Orthopaedic surgeons drive change to Department of Veterans Affairs (VA) Provider Equity Act
Policy battles in Washington, D.C., can seem very far away from the day-to-day activity of taking care of patients. Many of us chose this profession because we wanted to make a direct, immediate impact on people's lives. In contrast, the political process is slow-moving and often frustrating. However, orthopaedic surgeons can achieve real policy successes when we get involved.

For example, as representatives of the American Orthopaedic Foot & Ankle Society (AOFAS) and AAOS, we (the authors) were successful in changing legislation that would have labeled all podiatrists at the Department of Veterans Affairs (VA) as "physicians." It also would have raised salaries for podiatrists to make them equal to medical doctors (MD) and doctors of osteopathy (DO) as well as allow them unrestricted access to clinical leadership positions.

Due to our direct intervention, the result was legislation that reinforced the necessity of clinical leadership belonging to MDs and DOs as well as the "physician" title.

That success did not come overnight, however. It started in July 2015 when Congressman Brad Wenstrup, DPM, (R-Ohio) introduced the Department of Veterans Affairs Provider Equity Act. This legislation was intended to improve foot and ankle care for veterans, a noble goal that we wholeheartedly support. Rep. Wenstrup is also a strong ally of orthopaedics and served his country with distinction in the U.S. Army.

However, based on the changes the bill would make to clinical leadership and the physician title, which we believe should be reserved for medical school and osteopathic medical school graduates, AOFAS and AAOS opposed this effort.

Although we didn't oppose raising salaries to help the VA recruit and retain the best qualified podiatrists, we maintained that the veteran population is best served by a physician-led care team. Podiatrists are a critical part of that team but cannot replace orthopaedic surgeons. Any equivalency between podiatry and orthopaedic surgery must be achieved through equal training and accreditation, not legislation.

The current 4-year podiatry school and (since 2013) 3-year surgical residency do not meet the standards of the allopathic or osteopathic medical school pathways and are not accredited by the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education. Podiatrists are not certified by a member of the American Board of Medical Specialties (ABMS).

We believe that equivalency can only be achieved through podiatrists undergoing accreditation by the same organizations as orthopaedic surgeons and certification by a member of the ABMS.

In February 2016, the VA Provider Equity Act passed the U.S. House of Representatives tucked into a package of widely supported, bipartisan, noncontroversial veterans' bills. The AAOS office of government relations (OGR) successfully stopped the bill in the Senate, but we knew the issue wasn't going away. With guidance from OGR, we decided that if we wanted to make an impact on policies that affect our practice and our patients, we had to roll up our sleeves, be preemptive, and engage directly.

In March, at the beginning of a new Congress, Rep. Wenstrup reintroduced his legislation. In response, the OGR formed a small task force to travel to Washington, D.C., and speak to Rep. Wenstrup. During the meeting, we discussed our concerns as well as points of agreement. It was the beginning of a long process of working toward a mutually agreeable solution that would increase veterans' access to the best possible care. We started communicating with the American Podiatric Medical Association (APMA) and expressed our willingness to work with them to draft legislative language that met our requirements.

We also spent a day meeting with key members of the House Veterans Affairs Committee, including Chairman Phil Roe, MD, (R-Tenn.), and Ranking Democrat Tim Walz (D-Minn.). Our key objective for these meetings was to educate and explain the differences between podiatrists and orthopaedic surgeons to congressional members and staff.

In April, the task force returned to Washington, D.C., during the AAOS National Orthopaedic Leadership Conference and continued lobbying efforts. We provided members of Congress and their staff the opportunity for face-to-face communication with physicians who were willing to explain the nuances of our position. We received positive feedback and started to feel some momentum building. While at the conference, we also met with APMA leadership and continued our dialogue with them.

In May, AAOS and AOFAS were invited to provide testimony at a House Veterans Affairs subcommittee hearing focusing specifically on the legislation chaired by Rep. Wenstrup.

A member of our group, U.S. Army Colonel (ret.) Jim Ficke, MD, did an outstanding job representing our profession and spoke from a veteran's perspective, providing the subcommittee with the rationale for our opposition.

Throughout the entire process, OGR staff continued to work behind the scenes with APMA staff as well as congressional staff, keeping AAOS leadership informed and ensuring AOFAS leadership approved every step before it was taken.

Finally, in July, at a critical final committee vote on the legislation, Rep. Wenstrup introduced an amendment to his bill—developed in partnership with OGR—that met our requirements.

This amendment allows for salary increases for podiatrists but clarifies that podiatrists are not eligible for peer-review or clinical supervisory roles over MDs or DOs. Furthermore, it retains the official "podiatrist" designation, referring to them as podiatric surgeons, not physicians.

The amended bill passed the House of Representatives in the following week and now awaits consideration in the Senate.

This amendment was the culmination of our efforts and an example of what we can accomplish when we get directly involved in the political process. By working through our differences with APMA, we not only helped advance access to foot and ankle care for veterans, but we also opened the door to increased cooperation in other areas as well.

We know that these issues will continue to reemerge, which is why we are not going to rest on our laurels after this victory. We are actively developing a structure that will allow us to continue the dialogue we have started and continue with our goal of resolving disagreements before they become legislative battles.

The OGR staff was invaluable throughout this process and continue to work with us and each specialty society to advance legislation that benefits orthopaedics. We urge you to reach out to them with any questions or concerns you may have on federal or state policy.

We hope our experiences will encourage others to act when they see problems with policies coming out of Washington, D.C. While there won't be any easy resolutions to the major healthcare debates of the day, direct participation from orthopaedic surgeons can only help us achieve better solutions for our patients and our practices.

Thomas Lee, MD,is the president of AOFAS.

Jeffrey Johnson, MD, is the immediate past president of AOFAS.

James Ficke, MD, is a member of the AOFAS Advocacy Council and is professor and chairman, department of Orthopaedic Surgery, Johns Hopkins Medicine.

Michael Aronow, MD, is the former chair of the AOFAS Health Policy Committee and current AOFAS representative to the AAOS Board of Specialty Societies and to the American Medical Association.