AAOS Now

Published 5/1/2011
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James B. Rickert, MD

It’s time to make a choice

Fixing the healthcare system may require some sacrifice

It’s time for America’s orthopaedists to make a choice. Are we primarily business owners with a keen eye on the financial bottom line, or are we above all professionals, well versed in the healing arts and dedicated to our patients’ care, regardless of their circumstances?

America’s medical system is breaking apart: The high cost of health care, including physician fees, is breaking both federal and state budgets and negatively affecting patient care. Will physicians be contributors to rising costs or to a desperately needed solution?

Define the problem
As physicians, we know the damage that can result when patients do not receive the medical care they need due to a lack of health insurance. The crisis in Medicaid funding is causing many states to reduce benefits and eliminate eligibility for hundreds of thousands of patients. Indeed, 20 states reduced their Medicaid benefits in one form or another last year, and 13 others plan to follow suit this year.

Medicaid expenses are consuming up to 36 percent of states’ general funds, and these numbers are growing as our economic downturn has forced many more Americans to rely on government assistance. During the 2008/2009 recession, enrollment in Medicaid grew by more than 17 percent; it now provides essential coverage to 50.3 million people, or one in six Americans.

Although the fiscal crisis affecting Medicare is not as acute, it is no less dire. It should come as no surprise that both President Obama in his State of the Union address and Rep. Paul Ryan (R-Wisc.) in the Republican response agreed on the need to restrain Medicare’s relentless growth. President Obama called “programs like Medicare and Medicaid…the single biggest contributors to our long-term deficit,” while Rep. Ryan stated that “Healthcare spending is driving the explosive growth of our debt.”

Despite efforts to buttress Medicare’s finances in the recently passed Affordable Care Act, payments to providers are still projected to exceed revenues to Medicare’s Hospital Insurance Trust Fund in just 9 years, and Medicare’s actuaries project that the fund will be exhausted by 2029. At that time, Medicare will be unable to adequately compensate hospitals for their care of the nation’s elderly.

The Republican response
In response to this crisis, Rep. Ryan and House Republicans have approved a budget that would end Medicare as we know it. No longer could any physician discuss treatment plans with an elderly patient under the assumption that money would likely be available to pay for the agreed course of care. Calculations derived from a Congressional Budget Office analysis show that in 2022, when the Ryan plan would kick in, a typical 65-year-old would pay $6,400 to $7,000 more per year than he or she would pay for comparable coverage under traditional Medicare.

Although elderly Americans typically live frugally on fixed incomes, it is highly unlikely that a married couple could afford $14,000 more in medical expenses. Instead of Medicare-like health insurance, they will likely buy less expensive insurance products with reduced benefits. Such products may not pay for elective surgery or doctor’s office visits—greatly reducing patient access to medical services.

Surely, America can do better than this for our elderly. Physicians are in the enviable position of being able to offer leadership and guidance to federal and state governments during this transition. America needs a better system to deal with healthcare obligations while preserving all that is best with American medicine: access to cutting edge care, the sanctity of the doctor-patient bond, and the ability to care for all Americans due to Medicare and an expanded Medicaid program.

An untapped resource
Physicians—who are immersed in the medical system, aware of effective treatments, and understand patient behavior—are the best resource available for improving both Medicare and Medicaid. Specialty physicians are also in the position of being able to make some financial sacrifices to improve the solvency of the system and provide states and the federal government a measure of needed relief from healthcare liabilities.

When last surveyed in 2007, orthopaedic surgeons had an average income of nearly $440,000. Many also have partnerships in imaging or surgery centers, pain clinics, or physical therapy centers that generate additional income. Current incomes compare very favorably with those in any other developed nation and far exceed the historical averages for the specialty. Reimbursement for specialty care outpaces that for primary care doctors by a factor of between two and three.

Orthopaedic surgeons need to acknowledge that a severe funding shortfall exists in American medicine that is affecting the health of patients. Then, as part of a needed overall reorganization of the entire system, orthopaedic surgeons must take a leadership role in bringing down these costs. Ultimately, every healthcare provider—including doctors, hospitals, drug companies, and device makers—must be prepared to make sacrifices.

Someone must have the courage to stand first and be counted. Specialty physicians can most easily afford to take this leading role. As costs are cut, we must forcefully argue to protect our patients’ interests; their health must be paramount. But we must also argue for our profession. If we bury our heads in the sand and insist that our incomes are inviolable, we are dooming ourselves to practice in a bureaucracy-centered medical system where all important decisions are made by politicians and bureaucrats.

Holding the line on costs
By denying the existence of a problem on the cost side of the equation, physicians are excluding themselves from a leadership role in solving one of the great current challenges of American medicine: balancing healthcare spending with available revenue. Emblematic of this attitude was the presentation of Resolution #8 at the 2011 Annual Meeting: “The Board of Councilors, Board of Specialty Societies, and AAOS Board of Directors continue to support the Association’s taking appropriate steps to challenge reductions in Medicare reimbursement for orthopaedic procedures.” Such a stance will not help craft new policies or defend patients.

If physicians continue to deny that their own costs are part of the problem and insist that governments simply need to find more money to fund organized medicine, politicians will inevitably begin to make decisions about treatment options—as Arizona did in opting to defund certain heart and bone marrow transplants when their state medical community could offer them no guidance or partnership for cutting Medicaid costs. This will never result in the best use of healthcare resources.

America is clamoring for physician leadership. Now is the time to come to the bargaining table ready to make sacrifices for the good of patients and the country but also ready to ask for real reform in return—in medical liability legislation, insurance billing, payment stability, and patient-centered care. Wouldn’t we all rather practice medicine in a system that we helped design than in a government-designed cost-containment system?

As physicians, we have the knowledge and skills to be problem-solvers. We must acknowledge the problems and work to save everyone—physicians and patients alike—from this imminent healthcare crisis.

James B. Rickert, MD, is a member of The Society for Patient-Centered Orthopaedics; this article is also endorsed by society members William H. Salot, MD; Thomas J. Grogan, MD; Thomas S. Boniface, MD; Walid H. Azzo, MD, PhD; Robert E. Rutherford, MD; Augusto Sarmiento, MD; and Mark O. Hansen, MD.