AAOS Bulletin - December, 2005

Fall leadership meeting focuses on health policy concerns

By Susan A. Nowicki, APR

Orthopaedic leaders from across the country, including the AAOS Board of Directors (BOD), Board of Councilors (BOC) and Council of Musculoskeletal Specialty Societies (COMSS), gathered in Williamsburg, Va., Oct. 27-30, for the Fall Leadership Meeting. In addition, COMSS and the BOC each met separately to discuss issues and topics of interest to subspecialty practice and grassroots orthopaedics.


Frank B. Kelly, MD, BOC chair, welcomed new councilors to the BOC meeting and dedicated the meeting to the memory of William W. Tipton Jr., MD, former BOC chair and former AAOS executive vice president. Dr. Kelly updated his 2005 goals, including successfully achieving 100 percent councilor participation in the Orthopaedic Political Action Committee, increasing individual participation in BOC activities and improving communication efforts among the BOC and grassroots orthopaedists.

In his presentation, Michael J. Goldberg, MD, chair of the Evidence-Based Practice Committee, took a humorous, allegorical approach to explaining the rise of pay-for-performance formulas.

Under the advisory opinion process, the BOC Resolutions Committee Open Hearing approved three Advisory Opinions and eight AAOS Resolutions adopted in 2001 that are undergoing their five-year review.

Advisory Opinion #1: “Orthopaedic Device Sales Personnel Training”—The BOC recommended that the AAOS BOD “charge the Council on Education with considering a proposal to provide formal, appropriate training for orthopaedic industry sales representatives who assist orthopaedic surgeons in the operating room.”

Advisory Opinion #2: “Increasing the Effectiveness of the AAOS Expert Witness Document Clearinghouse”—The BOC recommended that the AAOS BOD “charge the Expert Witness/Professional Compliance Program with making the documents in the expert witness document clearinghouse available to fellows and members on the Internet, with a keyword search feature, and the enhancement of the program and the ability to submit additional testimony should be widely publicized to the fellowship.”

Advisory Opinion #3: “Imaging Issues and Orthopaedic Surgery”—The BOC recommended that the AAOS reaffirm its current policy of resolutely opposing any policy prohibiting orthopaedists from performing and interpreting diagnostic imaging because this interferes with the patient’s ability to receive optimal care; and that the AAOS continue to support and be an active participant in the Intersocietal Commission for the Accreditation of Magnetic Resonance and CT Laboratories.

The BOC comments were forwarded to the AAOS BOD for consideration at its December 2005 meeting.

Patient-centered care

Participants heard a series of presentations on the AAOS initiative on patient-centered care (PCC). The goal was to help attendees better understand PCC and further define the need for PCC.

BOC chair-elect Dwight W. Burney III, MD, spoke to the payer perspective of PCC. Health care costs are a major business expense and end users are not engaged as consumers, often because health plans do not provide patients with meaningful information so that they can make informed, cost-efficient decisions about their treatment options. Employers often do not “buy right” when it comes to health care for their employees. He said that health care purchasers will pay for quality and view PCC as a way to improve outcomes, safety and satisfaction.

Mark C. Gebhardt, MD, chair of COMSS, discussed the core concepts of patient-centered care and what patients want. Patients want clear communication, a sense of partnership and tools for how to stay healthy. They want to be empowered and quality health care requires a team focus.

Pay for performance

AAOS Executive Director for Medical Affairs Robert H. Haralson III, MD, MBA, led a panel discussion on pay for performance. He provided an overview of the issue and described the Academy’s efforts in this area. The AAOS is already involved in developing practice guidelines and will become more involved in the creation of performance measures.

Michael J. Goldberg, MD, chair of the AAOS Evidence-based Practice Committee provided an allegorical history of pay for performance, highlighting problems and developments. AAOS President Stuart L. Weinstein, MD, emphasized the need for physicians to be part of both the pay-for-performance process and the solution.

