Kenneth E DeHaven, MD

There are many reasons for us to be concerned about changes in health care and how they are affecting us. At the federal level we have the impending Medicare and Medicaid reforms, proposed cuts in funding for research and graduate medical education, and continuing regulatory constraints from the FTC, the FDA, and the Health Care Finance Administration. State and local concerns center on the continuing growth and evolution of managed care, and the local consequences of Medicare and Medicaid reforms. These are having significant impact on our ability to deliver quality care because of the over-riding focus on the "bottom line", the loss of physician control of clinical decision making, limitations in access of patients to our care, and indeed the viability of our practices and our specialty.

These concerns are becoming so overwhelming that there seems to be a growing sense of despair that there is little, if anything, we as individuals or an Academy can do about it. The changes are being cost-driven by forces of immense power-federal and state governments and big business. Individual Orthopaedists are vulnerable if they attempt to directly address problems associated with managed care. We have concerns that too many Orthopaedists are being produced, but anti-trust laws and the FTC limit our ability to act as groups of individuals or as an organization. Finally, federal and state legislators have little or no interest in what we think because they see us as being self-serving and merely trying to preserve our incomes.

Certainly there are reasons for concern, but I do not believe there is reason for despair. There ARE things that can be done that can make a difference. Before turning to some of the things that we can do, I want to first emphasize a few things that have not changed. First we must remain dedicated to keeping the needs of our patients our highest priority. Second, we also need to remember that we possess great expertise in the care of the musculoskeletal system, and while others also treat these problems, many of the things we do are not done by anyone else. Finally, we need to remember that we belong to one of the premier organizations in medicine that remains committed to serving our patients and our membership.

Along those lines, I want to be sure you are aware that your Academy has been working hard to enhance it's ability to serve. Over the last two years we have increased our commitment to the strategic planning process which articulates what we stand for and what we are committed to strive to accomplish. I want to emphasize that it is not my plan, the Presidential line's plan, or even the Board of Directors' plan. It is truly the Academy's plan.

Initially drafted by the Board of Directors, the Council Chairs and senior staff each year at our March workshop, it then goes out for review by the three Councils, the Board of Councilors, the Council of Musculoskeletal Specialty Societies, and the Fellowship at large before being adopted and prioritized. If and when we have to make difficult choices between desirable programs, our prioritized Strategic Plan allows us to be sure that our financial and human resources are being applied to the programs and initiatives we believe are most important.

In addition, the Presidential line has an ongoing, strong commitment to the concept of continuity of leadership. We realize that few worthwhile projects can be conceived, developed, and executed in the short span of one year, and have buried the old tradition of one year presidential agendas. Instead, all three presidents now fully participate in the planning and implementation discussions which feed into the Strategic Planning process. This helps assure a smooth transition from year to year without abrupt and disruptive changes in direction for the Academy which could be particularly disastrous in these perilous times.

Third, over the past three years we have strengthened our financial position through a major fiscal responsibility initiative which enhanced revenues while reducing costs throughout the Academy, and has resulted in a swing of nearly 3 million dollars in the bottom line. This was not done to increase our reserves, but to provide more resources to apply to the programs and initiatives which support our strategic priorities.

Now I want to single out four things that we can do to make a difference. First and foremost is education, which, quoting from the Strategic Plan, "remains the fundamental endeavor of the Academy which allows us to deliver the highest quality, cost effective patient care and to advance the profession". Our ability to provide this level of care is crucial to our individual and collective professional success and legitimacy. Each one of us must remain committed to our own continuing education. For the Academy, education continues to dominate our strategic priorities, as 10 of the top 29 objectives in the new Strategic Plan relate to educational initiatives. The Council of Education and it's committees will be continuing to offer outstanding educational opportunities to upgrade our clinical skills, and help us keep abreast of practice management issues as things continue to evolve.

