Now is the time to define priorities, work to represent interests of all orthopedic surgeons
The AMA was founded in 1847 to represent the values and opinions of practicing physicians in the United States. As a collective voice of more than 870,000 physicians, the potential influence of this organization could be felt in all aspects of medical care and politics.
Fifty years ago, 75% of practicing physicians were members of the AMA, however, only slightly more than 25% of physicians are members today. This percentage is less in surgical subspecialties, such as orthopedic surgery. Despite limited membership, the AMA and the opinions of its leadership are commonly reported to represent all practicing physicians. In 2010, when the leadership publicly supported the Affordable Care Act (ACA), there was public criticism within and outside the organization. Membership decreased almost 6%, a significant change after the AMA made strong efforts to improve membership.
Anthony A. Romeo
Recently, when orthopedic surgeon Rep. Tom Price, MD, (R-Ga.) was nominated by President-elect Donald J. Trump to be Secretary of HHS, the AMA released a statement that strongly supported the nomination and urged the Senate to promptly consider and confirm Price for this important role. Immediately after release of the AMA statement, a faction of the AMA, as well as the public, protested the selection of Price based on positions he has taken on health care while serving in the House of Representatives. Among the conflicts raised were Price’s efforts to repeal and remove the ACA and replace it with a free-market model, reduce Medicaid, defund Planned Parenthood, and introduce the concept of Medicare vouchers. Supporters suggest he is taking away subsidized programs that could not exist in the free market and, therefore, will continue to require increased taxpayer support beyond what is sustainable, as is projected with Medicare.
The National Physician’s Alliance (NPA), founded by former leaders of the American Medical Student Association “as an alternative to traditional trade associations that primarily service the economic interests of physicians,” is leading an organized approach to develop a plan to block Price’s confirmation. They have condemned the AMA’s endorsement of Price. While the NPA’s goals are lofty and have included health care funding for all disadvantaged patients, they do not provide insight to a financially sustainable method to achieve these goals. Their effort, as well as others within the AMA membership, speak to fragmentation and the AMA’s inability to represent all physician viewpoints. A continued decline in membership is likely, while the belief that the AMA speaks on behalf of all physicians is completely evaporated, except when a press release serves to support the political position of special interest groups.
A recently published study from Yale researchers suggests physicians tend to share the political position of their peer colleagues, such that primary care specialists and psychiatrists are more likely to be Democrats and surgeons are likely to be Republicans, with more than 80% of orthopedic surgeons who vote Republican. Not surprisingly, societies predominately comprised of internists, pediatricians, psychiatrists and family medicine physicians, like the AMA, will typically express a liberal, democratic platform. While it is unknown if these factors affect care, there is concern these factors may ultimately bias a physician’s decision-making process, especially when evidence-based medicine fails to offer clear guidelines.
Even with its high membership participation, the American Academy of Orthopaedic Surgeons (AAOS) is one-tenth the size of the membership of the AMA at this time. The AAOS provides educational programs, practice management services and advocates for improved patient care. Currently, there are 23 members of the Board of Specialty Societies (BOS), which was created in 1984 to bring together leaders of the different subspecialty groups. The BOS serves to unify the various special interest groups on mutually valuable issues, such as education, advocacy, research and education. The BOS can then advise AAOS leadership on critical issues that affect the AAOS members. The AAOS has a full agenda with political advocacy serving its membership, including access to specialty care, medical liability reform, the Sunshine Act and aspects of the ACA that affect orthopedic care.
The continued demise of the AMA as the organization that represents all physicians may be inevitable in this era of increased specialization. However, this same social force acts on the membership of the AAOS and there are some lessons to be learned.
The AAOS must continue to strive to represent all orthopedic surgeons, not just the vocal minority who participate in governance and advocacy. Many past and present leaders have been esteemed colleagues with academic pedigrees that underscore their accomplishments in education, research and the advancement of the knowledge of musculoskeletal care.
However, in our current climate, there is an increasing divide between the methods that health care systems, hospital and academic centers use to control their providers of musculoskeletal care and the private practice orthopedic surgeon who represents more than 50% of the AAOS membership. For example, a chairman of a department at an academic institution may be unaware, or uncomfortable with the knowledge, of the true value of the services the department provides to the health care system. The business of orthopedic care is managed by the health system, and at its discretion, information is shared to the department leadership. However, this information is often processed in a way that does not accurately provide a clear understanding of the balance sheet, usually focusing on the expense side but not the revenue side.
National physician specialty organizations, such as OrthoForum whose membership includes the largest privately owned orthopedic practices in the United States, will de-identify and share data among the membership. Members are aware of the value of an orthopedic surgeon, ancillary services and OR facility fees. With this information, it is then possible to recognize expenses that can be managed and reduced, such as moving outpatient surgical cases from the hospital setting to the ambulatory surgery center setting. Typical cost savings for moving these procedures from the inpatient to the outpatient setting can be more than 40%. If the outcome is the same or better, then a tremendous value has been imparted into the system.
Opportune time to come together
Leadership of the AAOS should not sit on the sidelines in this inevitable process. They should lead the process of enlightenment for CMS about the inpatient restrictions of spine, joint replacement and other reconstructive procedures. The goal should be to provide care to patients in the best, safest and most cost-effective environment. Many of these procedures are still required to be done in an expensive and inefficient hospital setting. The full strength of the AAOS could facilitate these positive patient care and value-based improvements.
The AAOS has been a successful advocate for orthopedic surgeons in all specialties — from different practice environments and in a number of key areas. Despite increased specialization, a strong effort has been made to keep the membership together with activities of the AAOS and BOS. However, a number of significant areas, such as the ACA and its nuances for value-based care, have not been successfully managed by the AAOS or other medical organizations in ways that have satisfied the majority of its membership.
With a Republican president, a Republican Congress and a Republican orthopedic surgeon as the Secretary of HHS, now is an incredibly opportune time to come together and define priorities. We need to work toward representing the best interests of all practicing orthopedic surgeons in our efforts to provide better care in the most appropriate environment and at the highest value to patients.
- Hersh ED et al. Proc Natl Acad Sci USA. 2016;doi:10.1073/pnas.1606609113.
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- Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: email@example.com.
Disclosure: Romeo reports he receives royalties, is on the speakers bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.