Cover Story

Advocacy gives physicians a voice, benefits patients

Since the 1990s, the American Association of Orthopaedic Surgeons has engaged in health policy and advocacy activities for patients and the orthopedic surgery profession. Orthopedic subspecialty groups, such as the American Shoulder and Elbow Surgeons, the American Association of Hip and Knee Surgeons, the American Orthopaedic Society for Sports Medicine and the Orthopaedic Trauma Association, have also joined the cause. With the many opportunities today to improve the delivery of health care, sources who spoke with Orthopedics Today said that, because they are the experts in the specialty, orthopedic surgeons should be the ones who manage how health care reform impacts orthopedic surgery.

“I believe 100% of the American Academy of Orthopaedic Surgeons members should have an interest in advocacy because it affects all of us,” Theodore F. Schlegel, MD, chair of the ASES Political Advocacy Committee, said. “Whether you are in private practice or a hospital-based physician, all of us face challenges and we need help and representation, at both the state and federal level, to help us advance our issues.”

Political advocacy can take many forms for orthopedic professionals, according to A. Seth Greenwald, DPhil(Oxon), director of Orthopaedic Research Laboratories.

Theodore F. Schlegel, MD, said orthopedic surgeons should engage in advocacy at the state and federal levels to influence political decision-making, advance key legislative issues and maintain access to high-quality patient care. Education surrounding the importance and potential impact of advocacy should begin during residency, he said.

Source: Kelli Sessions

“Orthopedic surgeons should always serve and advocate in the best interest of their patients, noted Kristy L. Weber, MD, president of AAOS.

“Whether it is access to care, access to specific specialty care or anything else that advantages our patients to have high-value orthopedic and musculoskeletal care; this is how we should advocate. Sometimes it means speaking up for rules that allow the orthopedic surgeon to better care for the patient,” Weber, of the University of Pennsylvania in Philadelphia, told Orthopedics Today.

Education in political advocacy

Frederic E. Liss, MD, clinical associate professor of orthopaedics at Thomas Jefferson University and Rothman Orthopaedic Institute and secretary of the AAOS Political Action Committee (PAC) executive committee, advises orthopedic surgeons to reach out to their state and national societies and become engaged in political advocacy at some level. Regardless of whether that involves traveling to Washington, D.C., or being part of a committee or grassroots network, it is an integral part of an orthopedic surgeon’s career. He said orthopedic surgeons need to be aware and informed of the major issues.

“If you do not have an opinion because you do not understand or do not know, it means that you have not engaged,” Liss said. “You have to engage and try to learn what the issues are and discuss it with your ... colleagues, discuss it with your patients. Tell your patients about these issues that are concerning you and ask them their opinions about it because patients are super smart. They understand and they could give you great support to advocate for what it is that they want.”

To become educated in the avenues of political advocacy, James I. Huddleston III, MD, Advocacy Council Chair of AAHKS, said orthopedic surgeons can join political advocacy teams established within the AAOS and specialty societies, such as AAHKS and ASES.

“There are advocacy committees and councils within specialty societies, as well as the American Association of Orthopaedic Surgeons, and those positions are for a defined period of time, generally between 2 and 3 years, so the seats are coming open on a regular basis,” Huddleston, associate professor of orthopedic surgery and adult reconstruction service chief at Stanford University Medical Center, told Orthopedics Today.

Frederic E. Liss

The AAOS Office of Government Relations (OGR) can provide materials to inform orthopedic surgeons about important advocacy issues and their team works 52 weeks per year to educate the representatives and senators in Congress about musculoskeletal concerns important to AAOS, according to Weber.

“[The AAOS has] the connections to lawmakers and regulators, and they can provide advice to help guide [orthopedic surgeons] to develop relationships with the decision makers in Washington, D.C.,” Weber said. “For example, maybe [an orthopedic surgeon wants] to host a fundraiser, maybe they want to know what the best ways to access their particular Congress person are. The OGR can facilitate that.”

Huddleston noted orthopedic surgeons can attend webinars hosted regularly by AAOS on important advocacy issues. They can also attend either the annual National Orthopaedic Leadership Conference hosted by AAOS or a similar retreat hosted by AAHKS, both of which focus on educating orthopedic surgeons about the advocacy process and visiting Congress members and their staff on Capitol Hill, he said.

