Orthopedic surgeons: Trends and changes for 2010

Douglas W. Jackson

Let me start my first column of 2010 by wishing you, your loved ones and your current and future patients a wonderful and successful New Year. As we start this year, we continue to share a common blessing: We are members of a great vocation and, for many of us, an avocation. One thing we know is that being an orthopedic surgeon in 2010 will continue to be personally and professionally rewarding.

Looking forward to the New Year, I see some of the trends that have been developing being further defined. Regardless of the type of practice environment in which we work in 2010, the changes that lie ahead may require adjustments on our part. Some of us will be affected more than others, and some may see minimal changes in their practice style. I am listing some of the areas I feel may be impacted and/or change as health care reform progresses.

Patients

Interacting with and helping patients were the reasons we chose our careers in medicine. Many patients have told me they are concerned and fearful of what will happen if the health care changes that are being debated in Washington become reality. Their concern is warranted because many of the proposed changes and trends that may occur in 2010 will impact them — they may see effects on their insurance; many will remain out of work and others will face losing their jobs; and some will see their COBRA coverage run out and face increased financial hardships. As a result, many will be forced to change their coverage, deal with increasing co-pays and have further loss of control over some of the major decisions in their health care.

At some point, the threat of losing their choice in medical care will lead many people to believe that enough is enough and finally speak out politically and communicate their uneasiness through their votes. Americans have a history of wanting choice and have resented being told what doctor, procedures or drugs are available to them.

The public will realize that much of this health care cost-accounting for the future is a shell game. The subsidized lower premiums and other cost-shifted expenses will be funded by them through tax revenues. Hopefully, patients will hold the responsible politicians accountable in 2010.

Escalating health care costs

Providing more high-quality medical care for longer periods of time to an aging population will be a major challenge for our society. The additional funding for caring for the aging baby boomers while extending coverage to the uninsured will challenge the limits for our capacity to fund uncontrolled utilization of medical care. The tough choices that will be required to gain control on our escalating health care costs will be beyond the ability of the U.S. Congress. They will continue to avoid and defer the hard issues and changes that will be necessary to get meaningful reform. The existing system, Medicare, is currently out of fiscal control and not solvent for the long term.

Public policy will have to change to address these current funding problems. The ethical issues involved in rationing health care will probably not be addressed in 2010, but will be delayed until funds are almost gone. Hopefully, in 2010 the borrowing from future generations and taxing the affluent will be seen as not sustainable. The costs of our escalating health care need to be addressed directly, not by shuffling around the numbers.

Mandates and compliance

Mandates and regulations requiring our compliance will cover a broad scope of issues, including: infection-control compliance, implementing electronic medical records (EMRs), HIPAA adherence and decreasing reimbursements. In 2010, regulators will move toward the need for critical oversight. If we are not involved in meaningful and leadership roles, these will be performed by panels of academics, politicians, insurers and other non-physicians.

Practicing physicians have forfeited many of the oversight roles in the writing, reviewing and editing of the science on which the bench marks and guidelines for many compliance standards are being based. I will address this topic in future columns this year, and Orthopedics Today will include coverage of pertinent articles and discussions both inside and outside the orthopedic community.

Be aware that much of the effort to reduce reimbursement will be done under the guise of eliminating “waste” in health care. The New England Healthcare Institute has defined waste in health care as, “Healthcare spending that can be eliminated without reducing the quality of care.” How this waste will be defined and enforced will begin to be addressed and implemented in 2010.

Survival of private practice

Private practice will continue to do well in 2010 for most orthopedic surgeons. However, the survival of private practice will remain to be challenged more than any time before in my career. We will see increases in consolidations (foundations), mergers and implementations of innovative business models. These changing practice profiles will be done to maintain and possibly increase market share, bargaining power and leverage with insurers, and potentially maximize efficiencies. The bottom line will be the margin for private practice, and it will be challenged by further cuts in reimbursement by governmental agencies, which will undoubtedly be followed by private payers. We are at the point where downsizing and “doing more with less” is not a long-term answer. Seeing greater volumes is not a desired solution: Working smarter has limits.

Frustration can overwhelm the desire to be in the private practice of orthopedics, and the option to let others run our businesses may become more attractive in 2010. This will lead to an increased number of physicians willing to work as salaried employees. As long as there are viable private practices, salaried physicians will have some degree of bargaining power. But this will be threatened by more of our younger colleagues who would rather be sheltered from the burden of the risks and uncertainties of the business of medicine.

In this New Year, we should remember the words of Sister Irene Kraus of the Daughters of Charity, who ran a 49-hospital system: “No margin, no mission.” Hospital administrators, even of a higher calling, need some profit to survive. Those in private practice will continue to look at their margins more closely.

Data management

Medicine and physicians have entered the information age: some by choice and some by force. This will occur even if we have to financially subsidize most of it with little or negative return on our investments. Those with fewer than 10 years left to practice may never regain the costs of implementation of the eventually required EMR applications. Adding to those costs will be the time and frustration of choosing and implementing a system — which must be approved and used in an, hereto undefined, “meaningful way” to get the promised tax cut that falls short of covering the expense.

Widespread use of the Internet and information technologies is evolving and electronic records are the product. Data are essential to help evaluate care and outcomes, as well as establish and modify benchmarks. Just remember as you go through the conversions, these systems have not been documented to improve the quality of care, nor may they be the most cost-effective solution.

In 2010, hospitals will continue to gain control and influence in health care delivery systems. We will see increasing numbers of salaried physicians working for or in conjunction with hospitals in nonprofit foundations or for-profit models. These new incentive models for physicians will eventually see the greatest profits derived from the systems spending less and/or rationing care, all the while claiming to offer improved quality.

As health care costs continue to increase, driven by inflation and volume demand, policymakers will consider further limits on reimbursement rates for doctors and hospitals, as well as technologies to reduce costs in the long term. The voluntary pay-for-performance programs will continue to become more compulsorily with the passage of time.

Younger MDs

The next generation of physicians has different lifestyle expectations and beliefs about the hours they should work. They desire a better quality of life outside of their profession. In addition to not wanting to take on the uncertainties of small business (private practice) ownership, there will be increased attempts to train younger physicians to work under the concept of a physician’s responsibility to society — a new interpretation and addition to the Hippocratic Oath. This challenges the concept of caring for a patient without considering costs and opens the door for increased attempts to control our medical decision-making process.

The team model

In 2010, physician assistants, nurses and technicians will continue to play an increasing role in health care delivery. California’s legislation that sets mandatory staffing ratio of nurses to patients is an example of the increasing influence of lobbying groups and political support. We have a relative nursing shortage now and as more states consider similar legislation, nurses will command increasing roles in health care delivery. There are already deep fissures within the medical and nursing community whether such laws are necessary or even harmful to the system’s flexibility in caring for patients.

These trends and changes I am discussing usually come slower than we often fear and hopefully will be modified and redirected as they play out. I am in this with you and will continue to write my thoughts in 2010. Let us all make the most of this New Year. We will continue to place our patients first while we listen to and participate in the dialogue of health care reform.