators and express your point of view.”

Rationing care
“Dr. Callaghan had mentioned that 95 percent of healthcare dollars are spent in the last 30 days of life,” said J. Patrick Flanagan, MD, of Akron, Ohio. “Given that, is rationing going to become an issue?”

“Americans have an insatiable appetite for very expensive health care,” responded First Vice President John R. Tongue, MD, “and an undeniable lack of resources to pay for it in the future. In 1986, in Oregon, the state legislature wrote the first explicit rationing healthcare plan in the history of the world, for the Medicaid population. All other nations that control their costs have some degree of rationing.

“When asked about rationing, Donald M. Berwick, MD (administrator of the U.S. Centers for Medicare & Medicaid Services), denied that there would be any rationing of health care,” continued Dr. Tongue. “And the ‘r-word’ is a very bad word politically in Congress, but we have to have this conversation, because eventually that’s going to be how we prioritize getting value into health care.”

“It’s a very important question,” agreed Graham Newson, associate director of the AAOS office of government relations. “If we’re serious about cutting costs and maintaining quality, we need to come together as a country and in Congress; both parties need to come together and put all their good ideas on the table.

“End-of-life issues are something the country will need to come together on to address effectively,” he continued. “I think that day is coming, because our healthcare system is no longer sustainable as it is. Some changes do need to occur. But it’s going to take a bipartisan effort.”

Private practice: still relevant?
“Does private practice still have value to our patients?” asked Ned A. Wilson, MD, of Kalispell, Mont. “Does Congress recognize that value? And what is the likelihood that private practice is going to survive future changes?”

“Nobody knows the answer to that,” responded Dr. Mandell. “I think there will always be a role for private practice in rural areas, but I think in big cities and higher density areas, the accountable care organization (ACO) approach is what legislators are looking at. They have to get costs down, and if they can’t do that, we’ll see more medical tourism, with patients going to Asia and Europe for treatment.

“ACOs will result in a tremendous cultural shift,” he continued. “In the Kaiser model, doctors still have some autonomy, but they’re also grouped together. It’s not exactly private practice but may be the best we can hope for.”

“More and more of our graduates and residency programs adopted an employee model,” added Dr. Weinstein. “What happens in the future will depend on us. We have to show that what we do adds value, and we have to show that it improves quality. Right now, Congress believes that the volume system, in which you do procedures and order tests through which you profit, just adds to your income, but doesn’t necessarily improve quality.”

“Our challenge is to make sure that we help define the value of what we do and how the things we do add value to the system,” he continued. “If we can show there is a value, and that we improve quality, then we’ll have the opportunity to maintain the private practice system. If not, I think the trend toward the employee physician will continue.”

“Much of the discussion is about how money is spent poorly. We need to talk about how money is spent well,” said 2011 President Daniel J. Berry, MD. “As orthopaedic surgeons, we have a good story to tell. We have data to demonstrate the value of our efforts in quality-adjusted life years. We need to be strategic about finding ways to get the word out. Our patients know it; we just have to get the word out to the public and the policy makers.”

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org