Advocate with FDA, CMS

Advocates are also needed within the FDA to ensure new implants and methodologies are safe and effective for patients, according to Greenwald.

“[The FDA] relies on the experts. They have an FDA Orthopaedic Advisory Panel ... and they involve surgeons, life sciences engineers, people who are experts in particular areas and who can give the FDA advocacy and advice on products that come before them,” Greenwald, who is an Orthopedics Today Editorial Board Member, said.

Kristy L. Weber

He noted orthopedic surgeons can advocate for patients by working with CMS to provide adequate coverage decisions and sufficient indications for surgeries and outpatient same-day surgical facilities.

“The role that is played by surgeon advocates must be to inform or continually partner [with] and inform CMS about nuances of the discipline so they can make effective coding for situations like total knee replacement and total hip replacement,” Greenwald told Orthopedics Today.

Involve residents

One of the best times for orthopedic surgeons to become involved in political advocacy is during their residency, according to Schlegel.

When residents engage in political advocacy, Liss said they gain another example of and greater insight into the full extent of what it means to be an orthopedic surgeon.

“It is about doing the right thing, not only for what is good for orthopedics, but for patients and for the health care system, in general,” according to Liss.

To get involved, orthopedic residents can apply for a 2-year health policy fellowship supported by AAHKS, according to Huddleston.

Liss noted the AAOS PAC also includes one resident representative on its executive committee, and provides programs that encourage resident engagement in advocacy.

“We think that one of the most important keys to the future success of advocacy for orthopedic surgeons is engaging the youth, engaging the young residents, because they are creative, they are smart and they are in tune with what is going on in the millennial group and presently in ways that some of the older folks are not,” Liss told Orthopedics Today.

Similarly, ASES established the Mark Frankle, MD, Health Care Policy Award with the goal to “improve health care legislation by measuring advocacy effectiveness and identifying key legislative areas that can advance shoulder and elbow care,” according to Schlegel, of the University of Colorado School of Medicine. Through the program, two ASES representatives focus on an actionable item throughout the year while participating in a fellowship at the AAOS office in Washington, D.C., as well as at the National Orthopaedic Leadership Conference and with the Board of Councilors, Schlegel said.

“This is another way for us to engage our membership, by showing a commitment to advocacy and creating this ongoing education of our members,” Schlegel said. “We are asking these two winners to write up a white paper that could be published and spend time at our annual meeting educating our members about what they learned over the year on a specific topic,” he said.

Huddleston noted constraints on a resident’s time may limit their ability to participate in political advocacy.

Orthopedic residents should focus on learning how to become an orthopedic surgeon first and add in political advocacy when they “have the capacity to do more,” according to Weber.

“I think there is opportunity for those who feel like they have the time, but regardless of whether people want to be involved in hosting a fundraiser or going to [Washington,] D.C., I think it is incumbent upon all of us in the medical field, and specifically in the orthopedic field, to understand the issues that affect patient care,” she said. “It is hard to put your head in the sand and say you do not want to know about this for a while, because it is going to affect your practice, your long-term employment and, most importantly, your patients.”

Surprise billing

With 2020 being an election year, sources who spoke with Orthopedics Today discussed current legislation of which orthopedic surgeons should be aware.

Presently, the AAOS is focused on surprise billing, which is when patients receive surprise out-of-network bills for emergency care received, Weber said.

James I. Huddleston III, MD, said joining an already established political advocacy team provides a fast track for orthopedists who seek to make a difference.

These surprise bills can occur when health insurance companies rely on “narrow and often inadequate networks of contracted physicians, hospitals, pharmacies and other providers as one mechanism for controlling costs”, which can lead to patients unknowingly going to out-of-network providers during their care, according to a letter to Congress from the AMA, AAOS and numerous medical societies.

“There are a number of different proposals out there from different lawmakers and the Academy is going to be supporting ones that allow the actual surgeons and doctors to negotiate fairly with the insurance companies rather than the insurance companies setting rates and putting a mandate down about what has to happen,” Weber said.