Laura L. Tosi, MD, past member of the AAOS BOD, looked at fracture care as an example of the pay-for-performance process, particularly with regard to management of fragility fractures. She urged orthopaedists to rethink how fracture patients are cared for and how they are measured for providing that care.

“On average, Americans [with a fracture] receive about half of the recommended medical care processes. For hip fracture patients, it’s even worse,” Dr. Tosi said. “Only 23 percent of patients with hip fractures received evidence-based care. Hip fractures have serious consequences: 18 percent to 33 percent of hip fracture patients die within one year, while 25 percent to 75 percent will not regain pre-fracture function.”

Education on fragility fracture prevention is at the bottom of the pay-for-performance list of what should be measured, noted Dr. Tosi. She continued, “Orthopaedic surgeons are seen as part of the problem here, not part of the solution. We repair the fracture, but do not identify, much less treat, the underlying osteoporosis that led to the fracture in the first place.”

Debating medical liability reform

A panel led by Matthew S. Shapiro, MD, secretary of the Board of Councilors, discussed the tools needed to make convincing arguments for noneconomic caps in the medical liability reform debate. Dr. Weinstein pointed out that caps on noneconomic damages are the only proven, effective method in holding down professional liability rates. He pointed out that the threat of litigation does not improve health care, but rather drives up costs.

Renee Wenger, JD, claims representative with Physicians Northwest Mutual Insurance Co., discussed the situation in Oregon, highlighting the close correlation between the loss of noneconomic damage caps and skyrocketing insurance rates.

David Teuscher, MD, chair of the AAOS Committee on Professional Liability, provided arguments to counter the claims that malpractice rates are linked to the economic cycle rather than damage caps. He concluded by saying that only noneconomic damage caps are likely to create any improvement in the medical liability market.

Alternative coverage options

Andrew M. Wong, MD, chair of the BOC Work Group on Alternatives to Medical Liability Insurance, led a panel on practical suggestions for physicians dealing with the skyrocketing costs of medical liability insurance. The discussion focused on two options—captive insurers and risk retention groups (RRGs).

Dr. Teuscher gave a preliminary report on a proposal for the AAOS to create its own captive insurance entity. Although members have expressed only moderate interest in the concept, further exploration of the idea is underway. Jeffrey A. Baum, MD, discussed the experiences of the Pennsylvania Orthopaedic Society in establishing a captive insurer, including the initial problems that led to its development and the difficulties encountered in its implementation.

Mark R. Brinker, MD, a councilor from Texas, and Peggy Pierce, FACMPE, his practice administrator, discussed their experience with a risk retention group for the Fondren Orthopaedic Group. The RRG covers 48 doctors in 16 locations; they average approximately 22,500 surgical cases each year. They were able to trim insurance costs for their practice through the program.


Guest speaker Allan Johnson, PhD, provided meeting participants with an overview of diversity and the problems brought about by racial privilege, particularly in the delivery of health care. He stressed the need to understand patterns of privilege and oppression that are embedded in social systems and go beyond individual issues. He pointed out that these patterns are so ingrained that people discriminate against others without realizing that they are doing it.

Dr. Johnson called for change on a systemic level, including identification of institutionalized privilege. He concluded that decision makers in the health care field need to rethink how issues of diversity are approached.

Physician stress

John D. Kelly IV, MD, chair of the BOC Work Group on Medical Liability Support, spoke about physician stress and described the development of an AAOS task force of trained peer volunteers to help colleagues dealing with related issues. (See article on page 11 for tips on dealing with “on-call” stress.)

Wayne Sotile, PhD, and Mary Sotile, MA, gave a joint presentation on “Medicine and Marriage.” They discussed the stresses within a physician’s family, especially during a lawsuit.

Alexander Blevens, MD, BOC member from Mississippi, described the damage from Hurricane Katrina and updated participants on how members in the Gulf Coast area are coping.

COMSS meeting

Dr. Gebhardt led the society representatives in a discussion of how to reconfigure the organization to make it more effective. He explained that COMSS integrates the interests of the specialty societies within the BOC, AAOS Board of Directors, councils and committees.

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