December 2003 Bulletin

Fall Leadership Meeting held

Health policy concerns discussed

The leadership of the orthopaedic community, including the AAOS Board of Directors, Board of Councilors (BOC) and Council of Musculoskeletal Specialty Societies (COMSS), participated in the annual AAOS Fall Leadership Meeting, which was held Oct. 2-5 in Austin, Texas. Participants explored a variety of issues, including an AAOS resolution and proposed bylaws change that will be presented to the fellowship at the 2004 Annual Meeting; political fund raising; the AAOS Medical Liability Reform Campaign; emergency coverage and the effects of EMTALA; patient safety; and stress and other health problems affecting orthopaedists and other physicians because of the changing practice environment. In addition, COMSS and BOC each met separately to discuss issues of interest to their respective groups.

AAOS resolution and proposed bylaws change
Participants reviewed a resolution from the California Orthopaedic Society calling for the AAOS to do more to encourage and support orthopaedic researchers. Participants supported many, but not all, of the points in the resolution. The recommendations have been forwarded to the Board of Directors consideration.

The orthopaedic leaders looked at a proposed bylaws change that would make the AAOS fellowship admissions process less cumbersome for applicants while protecting the AAOS’ ability to identify potential problem applicants. Most participants agreed with the proposed bylaws change. This too has been sent to the Board of Directors for comment before it is presented at the Annual Business Meeting.

In addition to this resolution and proposed bylaws change, the Board of Councilors discussed a proposed Advisory Opinion for the AAOS Board of Directors to consider. It calls for the AAOS to create a coalition to deal with the denial of payments by Medicare and other payers for implants, technology augments and instrument augments in ambulatory surgery centers. The Board of Directors will discuss this Advisory Opinion and, if it is adopted, will ask the appropriate committees and staff to implement its provisions.

Political fund raising
A professional political fund-raiser, a representative of the Democratic National Committee and a Texas State Representative held a jointly-conducted training program on raising money for candidates at home. The purpose of this session was not only to teach participants the skills involved in doing political fund raising but also to help them pass on these skills to orthopaedists in their states and communities who may be interested in political advocacy activities. Given the importance of Orthopaedic PAC activities and, especially, the current Medical Liability Reform Campaign, this session on political fund raising was timely and important.

Medical Liability Reform Campaign
Last spring, the AAOS Board of Directors committed $1 million to fight for medical liability reform at the federal and state levels. The Board also launched an ambitious fundraising campaign to obtain additional support from AAOS fellows. In the last few months, the American College of Surgeons (ACS) has joined this effort, and has also pledged a contribution of $1 million. To date, five medical societies have each committed to contributing $1 million. In addition to the ACS, these groups include: the AAOS, the American Association of Neurological Surgeons/Congress of Neurological Surgeons, the Society of Thoracic Surgeons, and the American College of Emergency Physicians. The American College of Cardiology has committed $500,000, and North American Spine Society has contributed $100,000.

Participants learned the current status of AAOS efforts to achieve medical liability reform on the state and federal levels working with other national medical specialty societies and state orthopaedic societies. Speakers described an attempt by the U.S. Senate Republican Leadership to elevate the need for medical liability reform legislation by scheduling a series of votes on incremental bills, beginning with tort reforms for obstetric services followed by protections for trauma services.

AAOS and the Alliance of Specialty Medicine (ASM), an umbrella organization representing over 170,000 physicians in the United States, joined in a letter with the American College of Obstetricians and Gynecologists, and other medical associations, thanking Senate Republican leaders for their continued attempts to highlight the medical liability crisis and urging that Congress must pass, and the President must sign legislation that will solve the crisis for all physicians and patients. The letter indicated that no one element of reform is enough to solve the enormous medical liability crisis facing America but acknowledged that medical liability reform for obstetric care is one step toward a goal of enacting national medical liability reform for all physicians and patients. AAOS and ASM representatives also met with key Senate Republican leadership and committee staff to discuss these issues.
In the meantime, the national liability reform coalition has been formalized and will be incorporated as Doctors for Medical Liability Reform (DMLR). During the next few months, the DMLR will launch a public education effort to encourage passage of medical liability reform legislation.