In December 2019, AAOS released a statement on a new combined version of the Lower Health Care Costs Act of 2019 which not only removes patients from the middle of medical billing disputes, but includes independent dispute resolution and a lowered threshold for access to this critical process, according to AAOS. However, AAOS expressed concerns over the continued use of the median in-network rate, which is a number or rate controlled by insurers.

“Even when filtered through arbitration, the use of this rate as a benchmark is tantamount to government rate-setting. It will allow insurers to systematically drive down in-network rates to serve their bottom line, consequently harming patient access to care throughout the country,” Weber said in a press release. “Furthermore, the new 90-day waiting period between disputes for the same procedure type undermines the effectiveness of the [independent dispute resolution] IDR process, which sole purpose is to bring both sides to the table and incentivize fair, reasonable offers.”

Physicians ownership

Another area of interest that has resurfaced is the physician’s right to own hospitals, which Section 6001 of the Affordable Care Act not only eliminated, but made it so existing physician-owned hospitals (POHs) could not expand, according to Liss. The Hospital Competition Act of 2019 was introduced to “combat the rising cost of health care by increasing choice among hospital providers,” according to AAOS. The bill also lifts restrictions on POHs, discourages hospital consolidation and certificate of need laws, expands site neutral payments and increases price transparency.

In addition, Congressman Michael C. Burgess, MD, (R-Texas), Republican leader of the Energy and Commerce Subcommittee on Health, encouraged CMS to design a Center for Medicare and Medicaid Innovation demonstration that expands access to POHs.

“Physician-owned hospitals play an important role in providing quality, efficient and cost-effective care in modern medicine. Patient care begins and ends with doctors, and no one is more aware of this fact than physicians themselves,” Burgess said, in a press release. “It is wrong that the Affordable Care Act penalizes physicians simply for the two letters behind their name. Through innovation, CMS can optimize the role of physician-owned hospitals to improve health care for American patients, restoring doctors’ liberty and expanding Americans’ access to quality care.”

The recommendation received support from more than 30 fellow members of Congress and numerous medical specialty organizations.

“There has been a long sustained effort over the past decade since the Affordable Care Act came into play to reverse that legislatively, which has not been successful,” Liss said. “Now there is a significant and likely mechanism that is going to go down in the regulatory world to do a demonstration model to show how much physician-owned hospitals saved on cost, raised the quality, raised the patient satisfaction for surgical and non-surgical care for Americans.”

Involvement at state level

Although lobbying and attending retreats in Washington, D.C., may have the biggest impact on an orthopedic surgeon’s advocacy education, Huddleston said some physicians may find it difficult to take time out of their practice to participate in such activities.

Weber encouraged orthopedic surgeons who cannot travel to connect with their state representatives at the office in their district rather than meeting with them in Washington, D.C., or to join their state orthopedic society and participate in its efforts.

“Every state has their own specific orthopedic issues related to patient care and each state is different,” Weber said. “So, [orthopedic surgeons can work] with their state orthopedic society to lobby in their state for a particular bill. It might be related to scope of practice, surprise billing, the sports medicine licensure, etc.”

Liss said it is important for surgeons to also network with individuals in their community outside of their practice or specialty group.

“The whole point is that all the component parts are super important and if you are involved at any level anywhere along the way that is an important piece to communicate upstream, to have a voice nationally with a leadership group like what we do at the association,” Liss said.

Whether orthopedic surgeons take the time to meet with representatives at home or in Washington, D.C., Schlegel believes it is “imperative that every physician get to know their political leaders.”

“We all have busy practices and it is easy to think that your voice will not make a difference, but if we are going to support and want to have a voice in this transition from fee-for-service to value-based care, then we need to have a seat at the table. Having a seat at a table requires taking time away from your practice, but it is almost certainly time well spent given the influence we have,” Huddleston said. – by Casey Tingle

Disclosures: Liss reports he is a minority owner and board member of Physicians Care Surgical Hospital. Schlegel reports he serves as chair for the ASES Political Advocacy Committee. Weber reports she is president of AAOS. Greenwald and Huddleston report no relevant financial disclosures.

Click here to read the Point/Counter, "Should physician advocacy be a core component of medical professionalism."

