AAOS Now Editor-in-chief Robert M. Orfaly, MD, MBA, FAAOS, sat down with two great leaders of AAOS, David Teuscher, MD, FAAOS, and John Gill, MD, FAAOS.

AAOS Now

Published 12/20/2023
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Robert M. Orfaly, MD, MBA, FAAOS

Persistence and Partnerships Are Key to Successful Political Advocacy

An interview with AAOS leaders David Teuscher, MD, FAAOS, and John Gill, MD, FAAOS

In the world of political advocacy for orthopaedic practices, few issues have remained of perennial focus as much as medical liability reform. To both celebrate one of the significant wins on this front and learn lessons for the future, AAOS Now Editor-in-chief Robert M. Orfaly, MD, MBA, FAAOS, sat down with two great leaders of AAOS, David Teuscher, MD, FAAOS, and John Gill, MD, FAAOS. They discussed the history of liability reform in the state of Texas in order to understand the history of the process, as well as defined how those within AAOS can advocate for our profession and for the issues that affect our patients.

Dr. Teuscher, who is a past president of AAOS, began by recounting the beginnings of medical liability reform known as “MICRA” in California in the early 1970s, followed by a cap on noneconomic damages in Texas passed in 1977. That statute was later vacated by the state supreme court following an 11-year legal challenge. Advocacy followed in subsequent years to reconstitute the court, with all nine Supreme Court of Texas justices replaced in three election cycles.

Despite these efforts, Dr. Teuscher explained, “By the time it came to the late ’90s, we were in a real crisis. The liability premiums were going through the roof. They were tripling some years. We were losing our really good orthopaedic surgeons. We weren’t able to retain or recruit orthopaedic surgeons. We knew something had to change.”

Dr. Gill, past chairman of the Political Action Committee of the American Association of Orthopaedic Surgeons, added, “We were losing all of our high-risk specialists—neurosurgeons or high-risk OBGYNs to deliver your baby. You had to go to San Antonio or even to Dallas to find someone, so it was a terrible problem for patient access.”

The situation seemed dire, but the solution was rooted in relationships that developed over time. When George W. Bush was elected president in 2000, Lieutenant Governor Rick Perry became governor and had a rocky start with his first session and a hostile legislature makeup. At that time, Dr. Gill tried to speak to legislators about the liability crisis but found it difficult to get their attention. Speaking to senior professional lobbyists, he was asked pointed questions. “Where were you during the election? Did you help this guy get elected? Did you raise any money? Did you write a check? Next time, try that.” Empowered with this new perspective, Dr. Gill approached Governor Perry during his first election for a full term and forged a relationship with him against the stance of the Texas Medical Association, which was backing Perry’s opponent. “I built a successful Physicians for Perry campaign, raised a lot of money, and I made a new friend in the governor. So then when it comes into the next session, we now have the players in place: a Republican Senate, a Republican House, and Republican governor. The success of any sort of advocacy campaign is your personal relationships with elected legislators so that they will listen to and trust your opinions.”

When asked about the importance of creating alliances, Dr. Gill explained the critical significance of creating an alliance of not only physicians but also the state hospital association, nursing association, allied health professionals, and business and insurance associations. Despite this large coalition, significant challenges existed, noted Dr. Teuscher. “The biggest challenge was we knew since we had already lost at our Supreme Court previously in 1988, we had to have a constitutional amendment that would make any reforms we had permanent. We had Democrats and Republicans on both sides of the aisle. Not all Republicans agreed with medical liability reform, not all the Democrats were against liability reform; but all the patients are Republicans or Democrats or independents, so we defined the problem as patient access to care. … Getting that bill across the finish line was a Herculean effort that took everyone—nurses, doctors, hospitals, most of all our patients. We had push cards for our patients when they came to see us in the office. And then when we went for the constitutional amendment, we had to get out the vote because the people get to decide if we amend the constitution. And we won on Sept. 12, 2003, by 51 percent.”

Even with all this work, Dr. Gill shared that negotiations came down to the wire. “In the final steps of the negotiation, one of the real stumbling blocks was that one of the key legislators felt the $250,000 cap was too low. But actuaries who ran the numbers reported that a $500K or $750K non-economic cap would not be effective at lowering premiums. In the final hours, literally the last day of the legislature, what was called the triple cap was created, and it was $250,000 against a physician, $250,000 against a hospital, and $250,000 against some other group (physical therapy, radiology, home nursing, etc.). [This breakdown] satisfied the legislators’ desire to have that $750K. It was a very unique solution, but it got done.”

The legislation and constitutional amendment went into effect the following year. According to Dr. Gill, “Immediately we started seeing a reduction in our medical liability premiums each year, [which] have gone down every year since then. We started seeing the ability to recruit physicians to Texas, recruit them down into the valley in areas that were devoid of high-risk specialists. We’re now keeping and graduating residents in all of our programs, instead of seeing them all leave the state after they finish their residency programs. It’s been a huge success throughout the 20 years now that it’s been in place, which is 10 legislative sessions.”

As Dr. Teuscher was quick to add, “The price of liberty is eternal vigilance.” However, he assured that the results were very much worth the effort. “Hospital administrators were telling us they finally were able to get neurosurgeons [and orthopaedic surgeons] to stay on call if there was an accident or a child was injured. The results have been incredible. … It’s not about our premiums, it’s about patient access to care.”

Given the success of their long and diligent efforts, Dr. Gill and Dr. Teuscher were asked to offer advice for AAOS members who would like to advocate for patients on any piece of legislation.

Dr. Gill responded, “The first lesson I learned in politics is that you have got to build a relationship with your legislator. Not only do you need to know their name, but they need to know your name, and you do that when they need more from you than you need from them. That’s generally when they’re running for election or re-election. If you get out and help them by either giving money, raising money, phone banking, block walking, something, then you will get to know the member, have that relationship, [and] now have access to tell your story.”

Dr. Teuscher advised, “Alliances are absolutely critical, and you don’t know where you’re going to have the next friend that you need—[alliances may come from] a rotary club, a salesman club, your church, your synagogue. Remember you formed a relationship with every single patient who came ever to see you. They weren’t there to see your politics [but] to hear how much you really care, because they don’t care how much you know until your patients know that you really care. After you’ve had an opportunity to take care of them, it’s okay to say, ‘I’m concerned that I might not be able to continue to see you or take care of you in the way that I was trained to do that.’ It can be honest, it can be from the heart, and patients will know you are speaking from your heart.”

As a final thought, Dr. Gill offered, “The final take-home lesson is to be persistent. It’s not a sprint, it’s a marathon. It took Texas 20 years to get this reform, and it wasn’t a one-session deal. It was a long time coming with a lot of hard work. So build those relationships, build good coalitions, and be persistent.”

Robert M. Orfaly, MD, MBA, FAAOS, is a professor in the Department of Orthopaedics and Rehabilitation at Oregon Health and Science University. He is also the editor-in-chief of AAOS Now and chair of the AAOS Now Editorial Board.