by James W. Strickland, MD
For a little more than one year, the Academy has been functioning under the 1994-1995 Academy Strategic Plan developed by last year's Board of Directors. Considering the unfortunate tendency for organizations to exhaust themselves during the strategic planning process and subsequently fail to adhere to the goals and objectives of those plans, it is now appropriate to review how diligently we have implemented the major directives of last year's document. Consistent with the Boards' intent that the plan remain flexible and responsive to those developments which require rapid action, there have been some changes based on a reprioritization of last year's strategic plan.
Let's see how we've done with the most important objectives in each category of the 1994-1995 Strategic Plan.
Accomplishment: The Academy has continued and strengthened its time-honored emphasis on providing high quality, comprehensive orthopaedic education. From its unrivaled Annual Meeting, to the superb menu of comprehensive and skills courses, to an enormous number of books, monographs, journals and manuals published by the AAOS, the Academy stands at the forefront of educational products for those practicing musculoskeletal medicine.
Accomplishment: Through its electronic media and evaluation efforts the Academy has created home-study materials which are unequaled by any other professional organization. There are more than 100 tapes in the Orthopaedic Surgeons' Videotape Library and the At Issue in Orthopaedics intensive surgical skills videotape programs have proven to be a popular component of the Academy's effort to provide comprehensive home study learning opportunities. CD-ROMs are now available for orthopaedic journals, ICLs, OKUs, "Grand Rounds," and Orthopaedic Medline and more are currently in development. In 1996, an interactive CD-ROM entitled, The Athlete's Knee, with many high-tech features will be offered by the Academy. Self assessment examinations are available on floppy disks to further enhance orthopaedists' ability to assess their competence and enhance or refresh their knowledge base without leaving their practices. To help Academy members take advantage of electronic home study, computer "boot camps" have been conducted and, judging from their popularity, additional courses can be anticipated.
Accomplishment: To date, the Academy has developed a book, audiotape, and two course series, as well as articles and Annual Meeting programs, all on managed care and practice management issues. The book, Health Care Reform and Managed Care: A Guidebook for Orthopaedic Surgeons, and the first course, "Meeting the Managed Care Challenge...developing your orthopaedic practice strategy," were intended as "wake-up calls" regarding the new realities of medical practice. Both the book and the course provided a basic overview of managed care issues and were designed to help orthopaedists assess their practice environments. The second course, "Taking Charge: Managed Care Contracting for Orthopaedic Surgeons," took an in-depth look at managed care payment systems, collaborative arrangements with other providers, and contract negotiation.
The Academy is developing several new products for 1996. For example, a third course series will take us into the realm of quality management, cost-effectiveness, and patient satisfaction. There also will be a national conference on groups, mergers, networks, and affiliations for orthopaedists. We will be publishing a book on managed care payment arrangements, with special emphasis on capitation. This book will include a software spreadsheet program to help orthopaedists better understand how to calculate capitation rates. In addition, we will be publishing a book on managed care contracting, which will cover contract terms and terminology, legal and ethical problems, and exclusion and deselection.
The Academy, through its Committee on CPT Coding, also is preparing a third edition of the popular Global Service Data for Orthopaedic Surgery, that outlines which surgical services the Academy believes are and are not separately billable from the primary procedure. This edition, which will be published by mid-1996, will cover more than 1,000 CPT codes used by orthopaedists.
Among other possibilities for this year and beyond, we are considering developing a publication on socioeconomic issues related to orthopaedic practice. We also are exploring an audiocassette subscription series on practice management issues and other products related to the business and legal aspects of orthopaedic practice, including an on-line forum for orthopaedists to share information with each other. In addition, we are looking for ways to satisfy the data needs of orthopaedists to share information with each other.
Accomplishment: A task force from the Council on Education is looking at the quality, content and effectiveness of its educational programs and the Board has passed a mechanism to affect substantial changes in the Academy's Summer Institute. The 1996 Summer Institute is being extensively evaluated by a special task force, and new programs are to be designed to increase the attractiveness of the Institute to the generalist and specialist.