Since the 1990s, the American Association of Orthopaedic Surgeons has engaged in health policy and advocacy activities for patients and the orthopedic surgery profession. Orthopedic subspecialty groups, such as the American Shoulder and Elbow Surgeons, the American Association of Hip and Knee Surgeons, the American Orthopaedic Society for Sports Medicine and the Orthopaedic Trauma Association, have also joined the cause. With the many opportunities today to improve the delivery of health care, sources who spoke with Orthopedics Today said that, because they are the experts in the specialty, orthopedic surgeons should be the ones who manage how health care reform impacts orthopedic surgery.

“I believe 100% of the American Academy of Orthopaedic Surgeons members should have an interest in advocacy because it affects all of us,” Theodore F. Schlegel, MD, chair of the ASES Political Advocacy Committee, said. “Whether you are in private practice or a hospital-based physician, all of us face challenges and we need help and representation, at both the state and federal level, to help us advance our issues.”

Political advocacy can take many forms for orthopedic professionals, according to A. Seth Greenwald, DPhil(Oxon), director of Orthopaedic Research Laboratories.

Theodore F. Schlegel, MD, said orthopedic surgeons should engage in advocacy at the state and federal levels to influence political decision-making, advance key legislative issues and maintain access to high-quality patient care. Education surrounding the importance and potential impact of advocacy should begin during residency, he said.

Source: Kelli Sessions

“Orthopedic surgeons should always serve and advocate in the best interest of their patients, noted Kristy L. Weber, MD, president of AAOS.

“Whether it is access to care, access to specific specialty care or anything else that advantages our patients to have high-value orthopedic and musculoskeletal care; this is how we should advocate. Sometimes it means speaking up for rules that allow the orthopedic surgeon to better care for the patient,” Weber, of the University of Pennsylvania in Philadelphia, told Orthopedics Today.

Education in political advocacy

Frederic E. Liss, MD, clinical associate professor of orthopaedics at Thomas Jefferson University and Rothman Orthopaedic Institute and secretary of the AAOS Political Action Committee (PAC) executive committee, advises orthopedic surgeons to reach out to their state and national societies and become engaged in political advocacy at some level. Regardless of whether that involves traveling to Washington, D.C., or being part of a committee or grassroots network, it is an integral part of an orthopedic surgeon’s career. He said orthopedic surgeons need to be aware and informed of the major issues.

PAGE BREAK

“If you do not have an opinion because you do not understand or do not know, it means that you have not engaged,” Liss said. “You have to engage and try to learn what the issues are and discuss it with your ... colleagues, discuss it with your patients. Tell your patients about these issues that are concerning you and ask them their opinions about it because patients are super smart. They understand and they could give you great support to advocate for what it is that they want.”

To become educated in the avenues of political advocacy, James I. Huddleston III, MD, Advocacy Council Chair of AAHKS, said orthopedic surgeons can join political advocacy teams established within the AAOS and specialty societies, such as AAHKS and ASES.

“There are advocacy committees and councils within specialty societies, as well as the American Association of Orthopaedic Surgeons, and those positions are for a defined period of time, generally between 2 and 3 years, so the seats are coming open on a regular basis,” Huddleston, associate professor of orthopedic surgery and adult reconstruction service chief at Stanford University Medical Center, told Orthopedics Today.

Frederic E. Liss

The AAOS Office of Government Relations (OGR) can provide materials to inform orthopedic surgeons about important advocacy issues and their team works 52 weeks per year to educate the representatives and senators in Congress about musculoskeletal concerns important to AAOS, according to Weber.

“[The AAOS has] the connections to lawmakers and regulators, and they can provide advice to help guide [orthopedic surgeons] to develop relationships with the decision makers in Washington, D.C.,” Weber said. “For example, maybe [an orthopedic surgeon wants] to host a fundraiser, maybe they want to know what the best ways to access their particular Congress person are. The OGR can facilitate that.”

Huddleston noted orthopedic surgeons can attend webinars hosted regularly by AAOS on important advocacy issues. They can also attend either the annual National Orthopaedic Leadership Conference hosted by AAOS or a similar retreat hosted by AAHKS, both of which focus on educating orthopedic surgeons about the advocacy process and visiting Congress members and their staff on Capitol Hill, he said.

