The Most Important Thing You Can Do

A young woman, like roughly a hundred thousand other patients before her and like another hundred thousand patients after her, wiggled her toes one last time before going under the knife five years ago. At 23 years old, she was young—as we can attest using our PearlDiver Patient Records Database—for tumor removal from her spine.

She knew, because her surgeon at Denver Spine told her, that paralysis was a possible outcome of the surgery. 

Her next toe wiggle was four hours later and that became a toe wag and big-ass smile.

Last weekend she completed a 10-mile marathon run in Philadelphia and then shot an email to her surgeon saying, for the umpteenth time, thanks.

Dr. Richardson wrapping Spec. Koll’s leg in Iraq
Courtesy NBC News This is not a unique story. As a journalist and publisher I collect them. Here’s one more. Iraq. Roadside bomb. Two young U.S. Marines die. One survivor is ripped up pretty badly. Dr. Mark Richardson from San Antonio, who has volunteered for his second tour and is on duty at the combat support hospital just outside of Baghdad, gets to work on the young soldier. He talks to him as he works, stabilizes him, wraps him up and in a matter of minutes has him in a helicopter to Ramstein Air Force Base in Germany. More orthopedic teams in Germany and at Walter Reed put Specialist Evan Koll of Traverse City, Michigan, back together. A camera crew for NBC captures those urgent first moments when Dr. Richardson is working on his patient. That film wins AAOS’ MORE Award for 2008. Last week, for the first time since 2007, Spec. Koll and Dr. Richardson met again at an AAOS sponsored event in Washington, D.C. Spec. Koll walked up to Dr. Richardson with a slight limp and a cane. Their eyes were dry but many others at the award ceremony were not.

One more story (courtesy of NPR). Another young man dies in the service of his country. He was Marine First Lt. Nathan Krissoff of Reno, Nevada—a pianist, captain of his college swim team, violinist, and Marine. His brother is also serving as a Marine. His father is William Krissoff, M.D., a 63-year-old orthopedic surgeon. Just weeks after his son was lost in Iraq in 2006, Dr. Krissoff decided to volunteer to serve on the front lines in Iraq.  With dispensation from the White House, his request was granted. As I write this sentence, Lt. Commander Krissoff is serving in Anbar province, Iraq, patching up soldiers and civilians. 

Dr. Bill Krissoff (right) enlisted in the Navy Medical
Corps as a way to honor his son, First Lt. Nathan
Krissoff (second from right), who was killed in Iraq.Every hospital and every surgeon has stories like this to tell. But, not everyone knows that this is essence and ethos of our industry.  I’ve said it many, many times. What we are as an industry comes from the basic patient–physician interaction. From that point, we all start off playing our parts as suppliers, journalists, nurses, techs, administrators, and so forth.

Why am I rambling on like this? Because it is time for more of these stories to emerge and be told—publically, loudly and repeatedly. 

For the 12th year in a row, Medicare is proposing to cut surgeon reimbursement. For the umpteenth time, The New York Times last week ran a negative and factually challenged article about surgeons, companies and that pitiable $238, 000 fine that Synthes paid for miss-categorizing a couple forms for the FDA. It is time we responded.

The Million Dollar Question

So, the million dollar question is this: What is your specialty society doing to tell your story, to represent your interests as a surgeon and, more broadly, the interests of your specialty right now? In Washington. Is your specialty society championing you and your practice?

No?

Then pay attention to what AAOS is doing because it is fighting the good fight.

On March 18–19, AAOS organized a lobbying effort of more than 70 orthopedic patients, surgeons and researchers who met with U.S. senators and representatives to personally advocate for the future of musculoskeletal care and to stress the critical need for more funding for orthopedic maladies.

Participants at the AAOS 2008 Research Capitol Hill Days event.

Medicare Surgeon Compensation

Recently we read the following comment from an orthopedic surgeon:

“Medicare’s physician payments have been spiraling downward since the 1990s. A recent Texas public survey concludes the reasonable surgeon fee for total knee replacement is $5, 000. In Arizona in 2008 the exact Medicare-allowed surgeon payment is $1, 412 (this is a ‘global fee’ and includes day of surgery, hospital rounds, and all treatment for 90 days after surgery). This rock-bottom reimbursement schedule has many orthopedic surgeons, including me, contemplating dropping Medicare from their practices. This is a direction I am reluctant to take. I do not want to restrict needed care for ‘America’s Greatest Generation.’

“The current Medicare fee schedule fails to provide a high enough level of reimbursement for any orthopedist to run a financially successful practice. In reality, the Medicare segment of my practice is subsidized by having other payer sources. Deeper cuts in Medicare physician payment are on the near horizon. When these cuts occur, physicians will take ‘evasive’ action. Medicare is an all or none system. Doctors are either on the plan and accept Medicare rates or are off the plan and charge patients “market rates” that can be modified based on the patient’s ability to pay.” – Dr. Stefan D. Tarlow, M.D.

Demand for large joint replacement is expected to grow by 174% (hips) and 673% (knees) by 2030. According to the AAOS, physician payments are scheduled to be cut 40% from 2001 in the meantime.

The message from Medicare to the surgical community is unmistakable. Hopefully, as has happened in past years, congressional action will forestall these new proposed cuts. 

But that doesn’t fix the problem.

The U.S. is facing a growing shortage of orthopedic surgeons at the very time that this country’s boomer population is entering the Medicare rolls. 

If physicians begin to opt out of Medicare, who will take care of the flood of new patients? According to AAOS, the number of orthopedic surgeons per 100, 000 citizens has grown at an average rate of only 1.1% annually in the decade ending 2004. In the 2007–2008 fellowship year, 38% of the U.S. total joint replacement fellowships went unfilled!

Furthermore, 53% of all orthopedic surgeons are age 50 or more. The mean retirement age for most surgeons is 59. 

From 1992–2007 Medicare CUT orthopedic surgeon pay by 28% for the 25 most commonly performed procedures. Total joint surgeons were hit the hardest and experienced cuts of 42%–45%.

How have surgeons responded? You might be surprised. 

Between 1987 and 2006, Medicare fees for total hip replacement were cut 69%. But services per 1, 000 patients increased 60%.

For total knee replacements, fees dropped 66% but services increased 283% (all data is courtesy of the crack research department at AAOS).

We are reaching a breaking point. 

Medicare’s pattern of annually seeking to cut physician pay is driving orthopedic surgeons away from the Medicare system. 

Return on Investment

According to The Burden of Musculoskeletal Diseases in the United States (White Paper available from AAOS, February 2008), “In 2004, health care costs and lost wages for persons with a (bone/joint) disease diagnosis have been estimated to be $849 billion, or 7.7% of the gross domestic product.” Of that total, lost wages were $339 billion. In terms of lost tax revenue to the federal government, that was $17 billion in lost Medicare payments and $42.4 billion in lost tax revenue for a total of at least $50 billion of lost federal revenue.

If, for 2010, Medicare decided to DOUBLE the physician reimbursement for a large joint replacement from roughly $1, 400 to $2, 800, it would increase Medicare’s budget by less than $1 billion ($0.8 billion to be exact). 

Yes, the number of surgeons willing to take on Medicare patients would stabilize, maybe even rise. 

Yes, the number of patients served would increase.

But, the return on investment as measured by increased wages, higher tax revenues, stabilized surgeon satisfaction, and superior patient outcomes would be…priceless. 

The most important thing surgeons, nurses and all other health professionals can do is share their stories with their elected representatives even as, we fear, Medicare is gearing up to try to cut reimbursement for physicians again.