That’s just what happened recently, when the journal Health Affairs published a study that was interpreted by many to show that higher fees paid to physicians in the United States (as compared to payments to physicians in various other developed countries) were the main driver of higher healthcare spending in this country. The release of the paper triggered a barrage of reactions—from media representatives, policy makers, and, because an important aspect of the study focused on reimbursement to orthopaedic surgeons, AAOS members.


Published 10/1/2011

Speaking up—on behalf of orthopaedic patients and physicians

Although I’ve always tried to measure my words, I’ve never been one to hold back from sharing my thoughts, especially when it comes to our profession of orthopaedic surgery. We teach our residents and fellows to scrutinize studies carefully to ensure that the methodology is appropriate, the analysis is accurate, and the underlying assumptions are sound. More than once, I’ve seen media representatives, policy makers, and even my own patients eagerly accept conclusions that I realize are unsupported by the data.

Of course, once misinformation is out there, it’s much harder to correct and to change people’s minds. It helps to have a team of people coming at the problem from a variety of angles.

Daniel J. Berry, MD

The study, which also considered payments for office visits to primary care physicians, compared fees, income, and spending across six countries: the United States, Australia, Canada, France, Germany, and Great Britain. Perhaps not surprisingly, it found that U.S. physicians have higher incomes and that payments by public and private payers for services such as office visits and total hip replacements were higher in the United States than in these other countries. The authors concluded that “higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher U.S. spending, particularly in orthopedics.”

Newspapers, including The New York Times, pounced on the news, reporting that “as policymakers struggle to find ways to restrain health spending, they might consider doctors’ fees.” At a time when the U.S. government is focused on deficit reduction and cutting spending, such a conclusion could be devastating for all physicians and could create problems of physician access for the patients they treat.

Gathering facts, preparing a response
As soon as the article was released, the AAOS began to pull together a response. AAOS fellows well versed in economic policy reviewed the article, as did members of the Health Care Systems and Coding, Coverage, and Reimbursement Committees, representatives from the Board of Specialty Societies and from the Board of Councilors, and staff from the office of government relations, publications, and public relations departments. Within the first 24 hours, e-mails were shared, teleconferences were held, data were gathered, and a response plan was developed.

In preparing our response, we were also able to take advantage of external health economics and policy consultants currently working with AAOS First Vice-President John R. Tongue, MD, on a Board of Directors’ project team he chairs, “The Social and Economic Value of Orthopaedic Surgery.”

Doing it right
A consistent theme in these conversations was the need for a measured response, not a knee-jerk reaction. A positive message is important, and we focused on the commitment by the AAOS and the orthopaedic community to continuously improve quality, reduce cost, and add value to medical care. Therefore, a multiphase response plan was developed that included posting a statement on the AAOS website (See “AAOS response to Health Affairs article on physician fee payments,” below) and developing major “talking points” for media representatives and specific communications to media outlets and AAOS members.

Many concerns were raised about the validity of methodologic aspects of the article and about how it is being interpreted by the media. Some pointed out the difficulty of conducting meaningful analyses across different nations due to the myriad different factors underlying each country’s healthcare system. Others emphasized that compared to overall healthcare spending, physician services make up only a modest percentage. And others rightly focused on a point that the authors of the article themselves made: “…the medical care delivery sector cannot be fully separated from the rest of the economy. Physicians everywhere are drawn from the peak of the educational distribution, and their earnings reflect the cost of drawing highly skilled people to the profession in an economy where the rewards for skilled individuals are higher than elsewhere.”

Staff and volunteers are assembling data for a detailed article to appear in next month’s AAOS Now, which should provide context and greater perspective on this question.

Similarly, in our discussions with policymakers, we want to be sure that they understand our concerns—in particular our concerns about patients and their access to quality care. We have been in contact with members of the Joint Select Committee on Deficit Reduction (commonly referred to as the “Super Committee”) about issues such as the sustainable growth rate formula. We plan to follow up with them, sharing our data on the value of orthopaedic care and the steps the AAOS and its members are taking to support the delivery of cost-effective, appropriate, high-quality care.

Whenever your Academy is asked to respond about an issue, you can be sure that the response is developed with input from multiple voices, is supported by data, and reflects our mission to “champion the interests of all patients, serve our members and the profession, and advance the highest quality musculoskeletal health.”

AAOS response to Health Affairs article on physician fee payments
Orthopaedic surgeons diagnose and treat diseases and disorders of the musculoskeletal system. We also are highly trained surgical specialists focused on providing value to our patients by enabling them to improve or regain their quality of life. The study in Health Affairs failed to point out that physician fees are a very small piece of total U.S. healthcare costs; according to the Congressional Budget Office, Medicare payments for physician services comprise 13 percent of total Medicare spending.

Instead, the authors erroneously attribute the significant increases in total U.S. healthcare expenditures over the past several years directly to payment rates for physicians. Medicare payments for physician services have remained virtually flat or actually decreased in the last decade while healthcare expenditures continue to steadily rise. For instance, the Medicare payment for a hip replacement surgery has decreased by 7 percent in nominal (actual) dollars and 32 percent in real (inflation-adjusted) dollars since 2000, while total Medicare expenditures have almost doubled in the same time period, according to the Centers for Medicare and Medicaid Services (CMS).

The study in Health Affairs compares costs for physician services across six different countries. International healthcare cost comparisons are notoriously difficult to make due to variations across countries in practice setting, medical liability rates, the number of insured citizens, and each country’s economic complexities.

The American Academy of Orthopaedic Surgeons (AAOS) has actively engaged stakeholders and thought leaders in conversations to find ways to curb medical costs and enhance quality of care for orthopaedic patients. Academy members have been involved in public and private payer payment demonstration projects such as the Medicare ACE demonstration projects across the nation. The AAOS welcomes any opportunity to collaborate with all healthcare stakeholders in an effort to help drive down the cost of healthcare and will proactively continue to improve quality systems, using evidence-based medicine, clinical practice guidelines, appropriate use criteria measures, and registries.