Advocate with FDA, CMS

Advocates are also needed within the FDA to ensure new implants and methodologies are safe and effective for patients, according to Greenwald.

“[The FDA] relies on the experts. They have an FDA Orthopaedic Advisory Panel ... and they involve surgeons, life sciences engineers, people who are experts in particular areas and who can give the FDA advocacy and advice on products that come before them,” Greenwald, who is an Orthopedics Today Editorial Board Member, said.

PAGE BREAK
Kristy L. Weber

He noted orthopedic surgeons can advocate for patients by working with CMS to provide adequate coverage decisions and sufficient indications for surgeries and outpatient same-day surgical facilities.

“The role that is played by surgeon advocates must be to inform or continually partner [with] and inform CMS about nuances of the discipline so they can make effective coding for situations like total knee replacement and total hip replacement,” Greenwald told Orthopedics Today.

Involve residents

One of the best times for orthopedic surgeons to become involved in political advocacy is during their residency, according to Schlegel.

When residents engage in political advocacy, Liss said they gain another example of and greater insight into the full extent of what it means to be an orthopedic surgeon.

“It is about doing the right thing, not only for what is good for orthopedics, but for patients and for the health care system, in general,” according to Liss.

To get involved, orthopedic residents can apply for a 2-year health policy fellowship supported by AAHKS, according to Huddleston.

Liss noted the AAOS PAC also includes one resident representative on its executive committee, and provides programs that encourage resident engagement in advocacy.

“We think that one of the most important keys to the future success of advocacy for orthopedic surgeons is engaging the youth, engaging the young residents, because they are creative, they are smart and they are in tune with what is going on in the millennial group and presently in ways that some of the older folks are not,” Liss told Orthopedics Today.

Similarly, ASES established the Mark Frankle, MD, Health Care Policy Award with the goal to “improve health care legislation by measuring advocacy effectiveness and identifying key legislative areas that can advance shoulder and elbow care,” according to Schlegel, of the University of Colorado School of Medicine. Through the program, two ASES representatives focus on an actionable item throughout the year while participating in a fellowship at the AAOS office in Washington, D.C., as well as at the National Orthopaedic Leadership Conference and with the Board of Councilors, Schlegel said.

“This is another way for us to engage our membership, by showing a commitment to advocacy and creating this ongoing education of our members,” Schlegel said. “We are asking these two winners to write up a white paper that could be published and spend time at our annual meeting educating our members about what they learned over the year on a specific topic,” he said.

PAGE BREAK

Huddleston noted constraints on a resident’s time may limit their ability to participate in political advocacy.

Orthopedic residents should focus on learning how to become an orthopedic surgeon first and add in political advocacy when they “have the capacity to do more,” according to Weber.

“I think there is opportunity for those who feel like they have the time, but regardless of whether people want to be involved in hosting a fundraiser or going to [Washington,] D.C., I think it is incumbent upon all of us in the medical field, and specifically in the orthopedic field, to understand the issues that affect patient care,” she said. “It is hard to put your head in the sand and say you do not want to know about this for a while, because it is going to affect your practice, your long-term employment and, most importantly, your patients.”

Surprise billing

With 2020 being an election year, sources who spoke with Orthopedics Today discussed current legislation of which orthopedic surgeons should be aware.

Presently, the AAOS is focused on surprise billing, which is when patients receive surprise out-of-network bills for emergency care received, Weber said.

James I. Huddleston III, MD, said joining an already established political advocacy team provides a fast track for orthopedists who seek to make a difference.

These surprise bills can occur when health insurance companies rely on “narrow and often inadequate networks of contracted physicians, hospitals, pharmacies and other providers as one mechanism for controlling costs”, which can lead to patients unknowingly going to out-of-network providers during their care, according to a letter to Congress from the AMA, AAOS and numerous medical societies.

“There are a number of different proposals out there from different lawmakers and the Academy is going to be supporting ones that allow the actual surgeons and doctors to negotiate fairly with the insurance companies rather than the insurance companies setting rates and putting a mandate down about what has to happen,” Weber said.

