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New year brings a call for physician-based leadership in health care reform
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As we begin 2015, the turmoil in health care delivery is greater than it has ever been. It is the number one social and economic problem facing Americans. The inability to afford health care affects everyone from the tax dollars used to pay for uninsured patients to employees who cannot afford high deductible plans, or to the political landscape that resulted in the Affordable Care Act and its subsequent significant changes.
The method of health care delivery in the United States is the most expensive in the world, exceeding $2 trillion annually. With more than $30 trillion of unfunded Medicare obligations, health care is a leading driver of the national debt. The average spending on health care per capita in the United States is more than double other developed countries, yet we are not even in the top 20 in the value of health care by most standards.
Cost of health care
While health care costs continue to increase at double-digit rates, income increases are at low single-digit rates. The average family pays more than $15,000 per year for employer-sponsored coverage. Sadly, medical debt can destroy the lives of individuals and families every day. It is estimated that three of five personal bankruptcies occur as a last resort after their savings are spent, credit cards are at their limit and homes have been refinanced, and yet, medical bills cannot be paid. This is not just affecting patients who live at or below the poverty level, as more than 70% of uninsured or poorly insured Americans are people with incomes less than $92,200.
We must accept that the health care reform is going to continue at a rapid pace, with significant implications in how we practice medicine, and more specifically, orthopedic surgery. The burden of musculoskeletal disease in the United States is staggering, with more than 100 million adults having a musculoskeletal condition that lasts 3 months or longer during the past year — nearly 2 times the number of any other medical condition.
Anthony A. Romeo
A decade ago, the cost of treatment for musculoskeletal disease and the indirect costs related to lost wages was estimated to be close to 8% of the gross domestic product (GDP). With more than 70% of orthopedic surgeons in private practice, the majority of health care dollars are administrated in a fee-for-service system, incentivized by the high cost of procedural care not held in check by value-driven metrics as defined by patient-based benefits divided by cost.
As costs continue to rapidly escalate and without a clear improvement in benefit, the value is reduced. For example, more than 1 million patients will undergo a joint replacement procedure in 2015. Many patients will have their lives changed for the better with reduced pain, better mobility and improved quality of life. However, the overall cost for procedures is increasing, which is often related to new technology and innovation for implants proposed as solutions to recognized deficiencies in surgical care. As we have learned from recent metal-on-metal systems, new ideas do not always stand the test of time and can fail to match older, less expensive, yet proven systems with long-term follow-up. The potential value of new procedures is significantly reduced with higher revision rates and other unexpected complications. This either directly or indirectly challenges us to be involved in these important patient care decisions, especially with the various motivations of the other stakeholders participating in the process.
Key issues
In the larger context of the delivery of musculoskeletal care, key issues remain at the forefront of the discussion. Reformation of health care includes methods to reduce what has been termed “unnecessary care” due to lack of a clear benefit, patient safety or avoiding harm to patients, more cost-effective strategies to pay for health care as opposed to fee-for-service, and the lack of transparency among all health care providers and insurers. Many changes have already occurred, but we can expect more in 2015 and 2016 as the political climate becomes more tumultuous and health care expenses continue to spiral out of control with expenditures threatening to reach 20% of the GDP. It has been estimated that up to one third, or more than $700 billion annually, is spent on health care that does not improve outcomes.
Be a part of the reform process
As physicians and orthopedic surgeons, we are uniquely qualified to be a part of the reform process. In fact, we are uniquely qualified to be leaders of the process, especially as it relates to musculoskeletal care.
Most of us chose this profession because it offered us an opportunity to blend intellectual curiosities and talents in a way to help other people. Through many educational venues and experiences, we completed our residency, often proceeded to a 1-year fellowship, and then found an environment to practice what we had learned.
Remarkably, positions of leadership and authority also became part of our lives, whether it was working in an academic program or leading a surgical department or even an entire institution. It is interesting to note that the top five U.S. News and World Report orthopedic hospitals are run by physicians, and some of the most innovative and future-thinking organizations were established by physicians and continue to be led by physicians. More orthopedic surgeons are being asked to or seek to fulfill leadership positions in the delivery of health care at all levels, providing a direct impact on how health care reform affects institutions and practices. These orthopedic surgeons have a unique perspective on understanding the value of care and how to define its benefits. They can also add their voice to other critical areas, such as defining unnecessary care, excessive costs of care and technology, and the development of payment methods not based solely on the number of procedures performed.
Physician-based leadership is critical
Physician-based leadership in health care is critical. We need to make an effort to participate in the reformation of the system or we risk sitting on the sidelines hoping interest groups, hospital administrators and other business people will make decisions that positively impact our professional lives. Unfortunately, this is an unreasonable position.
One of the tenets of the Affordable Care Act was the development of accountable care organizations (ACOs). Initially, there was skepticism among policymakers that physician-only ACOs could provide appropriate care and generate cost-savings. Therefore, hospitals started the ACO process. A few years later, the majority of successful ACOs have physician leadership. Furthermore, as insurance negotiations and other contracts have become more physician-led, it has been revealed that many hospitals have benefitted from a lack of transparency and the creative cost-accounting that has shifted health care dollars away from patient care and toward administration.
It is no surprise that the administrative costs of health care in the United States is more than double any other developed nation and has outpaced reimbursement for physicians by double-digit numbers. Other sectors of health care that have seen the income growth include pharmaceutical companies, health care insurance companies and orthopedic implant companies, but not physicians.
Leadership comes in many forms
Leadership can come in many forms. For many orthopedic surgeons, it seems to come innately, developed from years as a leader in sports or academic environments, or as a personal gift. It is an intrinsic quality driven by personal motivations. The motivations can include the desire to be able to make their own personal decisions, the desire to be successful or achieve excellence, and a sense of purpose in life. This is not a management skill, which is often focused on external factors, such as finances or specific data-driven goals.
To some degree, we want leaders to be a reflection of ourselves so that the decisions they make and the impact these decisions have on our lives is the same as if we were part of the process. More than any other time during our practice of medicine, now is the time for all orthopedic surgeons to get involved. A patient-centric and purpose-driven voice can impact the dramatic changes in health care that are already in motion. There are numerous resources available to practicing orthopedic surgeons to help guide and develop leadership skills, including orthopedic society programs, the American Orthopaedic Association Leadership Emersion Series and academically based, short-term programs at leading colleges and universities.
The next few years will dramatically shape the way we practice orthopedics for the remainder of our careers. We need to be personally involved, provide inspiration for others and lead the inevitable changes if we want to continue to provide the highest level of musculoskeletal care that patients desire.
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: orthopedics@healio.com.
Disclosures: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.