Accomplishment: The Council on Education is currently developing a comprehensive text on musculoskeletal conditions for use by "first contact" or primary care physicians. An extensively revised sixth edition of the EMT "Orange Book" is now on the market and selling well. A new edition of Athletic Training and Sports Medicine is being developed. The second edition has been assisting nonorthopaedists who care for sports teams, and the Academy has published a variety of other educational products for allied health care providers.
Accomplishment: The Academy's department of health policy, the Washington office and the Council on Health Policy and Practice continually monitor developments in health care reform and, in order to determine the appropriate revisions of Academy policy necessary to respond to these developments, they seek input from orthopaedists through:
Because of the diverse managed care involvement and experience of orthopaedists in different geographic locations and the disparate views on some controversial issues, the Academy leadership has had to carefully consider the best interests of musculoskeletal patients and the majority of orthopaedists when making policy determinations. The rapid evolution of important health policy issues has required a fast system of policy assessment and timely Academy policy development and implementation. Nonetheless, the views of the membership are solicited and considered in making these important decisions.
Accomplishment: In December 1994, the Board of Directors approved all the recommendations of the Task Force on Access to Specialty Care and the essential elements of that plan were implemented throughout 1995. They included continued support of the Patient Access to Specialty Care Coalition, now with some 118 members at the federal level, which has worked diligently to make certain that the provisions guaranteeing patient choice and access to specialists are included in any health care or Medicare reform bill approved by the House or Senate. They have emphasized the need for a point-of-service feature in every health care plan and the Coalition's efforts were successful in gaining the Senate passage of a point-of-service amendment introduced by Sen. Jesse Helm (R-N.C.) which stipulated that, if any Medicare plan offered a closed-plan HMO or other managed care product which restricted patient access to a certain group of providers, then that plan must also offer, at the time of enrollment, a point-of-service product enabling senior citizens to go out of network and seek the physician of their own choice. A number of additional patient choice and access provisions advocated by the Coalition were included in H.R. 2350 the Medicare Choice and Access Act of 1995, introduced by Rep. Tom Coburn (R-Okla.).
Several of these provisions were included in the House- and Senate-approved Medicare reform bills. The House version included a ban on financial incentives which result in the withholding of care or the denial of a referral. The Patient Access to Specialty Care Coalition is now concentrating its efforts on ensuring that these important provisions are included in the House-Senate Conference Committee bill which is sent to the President.
In addition, the Academy, through its AMA representatives and the department of health policy, has sponsored resolutions in the AMA House of Delegates, calling for stronger patient protection measures in AMA legislative proposals regarding health care and Medicare reform. The Academy was instrumental in persuading the AMA to adopt the position that managed care plans should not create financial incentives for physicians not to refer patients. Currently, the Academy, along with other members of the Patient Access to Specialty Care Coalition, is attempting to persuade the AMA to adopt its position on the point-of-service issue.
The Academy's department of state society relations and the Board of Councilors also have been instrumental in helping state orthopaedic societies' efforts to influence state-level legislative initiatives that will impact orthopaedic health care delivery. Following the first State Legislative Strategy Meeting in June 1995, state-level patient access and choice coalitions have been formed or are being developed in 17 states. To date, three states-Maryland, Oregon, and New York-have passed point-of-service legislation. Although none have laws as comprehensive as the Academy would like to see, the Maryland law goes the furthest. The Maryland Patient Access Act requires that employers offer employees a plan with a point-of-service option, and bans withholds. It is likely to be used as model for other state initiatives.
To further aid the state orthopaedic societies in their legislative efforts, the Board of Directors has just approved adding a state legislative analyst to the department of state society relations. With this staff addition, the Academy will be able to provide members with early warning on state legislative issues that will impact their practice. The Academy also is working to implement a state-level key contact program to more effectively address state legislative issues.