In December 2019, AAOS released a statement on a new combined version of the Lower Health Care Costs Act of 2019 which not only removes patients from the middle of medical billing disputes, but includes independent dispute resolution and a lowered threshold for access to this critical process, according to AAOS. However, AAOS expressed concerns over the continued use of the median in-network rate, which is a number or rate controlled by insurers.

“Even when filtered through arbitration, the use of this rate as a benchmark is tantamount to government rate-setting. It will allow insurers to systematically drive down in-network rates to serve their bottom line, consequently harming patient access to care throughout the country,” Weber said in a press release. “Furthermore, the new 90-day waiting period between disputes for the same procedure type undermines the effectiveness of the [independent dispute resolution] IDR process, which sole purpose is to bring both sides to the table and incentivize fair, reasonable offers.”

PAGE BREAK

Physicians ownership

Another area of interest that has resurfaced is the physician’s right to own hospitals, which Section 6001 of the Affordable Care Act not only eliminated, but made it so existing physician-owned hospitals (POHs) could not expand, according to Liss. The Hospital Competition Act of 2019 was introduced to “combat the rising cost of health care by increasing choice among hospital providers,” according to AAOS. The bill also lifts restrictions on POHs, discourages hospital consolidation and certificate of need laws, expands site neutral payments and increases price transparency.

In addition, Congressman Michael C. Burgess, MD, (R-Texas), Republican leader of the Energy and Commerce Subcommittee on Health, encouraged CMS to design a Center for Medicare and Medicaid Innovation demonstration that expands access to POHs.

“Physician-owned hospitals play an important role in providing quality, efficient and cost-effective care in modern medicine. Patient care begins and ends with doctors, and no one is more aware of this fact than physicians themselves,” Burgess said, in a press release. “It is wrong that the Affordable Care Act penalizes physicians simply for the two letters behind their name. Through innovation, CMS can optimize the role of physician-owned hospitals to improve health care for American patients, restoring doctors’ liberty and expanding Americans’ access to quality care.”

The recommendation received support from more than 30 fellow members of Congress and numerous medical specialty organizations.

“There has been a long sustained effort over the past decade since the Affordable Care Act came into play to reverse that legislatively, which has not been successful,” Liss said. “Now there is a significant and likely mechanism that is going to go down in the regulatory world to do a demonstration model to show how much physician-owned hospitals saved on cost, raised the quality, raised the patient satisfaction for surgical and non-surgical care for Americans.”

Involvement at state level

Although lobbying and attending retreats in Washington, D.C., may have the biggest impact on an orthopedic surgeon’s advocacy education, Huddleston said some physicians may find it difficult to take time out of their practice to participate in such activities.

Weber encouraged orthopedic surgeons who cannot travel to connect with their state representatives at the office in their district rather than meeting with them in Washington, D.C., or to join their state orthopedic society and participate in its efforts.

“Every state has their own specific orthopedic issues related to patient care and each state is different,” Weber said. “So, [orthopedic surgeons can work] with their state orthopedic society to lobby in their state for a particular bill. It might be related to scope of practice, surprise billing, the sports medicine licensure, etc.”

PAGE BREAK

Liss said it is important for surgeons to also network with individuals in their community outside of their practice or specialty group.

“The whole point is that all the component parts are super important and if you are involved at any level anywhere along the way that is an important piece to communicate upstream, to have a voice nationally with a leadership group like what we do at the association,” Liss said.

Whether orthopedic surgeons take the time to meet with representatives at home or in Washington, D.C., Schlegel believes it is “imperative that every physician get to know their political leaders.”

“We all have busy practices and it is easy to think that your voice will not make a difference, but if we are going to support and want to have a voice in this transition from fee-for-service to value-based care, then we need to have a seat at the table. Having a seat at a table requires taking time away from your practice, but it is almost certainly time well spent given the influence we have,” Huddleston said. – by Casey Tingle

Disclosures: Liss reports he is a minority owner and board member of Physicians Care Surgical Hospital. Schlegel reports he serves as chair for the ASES Political Advocacy Committee. Weber reports she is president of AAOS. Greenwald and Huddleston report no relevant financial disclosures.

Click here to read the Point/Counter, "Should physician advocacy be a core component of medical professionalism."