The increase in the number of insured patients made possible under healthcare reform could result in both more patients and more payments for orthopaedic susrgeons.
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Published 1/1/2013
Stuart J. Fischer, MD

Challenges and Opportunities Under “Obamacare”

The re-election of President Obama and the Supreme Court’s validation of the Patient Protection and Affordable Care Act (PPACA) mean we are destined to live with “Obama-care.” Where does this leave us as orthopaedic surgeons? What does it mean for our future, the practice of orthopaedic surgery, and the care of our patients?

Many believe that further intrusion of government into our healthcare system bodes ill for the future. The record speaks otherwise.

A generation of orthopaedic surgeons in the 1960s complained bitterly that the Medicare program was “socialized medicine” and “government taking over everything.” But I can remember the reaction of my father, a community orthopaedic surgeon. He practiced in a blue-collar community where most people were hard-working and trusted their doctors.

At that time, hip fractures were a large part of an orthopaedist’s surgical practice. My father noted that even in a good community, one third of elderly hip fracture patients could not pay at all and another third could pay only a fraction of his regular fee. Medicare changed all that. It ensured that surgeons were paid on all cases and patients had better access to care.

Of course both the country and the practice of orthopaedic surgery have changed in almost 50 years. More people seek out musculoskeletal care and there is far more elective surgery and operative fracture treatment. Still, one parallel can be drawn.

Increased coverage means more patients
More patients will be insured and able to come to our offices. Most estimates place the current number of uninsured at 48 million. Under PPACA, approximately 30 million of these uninsured will become insured—many through expanded Medicaid programs and others (an estimated 20 million) through commercial exchanges regulated by states. Approximately 5 million will be young, active patients who up to now have carried no insurance but will be required to have coverage under the mandate.

A smaller group will be patients younger than age 26 who previously had no coverage but are now eligible under their parents’ insurance.

Many of these individuals are patients we have cared for through clinic rotations or emergency deparment calls. Think of how many long nights we have spent débriding and stabilizing open fractures in clinic patients. Now we will be compensated for the care we provide—and we will be able to provide the secondary care such as hardware removal and reconstruction resulting from those fractures. We will also have a large population of younger patients who may need meniscectomies, anterior cruciate ligament reconstructions, and instability repairs.

In short, more people will be seeking orthopaedic care and the demand for our services on a private basis will increase.

It takes a population of 10,000 to support one orthopaedic surgeon. An increase of 30 million patients will mean an immediate need for 3,000 surgeons. Considering that there are 20,000 practicing orthopaedic surgeons in the United States, many practices can expect to see a 10 percent to 15 percent increase in the volume of their practices. In some economically depressed areas, the figure will be greater.

In practical terms, many surgeons will be spending more time in the operating room and delegating more work to allied health professionals in their offices. More private patients will be going to physician-owned MRI, physical therapy, and outpatient surgery centers. Clearly, there will be economic benefits.

The downside, of course, will be less time spent with individual patients.

Shaping the future
So what can we as orthopaedic surgeons do to help shape our future in the changing environment?

First, we need to be involved on a statewide level as state governments move to form the insurance exchanges required under PPACA. The insurance exchanges will control what services will be covered and rates of reimbursement. They will define the role of specialists in the state’s healthcare system. It is important for orthopaedic surgeons to be part of the governing boards and advisory groups that will be formed to regulate the new exchanges.

In this regard we should emphasize the benefit of physician-owned ancillary services that hospitals or insurance carriers might attempt to limit under a state-regulated system.

Second, we will need to streamline our practices so we can take care of more problems and more patients in less time. This may mean greater use of physician assistants, nurse practitioners, or registered nurse first assistants. In many offices, staffing ratios and costs will increase.

It will, however, be an opportunity to broaden our practices and increase our patient bases as well as practice revenues.

It is said that patients don’t care what we know—they want to know that we care. Under the new rules, they will want to know if their government really cares. We need to make sure that programs sponsored by the state-run exchanges guarantee patients immediate and unlimited access to specialists.

As things now stand, government programs account for 43 percent of total healthcare spending. Government intervention in medicine is already here. PPACA is expected to increase the percentage of government healthcare spending number by 3 percent.

For many of us, although Medicare is not our best payer, it is our most reliable payer. Medicare patients don’t require “pre-certs” for MRIs or surgery. Far fewer properly coded Medicare claims are denied than claims for commercial insurers. Medicare pays all providers at a fixed rate according to a widely published schedule. Government requirements under the new law are likely to standardize levels of coverage and processing of claims. Although specific procedure payments may not increase, physicians will see the overall benefits of higher volumes and more guaranteed payments.

There is much not to like about “Obamacare,” including the Independent Payment Advisory Board, the lack of tort reform, and the failure to replace the sustainable growth rate formula. Clearly we need to maintain our advocacy to have Congress address these problems.

But much like the generation before us, we should recognize that changes in the system may provide additional resources to both doctors and patients. It is important that we position ourselves to take advantage of these changes.

If we do so, both our patients and our practices will benefit.

Stuart J. Fischer, MD, an orthopaedic surgeon in private practice in Summit, N.J., is a member of the AAOS Now Editorial Board and associate editor of the AAOS patient education website,