The Academy also has embarked on a comprehensive new public advocacy campaign designed and implemented by the Committee on Public Education and the Council on Health Policy and Practice. Multifaceted initiatives are being used to educate the public about the benefits of orthopaedic care and make patients more knowledgeable about health care plans. Two new brochures Specialty Care Works and A Guide to Managed Care have been circulated in orthopaedic surgeons' offices and distriibuted to the public throughout 1995.
Accomplishment: This broad health policy objective speaks to those programs which are developed and implemented in an effort to prevent private and governmental health care reform from instituting policies that unfavorably impact physicians' and hospitals' ability to deliver the highest quality musculoskeletal care. While there are many Academy programs which directly or indirectly come under this objective, several stand out. Certainly, those efforts in support of patient choice, access, and timely referral are critical to an orthopaedist's ability to deliver the best possible care and on-going discussions with the U.S. Food and Drug Administration, designed to ensure that new orthopaedic technology can be assessed and made available to the practitioner within a reasonable period of time, would also be part of this objective. I also think that recent Academy efforts to help orthopaedists maintain high quality care while reducing both their practice costs and the overuse of some services should be viewed as an attempt to maintain high quality patient care in an environment that seems to emphasize cost control above all else. The Academy also is attempting to develop a relationship with the National Committee for Quality Assurance to influence the development of strong standards for accrediting managed care organizations in the area of musculoskeletal care.
In addition, the Academy's Work Group on the Role of Orthopaedic Surgeons in Future Delivery Systems for Musculoskeletal Care has been studying the experience of orthopaedists in emerging new delivery systems with a goal of improving patient care. We are studying new ways in which orthopaedists can better collaborate with other musculoskeletal providers in these new delivery systems through team-oriented approaches.
Accomplishment: In order to reflect the Academy's ethical
response to the emergence of the managed care environment, the
Committee on Ethics has revised the Principles of Medical Ethics
in Orthopaedic Surgery and the Code of Ethics for Orthopaedic
Surgeons. The Academy's Board of Directors also has adopted
two important statements against medical and surgical procedure
patents. The Board of Directors also has endorsed the National
Membership Committee's proposed amendments to the Bylaws which
would reduce the number of grounds for which disciplinary actions
may be brought and expedite the
Accomplishment: Throughout the Medicare debate, the Academy, through its Washington office, has spoken out strongly against further cuts to providers, indicating that the short-term savings gained by cutting physician and hospital reimbursement will not solve Medicare's long-term financial crisis. We also have strongly (but unsuccessfully) opposed the provisions in the Senate and House Medicare bills which call for a single conversion factor update that would be lower than the separate conversion factor that now exists for surgical services. We are continuing our efforts, however.
In 1995, the Health Care Financing Administration (HCFA) changed the Medicare payment policy regarding multiple procedures. The new policy requires a payment of 100 percent of the fee for the highest valued procedure and 50 percent of the fee for all other procedures. This has generated about $4 million in additional payments for orthopaedic services annually, and about $37 million in additional annual payments across-the-board. The payment policy change occurred largely as a result of the efforts of the Academy, through its Committee on Health Care Financing and the department of health policy, to persuade HCFA to accept the well-researched findings of the Academy-sponsored Abt Associates study of physician work in multiple procedure.
Starting this year, Medicare will pay nonradiologists for X-rays that they interpret in the emergency room, provided they complete a report and are directly involved in the treatment of the patient. The Academy also was instrumental in this Medicare policy change through its efforts to convince HCFA and other payers that orthopaedists are well qualified to interpret X-rays for musculoskeletal conditions.
