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Prioritize efforts to develop a patient- and physician-centric solution to health care reform
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As we go to press with the November issue of Orthopedics Today, the United States is in the final 2 weeks of a presidential campaign that has been unlike previous races. There has been an unprecedented effort from both political parties to damage the reputation and qualifications of the two major candidates. Their abilities to make decisions about key issues facing the country has been challenged in every way possible, including professional and personal errors in judgement, with some bordering on potential criminal activity.
For many Americans, the decision was not about who they wanted, but rather who they did not want to lead the United States. In addition, more Americans now express the need for a third political party. In a recent Gallup poll, 58% of Americans suggested a third political party is necessary. However, incredible barriers have prevented a third political party from having any major impact on presidential elections.
At the end of this long presidential campaign, Americans will have elected a new president — a decision that is in place for the next 4 years.
Anthony A. Romeo
Health care delivery
While there are many areas to analyze and debate, decisions related to health care delivery are likely to have the greatest impact on how orthopedic surgeons manage their professional and personal lives. The candidates and their respective parties have offered two distinct platforms for continued health care reform. President Obama has had tremendous influence during this process, as evidenced with the Affordable Care Act (ACA) which was enacted in 2010. However, the legislature plays an important role as well. Since 2014, both the U.S. House of Representatives and U.S. Senate have had a Republican majority, although this may change in the Senate after this year’s election. Therefore, final decisions regarding health care are difficult to predict, but President Obama’s success in 2010 suggests the incoming president can reform health care more along his or her party’s platform.
Secretary Hillary Clinton is no stranger to U.S. health care policy. When her husband appointed her in charge of the Task Force for Health Care Reform in 1993, a plan was established that was named the Health Security Act. The key component was to provide universal health care to Americans. It was heavily based on a mandate for employers to provide health insurance coverage to all employees. However, many influential Democratic and Republican leaders, as well as the health insurance industry, were highly critical of the proposal and the bill died in 1994. It is interesting to note that Clinton appointed a committee of experts that included representatives from many different areas of health care, but not one physician was selected for the process. Hopefully, this process provided her with experience and perspective that will encourage a higher level of physician involvement for future efforts. In the broadest terms, she has planned to maintain and build upon the provisions in the ACA.
Donald Trump has no past government experience in health care reform. However, he has said he plans to work with a Republican-led Congress to repeal the ACA. This would affect many programs either new to the ACA or further supported by the ACA, including the Medicaid coverage and insurance marketplaces, Medicare coverage and women’s health services. Alternatively, Trump has said he would allow a more competitive marketplace for insurances, allowing people to buy health insurance across state lines and allow payments toward health care premiums to be tax deductible. The Trump plan has been criticized for the risk of dramatically increasing the number of uninsured people in the United States, after the ACA has reduced the number to less than 10% of the population. However, only 17 states set up marketplaces for health insurance and some health insurance companies have pulled out of the process due to lack of profits, creating concerns the ACA is not sustainable.
Other areas of comparison include out-of-pocket costs. Clinton wants to provide free sick visits every year, a refundable tax credit, in-network only cost sharing for facilities and better transparency for out-of-pocket costs from providers, prescription drugs and health care facilities. Trump wants to focus on tax-free health savings accounts and better price transparency across health care.
Clinton has stated provisions for covering immigrants, including undocumented and illegal immigrants. She also wants to expand Medicare, allowing people to buy in as early as age 55 years. Trump has acknowledged the current Medicare program may be unsustainable, but has not proposed any substantial changes. Medicare spending is now more than $600 billion per year, which is more than 5% of the gross domestic product and will potentially double in the next 10 years.
Health care affected by politics
Based on these broad concepts and the market forces that influence health care beyond politics, some areas of orthopedic surgery will be affected by the health care policies of our new president. First, it is highly unlikely the ACA will be repealed any time soon. Therefore, we can anticipate approximately 10% of the population will remain uninsured, which is a substantial decrease from 2010. This should help ensure some revenue can be expected from this patient population.
Second, the ever-increasing mandated burden to provide data to third parties involved in the payment for health care services has led to a tremendous increase in the cost for electronic medical record systems and the personnel required to acquire, process and provide the data to the government and other third-party payers. It has been estimated that physicians are paying more than $30,000 per year to fulfill these requirements, which often takes them more than 10 hours or more per week to complete the forms and documents.
These challenges, as well as increasing provider networks and institutional networks, has led to more orthopedic surgeons choosing to be employed, especially for those younger than 45 years. However, private practice is not dead, with more than 60% of currently practicing orthopedic surgeons in a private practice model. There is likely to be a gradual shift toward more employed physicians as the administrative and information technology burden continues, but balanced by the vertical integration and sophisticated business practices that leading private practice orthopedic groups have developed during the past 2 decades. Orthopedic surgeon leadership involvement in this area is essential.
Third, there is a tremendous shift toward outpatient orthopedic care. This is not being driven by orthopedic institutional or society leadership, but rather by the value-based proposition that if quality of care is equal and the cost is 30% to 50% less that of inpatient care, then the overall value is dramatically increased. Therefore, private practice orthopedic groups, the ambulatory surgery center industry and forward-thinking institutions and physicians are meeting and negotiating directly with insurance companies, employers and others responsible for the payment of health care to shift traditionally inpatient-only procedures, such as joint replacement, spinal decompressions and spinal fusions, into the outpatient setting. This is also appealing to the government, including both political parties, and therefore changes in CMS guidelines on inpatient-only procedure restrictions are on the horizon no matter who becomes president.
Value-based health care initiatives
Value-based health care initiatives that are challenging orthopedic surgeons with documenting performance measures, as well as the movement to outpatient care and care vertically controlled by practices or institutions, will further push the agenda of mandated alternative payment model programs, such as bundled care. The early phases of this process have demonstrated shared risk and the potential for decrease reimbursement will have an impact on orthopedic care. Practices and institutions that cannot fully integrate their services or efficiencies of providing care will lose revenue. However, the purpose of the program is to weed out those who cannot provide quality care at a reasonable cost.
No matter who is in the White House, these programs or some form of the programs are here to stay. Our efforts should include a role in the political process at both the state and federal government level to ensure the rules, regulations and laws provide a sustainable model for physician leadership. Without question, political decisions in the past have leaned toward hospitals, academic institutions and insurance companies without considering the possibility that those tasked with delivering health care may have the best ideas and solutions to health care reform.
Plan an active roll
The presidential election may be over, but the negative impact of this year’s race on leadership will be present for years to come. Decreasing respect among politicians in the United States, not to mention other world leaders, will undermine our president’s ability to lead the country’s health care reform. Many who have battled to elect their candidate to the presidency or another level of government will feel as if the fight is over until the new presidential cycle begins.
However, when leadership is fractured or ineffective, it becomes more important for the constituency to play an active role in the process of government and stewardship. Therefore, it is imperative we continue to focus and prioritize our efforts in government and leadership. Instead of offering a politically based solution, we need to provide a patient-centric, physician-centric solution to health care reform.
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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: orthopedics@healio.com.
Disclosures: Romeo reports he receives royalties, is on the speaker’s 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.