The second thing we can do is better document the quality and value of our services. While virtually all health plans and employers speak about the importance of maintaining quality, it's no secret that the changes which have been occurring in both private and public sectors are cost-driven, and the issue of quality is being given only lip service before being written off as too difficult to define and measure. We need to get quality back on center stage, and we are rapidly developing the ability to do just that.

The Committee on Outcomes Studies, lead by Bob Keller, has given the Academy a long standing interest in the emerging field of patient oriented outcomes research. While monitoring the increasing need for valid data of this type, it became clear that we were hampered by the fact that few outcomes instruments existed that addressed musculoskeletal conditions, and the few that were available were not practical for the office setting. In addition, we also realized that measuring outcomes of care with valid instruments before and after treatment, known as outcomes assessment, could be utilized to provide valid data without the necessity of waiting for formal outcomes research studies to be completed.

Two and one-half years ago these factors triggered our commitment to an ambitious Academy Outcomes program. First in collaboration with several of the COMSS Specialty Societies, we have developed and extensively tested four generic musculoskeletal outcomes instruments-one each for upper extremity, lower extremity, spine and pediatric problems. Only sensitivity testing remains to be completed.

Second, last year an Academy Task Force chaired by Jody Buckwalter began development of an Outcomes Data Management Program. A pilot study just completed has documented that it is feasible to use these instruments in a wide variety of practice settings, and to successfully transmit data to a central data base.

I am pleased to announce that draft versions of our four instruments are now available for general use so we all can begin measuring quality in our daily practices. At the same time I want to emphasize that we realize it is no longer enough to consider quality in isolation. It is also necessary to take into account the costs associated with providing that care. In the coming year our Data Management program will also begin to collect cost data and will be expanding it's capacity so additional practices will be able to participate.

By next year's annual meeting we fully expect to have completed the testing of the instruments and have in place an operational Outcomes Data Management system capable of linking quality and costs in individual episodes of care, which will then allow us to document the value of our services. This critically important information is needed to support our individual practices and our specialty. It will substantiate our successes with valid data, and will also provide the basis for making any changes necessary to improve the quality and cost-effectiveness of the care we provide. At the same time, it will also enhance our ability to negotiate individually with insurance companies.

The third thing we can do to make a difference is to maintain and enhance our public education and advocacy program. Over the past 2 years Nick Cavarocchi and our Washington office have been instrumental in putting together the Access to Specialty Care Coalition, which currently includes 119 members--55 professional organizations and 40 patient organizations. The coalition is a voice which is being heard in Washington and is continuing to press Congress to include its major points in Medicare and Medicaid reform legislation. Over the past year we have also worked with State Orthopaedic Societies to develop similar coalitions to more effectively address these issues at the state level. So far there are active or developing coalitions in 19 states.

We have learned some important lessons from these coalition efforts. First, it is possible to bring together large numbers of diverse groups and organizations around specific issues even when substantial differences exist between the various parties on other issues. We have also learned that even though we have the support of large numbers of professional organizations, and have valid messages which are in the best interests of the public, federal and state legislators pay little or no attention until we also have organizations which provide a voice of the public. Involving the public is the real key to success in influencing public policy.

Our public education and advocacy efforts are being refocused and expanded in the area of managed care. We need to acknowledge that all managed care cannot be painted with the same brush, and that we are not against managed care per se. There are instances where managed care programs are providing quality, cost-effective care, and administrators, patients and physicians are satisfied.

However, there are also onerous aspects of managed care which profoundly impact quality. Individual orthopaedic surgeons and practices are vulnerable if they attempt to address these issues because they risk being excluded from participation. This is clearly an area where the Academy can step up and provide support for our members by doing a better job of educating the public and government. Three particularly onerous aspects that need to be addressed are (1) the outrageous profits which are being taken in some plans at the expense of providing appropriate care, (2) continuing economic incentives for physicians to withhold care, and (3) provider "gag" rules. It is encouraging that the tide of opinion that managed care can do no wrong is beginning to turn, as evidenced by the increasing number of reports appearing on TV and in the print media which focus on one or more of these problems. But more needs to be done.