During the last several years, the Academy, through its Committee on Health Care Financing, has had effective representation on the AMA/Specialty Society Relative Value Scale Update Committee (RUC). Each year, the RUC gives HCFA recommendations on what the relative values for physician work should be for new and revised CPT codes under the Medicare resource-based relative value scale (RBRVS). These recommendations are developed in conjunction with specialty societies, including the Academy. Nearly all of the Academy's work value recommendations, in recent years, have been accepted by the RUC. Many of these recommendations, ultimately, also were accepted by HCFA.
In 1995, the RUC was involved in the five-year review of the current RBRVS work values, which HCFA is required to conduct. In this process, the Academy selected 83 of the most egregiously misvalued procedures for consideration by the RUC and HCFA. After a complicated review process, involving hundreds of orthopaedists, 37 of the recommendations presented by the Academy to the RUC were accepted. Each of these recommendations called for work value increases.
The Academy, through the Committee on Health Care Financing, is also participating in the two-year HCFA practice cost study which is designed to establish "resource-based" practice expense relative values in the RBRVS by 1998. (Currently, only relative values for physician work under RBRVS are truly resource-based, i.e., based on an actual study of physician work.) The current relative values for practice expenses, which make up nearly 50 percent of Medicare fees to physicians, are based on a formula using historical charges. The Academy also is participating in an American College of Surgeons-sponsored study on practice costs, which is designed to evaluate the findings of the HCFA effort.
Accomplishment: The Board of Directors approved the creation of a new Task Force on the Orthopaedic Work Force. That task force has extensively reviewed existing data and investigated all the legal ramifications of influencing work force change. While the FTC has largely thwarted efforts to generate and disseminate data or institute policies to influence it, the Academy will commission the Rand Corp. to conduct an in-depth and on-going study of the orthopaedic work force in order to more reliably address this important issue. Applications for orthopaedic residencies appear to be decreasing and the Academy will monitor this trend closely.
Accomplishment: The Academy has continued to work in concert
with Orthopaedic Research and Education Foundation (OREF) to generate
funding for important orthopaedic research. In addition, we have
strongly supported additional federal funding for methods to maintain
and restore musculoskeletal integrity. In particular, we have
emphasized the need for additional funding for the National Institute of Arthritis and Musculoskeletal and Skin Diseases. In August of 1995, the Academy sent a letter to the House Committee on Appropriations, requesting support for musculoskeletal research, identifying osteoarthritis, low back pain, and repetitive motion syndrome as the highest priority areas for funding. The Academy has published information regarding important advances in orthopaedic research including the recent books Bone Formation and Repair, Osteoarthritis Disorders, and Repetitive Motion Disorders of the Upper Extremity. A book on low back pain will be published in the fall.
Accomplishment: Academy initiatives in this area include numerous publications and education programs on global services data, outcomes studies and utilization review, as well as leadership in the difficult but vital area of clinical guideline development. Fifteen existing clinical policies have been revised and phase VII clinical algorithms have been extensively developed and are undergoing pilot studies for validity and utility. Two pilot phase II (for specialty physicians) algorithms on low back pain and knee pain also are being tested. It is important to understand that these guidelines are all developed by physicians for physicians. An Oversight Committee on Guidelines continues to monitor the development of these instruments and will assess the results of these initial studies to determine how to proceed. Dialogue also is being initiated with representatives of managed care organizations in order to forge partnerships to determine the utility of the guidelines.
Four outcomes instruments, upper extremity, spine, lower extremity, and pediatrics, are now in the testing process. An extensive Outcomes Data Management Project is now collecting data at 60 sites (at orthopaedic surgeons' offices) and it appears that analysis of the data collection methods will permit the Task Force on Data Management to present its long-term plan for data collection to the Board of Directors at the February meeting in Atlanta. The data generated from this program will provide invaluable support for outcomes studies, physician education and practice analysis, patient advocacy, health policy issues, musculoskeletal research, and interprofessional communication and liaison. A forum on Outcomes Data Management will be held in the spring, and almost all the organizations which were invited to participate in that forum have agreed to do so. This cooperative effort should assist a group of specialists to create standards by which the delivery of musculoskeletal care is measured consistently.