Emergency coverage and EMTALA
Meeting participants learned about changes to the Emergency Medical Treatment and Active Labor Act (EMTALA) and discussed how these changes will affect orthopaedic practices. As part of the changes, it is now clear that 24/7 call will not be required if hospital resources will not support it. Also, councilors learned that call at more than one hospital and elective surgery while on-call are allowed if policies exist to handle situations when the on-call physician cannot respond.

Participants looked very closely at many of the components of the EMTALA regulations. It became very clear to them that the AAOS should create on its Web site a “frequently asked questions” section on this issue. Participants will be asked to help create this section by submitting questions on EMTALA to AAOS staff. Staff will then post these questions with answers on the AAOS Web site, likely in the Health Policy section. The goal is to complete the project by the end of the year.

Influencing Medicare fees for orthopaedic services
Tye Ouzounian, MD, chair of the AAOS Health Care Financing Committee, spoke about how the orthopaedic community is able to influence Medicare regarding fees for individual services. This influence comes through the AMA/Specialty Society Relative Value Update Committee (RUC), of which the AAOS is a member. The RUC serves as Medicare’s main advisory body on Medicare relative value units.

When new CPT codes are created or established codes are changed, the RUC, through survey research, develops recommendations on what the relative value units should be for these codes. More often than not, Medicare adopts these recommendations. Dr. Ouzounian stressed the importance of having orthopaedists involved in this survey research. From time-to-time throughout the year, AAOS fellows and members of other orthopaedic associations are asked to complete surveys based on their clinical experiences. Dr. Ouzounian asked participants to carry the message back to their constituents that it is vitally important that orthopaedists fill out these surveys when called upon.

Patient safety
Participants discussed two issues relating to patient safety — how to deliver bad news to patients and the importance of having a pre-surgical checklist and debriefing after the surgery. A representative of the Bayer Institute for Health Care Communications, Frederick Platt, MD, discussed techniques for talking to patients before the procedure about unexpected outcomes as well as what they (the patients) can expect from the surgery. He stressed the importance of having this type of discussion first in anticipation of the possibility that the expectations of the patient and/or physician for the procedure are not met. The Bayer representative also talked about how to give bad news to patients in a way that is honest, empathetic and not defensive on the part of the physician.

Lawrence Brenner, JD, an attorney and editor of the AAOS publication, Orthopaedic Medical-Legal Advisor, and his colleague, Sal Fascina, MD, who is also an attorney, discussed how to talk to patients in ways that make them feel that they are part of the decision-making process and are being treated with honesty and intelligence. Handled correctly, these types of discussions can, in turn, lead to more realistic expectations regarding the outcomes of the procedure and less risk of being sued if the expectations are not fully met or there is an error.

Spence Byrum, a pilot and vice-president of Crew Training International, drew parallels between aviation and medicine, especially in the operating room. He discussed the need for checklists at the beginning and end of surgery to make sure everything is in order and has been accomplished. He also stressed the importance of a surgical team debriefing session after the operation to find out what went right and what may possibly have gone wrong in an effort to learn from the case and become a closer-knit team.

Stress and other health problems faced by physicians
Wayne Sotile, MD, a consultant on physician stress issues, discussed the problems orthopaedists, other physicians and their families are now facing because of the changing health care environment. Dr. Sotile cited statistics showing that physicians, especially surgeons, are becoming increasingly dissatisfied with their careers and there is much more “burnout” among younger physicians than in the past. Much of this has to do with the decreases in reimbursements that are forcing physicians to work much harder and longer for the same income. The growth in government and payer regulations and paperwork, which is giving doctors less control over their environments, is causing stress. There is more competition among physicians and less collegiality, which are also contributing stress factors.

John Jackson, MD, of the Texas Medical Association, described his organization’s program to help Texas physicians cope with stress. He also talked about his association’s efforts to help Texas physicians who have substance abuse problems. Meeting participants felt that these problems are on the rise among orthopaedists and that, perhaps, the orthopaedic community should look at ways to address them, using the Texas Medical Association model among others.

COMSS meeting
COMSS members voted to invite the Society of Military Orthopaedic Surgeons to join the Council and discussed the societies’ funding an additional staff person in the Washington office. This staff person would work on regulatory issues.

David Lewallen, MD, COMSS Chair, also led the society representatives in a discussion focusing on the development of an ideal comprehensive educational package jointly ventured by the specialty societies and the AAOS. .

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