Through our Council of Health Policy, we are making it a high priority to delineate specific onerous aspects of managed care which are parts of some programs, and to begin collecting individual stories of patient problems which have been encountered. They will be analyzed by the Committee on Health Care Delivery and whenever the problems are due to managed care restrictions, they will be passed on to the media and position statements will be developed. These will also be available to the national and state coalitions to support their legislative efforts, and to Academy members to support negotiations with local managed care organizations.

The fourth thing we can do to make a difference is take the steps necessary to have greater influence on the future delivery of musculoskeletal health care. The important first step of analyzing the role of Orthopaedic Surgeons as providers in current health care delivery systems has been done over this past year by a work group chaired by Doug Jackson. They surveyed 28 managed care organizations which they believed were representative of the managed care model most likely to be dominant in the market place. Eleven key findings are identified in their excellent report, which Dr. Jackson briefly summarized by saying that the good news is that physicians are regaining control of patent care decisions, but the bad news is that to do it we have to change.

The major strategy to influence the future is to work with other organizations that represent physicians who provide musculoskeletal health care, reinforcing the importance of the bridge building concept articulated by Jim Strickland in his address last year. If anyone is still skeptical about reaching out to these other organizations, I would remind you that Orthopaedic Surgeons make up only 3% of the physicians in the United States, and it is estimated that only 25% of the musculoskeletal health care in the US is currently being provided by orthopaedic surgeons. Alone, we have limited clout. The goal of the bridge building effort is to jointly develop models to provide coordinated care for populations of patients with musculoskeletal problems--- models which will address patient needs, emphasize a team approach, insure physician control of clinical decision making, are of high quality, and are cost effective.

Over the past few months we have had very encouraging initial meetings with the leadership of key organizations representing family physicians, internists, pediatricians, PM & R, and emergency medicine physicians. Each of these organizations has agreed to join the Academy to form a steering committee to work towards a Musculoskeletal Summit later this year. The summit concepts are to be inclusive and to promote and develop cooperative efforts in research, outcomes studies, guidelines, education, patent care models, and advocacy. An indication of the tremendous interest out there is that 23 professional organizations have accepted our invitation to participate in a one day Forum on Musculoskeletal Outcomes in Chicago a little over a month from today.

Clearly we have an extraordinary opportunity to move beyond traditional territorialism and work towards a united house of medicine for musculoskeletal problems. Jointly developed and jointly endorsed models for delivery of health care, education, and guidelines backed up by common outcomes data reflecting both quality and costs will give us far more compelling messages for our public information and advocacy programs, and provide us far greater leverage on government and health care organizations. While we as Orthopaedists will be only one of the players within a musculoskeletal house of medicine, we do have a legitimate leadership role because of what I emphasized earlier---- we possess great expertise in care of the musculoskeletal system and do many things that are not done by anyone else. In addition, this Academy is well positioned among these other organizations since we have already developed viable programs in most of the areas which will be addressed by the group

These four things that I have chosen to emphasize today are by no means the only ones we are actively pursuing. Believe it or not, in the interest of time there are many others I have not mentioned. The message is that your Academy is not a passive bystander in all of this. We are vigorously pursuing many initiatives that have promise, and stand prepared to make every reasonable effort to influence the continuing evolution of health care in this country.

As long as we keep the needs of our patients our first priority I believe we can and will make a difference. Access to the physicians of their choice continues to be extremely important to the American public, and once quality is measured and shown to also be cost effective, I believe it will return to it's rightful place in the Health Care equation. At the same time, we have to be realistic and recognize that we cannot expect to have everything go just the way we want. Even when we are unable to have something go our way, we might well have helped prevent something even worse from happening. That, too is an accomplishment and should be recognized as such.

In closing, I return to where I began---- there are many reasons for concern, but no reason for despair. I pledge that we will continue our efforts to make a difference and urge all of you to stay with us. No matter how bleak things may appear to be, THERE ARE THINGS WE CAN DO!

Previous Page

Last modified 27/September/1996