After long, often frustrating efforts, the Academy-funded Loyola Study of the cost-effectiveness of orthopaedic services has been reviewed by an advisory board and now cleared for peer review publication. Two prospective community-based studies of cost-effectiveness of specialty care (at The Brigham & Women's Hospital and at Mayo Clinic) have been approved and funded for $360,000. These important comparative investigations of upper and lower extremity problems are now underway.
Accomplishment: The Academy's On-Line Service has been in operation since July 1995. Almost 12,000 people from the United States and 53 other countries have accessed the system. The Academy has expanded its information base substantially during that time.
Through the Academy World Wide Web Home Page (http://www.aaos.org), Academy fellows are able (or soon will be able) to use their personal computers and a telephone line to access Academy information, communicate and share information with other subscribers, order products, collect information on orthopaedic devices and techniques, and, in the future, earn continuing education credits through on-line home-study educational programs and register for the Annual Meeting and other meetings. Also, we provided five discussion groups, Annual Meeting preliminary and final programs, and links to other orthopaedic societies. In its completed form, the system will be comprised of two parts: a private forum available only to Academy members and a public section that will be accessible to all health care practitioners and the general public. It will be (or is) separated into topics such as health policy, research, education, members services and products. The on-line libraries will contain articles, software and graphics pertinent to the orthopaedic surgeon. Academy position statements, clinical policies, the AAOS Report, Bulletin, radiographs, calendars of events, course schedules, and information on state and federal legislation are now or soon will be available at the Academy's Web Site.
Accomplishment: Despite the fact that the Academy is now committed to the adhering to its Strategic Plan, it is committed to annual reassessments and revisions of that plan in order to adapt to changes in the health care environment. While the revised plan must be reviewed by the Board of Councilors, COMSS, the Academy staff and other interested parties and really is not formally acted upon until the December Board of Directors Meeting, the Board certainly has the prerogative of implementing high priority components of the new plan if they believe that those objectives require prompt action. An example of this rapid redirection is the Academy's efforts to "Build Bridges" with other professional organizations whose members provide musculoskeletal care. This year's Board of Directors believed that cooperative initiative was so important and that efforts to join forces with other providers might be so difficult that it took immediate steps to begin the process. In addition, the Academy, like other modern organizations, has frequently used task forces, rapid response teams, work groups, or oversight committees to respond to those issues that require prompt action from individuals with great expertise in that particular area. To achieve the most informed and comprehensive input into many of these difficult assignments, the Board of Directors has created action groups from the Board, existing committees, the membership at-large or from outside medical or non-medical consultants.
Accomplishment: The Academy leadership remains committed to fiscal responsibility and because of careful budgeting and cost cutting measures, will enjoy a positive financial position for 1995-1996. We continue to look at revenue enhancement and cost containment. Educational products continue to do well, led by the sixth edition of the EMT "Orange Book" and Orthopaedic Knowledge Updates. Other publications, electronic media and course and symposia have supported the positive side of the ledger. In an effort to reduce expenses, there has been a particular emphasis on conducting the Academy's Board of Directors, council and committee affairs by fax and conference call rather than expensive meetings, and the Board of Directors, Board of Councilors and the Council on Musculoskeletal Specialty Societies have all reduced their expenses substantially. We have eliminated one Board of Directors meeting and we have saved considerable expenditures by eliminating the regional committees and the interview process for the membership process. Eliminating the annual $80,000-plus outlay for the banquet should strengthen the finances of the Annual Meeting. Although we have embarked on an ambitious array of projects in recent years, much of the work has been completed by the tremendous Academy staff and most projects have come in under budget.
Accomplishment: In response to the recommendations of the Task Force on Shared Interest Groups, the Board of Directors approved the proposed Bylaws amendment which would create a new category of membership in the Academy-International Affiliate Member. Eligibility for this category will require that applicants be a member in good standing with his or her respective national orthopaedic association. Dues for such a category are as yet undetermined, but we have seen a tremendously positive response from the international surgeons.
The task force also recommended a broadening of the requirements for Associate Membership-Allied Specialist category, consistent with the Academy's Strategic Plan to develop stronger relationships with allied organizations. There are many issues to be considered with regard to a Allied Specialist membership and the subject remains under consideration.
The Task Force on Shared Interest Groups also is attempting to determine the types of programs which would benefit those members who have retired or are considering retiring from practice.
Several new high priority areas were identified by this year's Board of Directors during the Strategic Planning Workshop and, in keeping with the desire to remain flexible and responsive to the needs of our membership, the Board instituted initiatives to address those issues in a prompt and aggressive manner.
A new category entitled Patient Care was created and has the following Value Statement:
"The American Academy of Orthopaedic Surgeons will be the pre-eminent organization providing highest quality programs to advance musculoskeletal health care. The Academy's programs will be responsive to the needs of the public and the profession in a rapidly changing environment and will be provided through innovative, ethical and fiscally responsible ways."
The Goal of the Patient Care category is:
"Our goal is to develop programs and relationships that will improve the quality of musculoskeletal care by exploring a variety of health care delivery systems."
There are three Objectives under the Patient Care category; they are:
These three objectives have a common emphasis on exploring and developing improved, integrated models for the delivery of musculoskeletal services and clearly speak to "Bridge Building" between the Academy and other organizations whose members provide musculoskeletal services. Those efforts are now under way and, if successful, may offer an exciting unifying of previously isolated medical organizations on behalf of the patients we serve. In brief, the accomplishments of the Academy designed to address the objectives of the Patient Care category of the 1995-1996 Strategic Plan are as follows.
The first major effort to involve other organizations who represent musculoskeletal providers in discussions that pertain to future systems of health care delivery will be an Outcomes Research Forum, hosted by the Academy in early 1996. This meeting will allow some 20 organizations to share their activities in the area of outcomes instrument development and to seek ways to cooperate and collaborate.
In May 1995, the Work Group on the Role of Orthopaedic Surgeons in Future Delivery Systems for Musculoskeletal Care was established by the Board of Directors. The work group was chaired by Douglas W. Jackson, MD, and was comprised of experts in evolving systems of health care delivery from all aspects of orthopaedic surgery. They conducted an in-depth "environmental assessment" of existing and developing systems and their research included interviewing 28 managed care organizations (MCOs). In the December report of the work group, extensive findings from many areas were discussed, including:
The recommendations of the Work Group on the Role of Orthopaedic Surgeons in Future Delivery Systems for Musculoskeletal Care were extensive and can be summarized as follows.
The Academy leadership has already begun the process of meeting with the leaders of other organizations whose members provide musculoskeletal care. The reception to the concept of working together, in the best interest of patients, to develop a team approach to the creation of "seamless" systems of musculoskeletal care has been enthusiastic by almost all organizations. It is likely that the "Musculoskeletal Summit" will occur sometime in 1996 and, we hope set the stage for cooperative efforts between all musculoskeletal providers in many important areas.
I believe that the Academy has done an excellent job of sticking with the most important objectives of the Academy's Strategic Plan. The plan has been reviewed, revised, and reprioritized and the updated plan, already partially implemented, is ready for next year's Board of Directors. We are indebted to the dedicated and energetic Academy staff for implementing the objectives and policies emanating from the plan in such a thorough, timely, and cost-effective manner.
In my mind the Academy Strategic Planning Process has been extremely
successful. It has given us clear direction and established continuity
from one Board to the next. We have clearly shown that the process
is flexible, allowing rapid alterations or additions if events
mandate rapid responses by our organization.
I hope that future Academy leadership remains committed to the strategic planning concept because I believe that it is the only way to responsibly address the complex and fast changing events which are occurring in health care delivery.