July 1997 Bulletin

Enough is enough

It struck me that if this month's Bulletin (April 1997) can be believed, then we may yet be able to save ourselves. Truly, enough is enough!

To date, I have not noticed that the Academy has been taking a proactive approach or attitude other than teaching us to attempt to deal with full-time business people. Don't get me wrong, I think that to date there has not been an overwhelming sense of anger in our community and so no approach with any degree of aggressiveness has seemed reasonable. As we watched Mr. Clinton get reelected and now continue to hear how Medicare/Medicaid will continue to deteriorate (with all insurance programs sure to follow), it is apparent to me that the time for a call to action to save our profession is close at hand.

Whether "unionization" - legal or not - is the answer, or AFL-CIO affiliation may be beneficial, no one knows. What I do know is that we have been taking it on the nose for too many years, while what we do has become more technically and intellectually demanding and patients have higher expectations because we can and do better than ever before. In the meantime, our families see less and less of us as we attempt to maintain income levels by working more.

When MCOs offer reimbursement rates at less than Medicare (with that reimbursement to decrease soon), and even worker's comp reimbursements beginning to be tied to Medicare rates, it surely is time to say No. "No" to being pushed around by bean counters who don't care about our profession except when the care that is to be delivered is to them. "No" to nonprofessionals who are nevertheless in decision-making positions for which they have little to no training except for the capacity to say that their company denies authorization. On the contrary, it is time for us to say "no" to letting others make decisions that affect the lives and well-being of those people/patients who put their trust in us to relieve their pain, return their ability to walk or grip, straighten their back, let them run and play and return to their lives. We must take back our profession, our patients must demand it.

Education of our patients will only get us so far. Washington lobbying will only get us a little further. I think that ultimately we will have to take the fight to the insurance companies themselves. By refusing garbage contracts, at rates that can't possibly be profitable we can force them to negotiate in more realistic terms. But we have to be unified. We have to know what a reasonable deal may be. The AAOS has and will continue to be helpful in these regards. I believe that more is and will be needed. We need to be very aggressive to avoid losing more than we already have. Whether we call it unionization or just use the methods of close communication and dissemination of information to allow more aggressive negotiation for all in our profession, only time will tell. I truly hope that it never gets to the point of considering strikes - that pulls at the very core fibers of our moral commitment to medicine and orthopaedics. But let's not kid ourselves, it could get to that point, and I hope that we have it well thought out long before then.

David F. Beigler, MD
Chicago, Ill.

Impact on surgery

(In response to the Across the President's Desk column in the April 1997 Bulletin.) It is my understanding that HCFA will be reducing the reimbursement for total hip arthroplasties 40 percent beginning Jan. 1, 1998. This 40 percent reduction is in addition to the 50 percent reduction that we have received since 1991. I have felt that the reduction to our present levels, though inconvenient, was reasonable. However, at this time, if the reductions take our total hip reimbursements down to a limit of $1,100-$1,200, I will be forced to no longer do any total hip replacements or revisions of total hips.

Frank A. Minor, MD
Grass Valley, Calif.

Protecting income

I am responding to Dr. Douglas Jackson's article in the last AAOS Bulletin (April 1997). He set out the Academy's plan to oppose the cutbacks proposed by HCFA in Medicare payments. This type of article has always irritated me because it seems to put the financial status of the orthopaedist above the interest of the patients. The statement was made concerning the access of Medicare patients to "top quality" orthopaedic care if there are further cutbacks in reimbursement.

I have yet to know an orthopaedist who is not doing very well financially. I would venture to say that most orthopaedists are in the top 2 to 3 percent of income in the United States, when you look at the population as a whole. We have been trying to hire a new chief of orthopaedics at OHSU and the school has found that we can't compete with the large salaries orthopaedists are getting at other institutions. I admit that there have been other factors involved that have made it difficult to recruit a chief, but salary has been one factor.

Dr. Jackson's article strikes me as another "elitist" attempt to maintain the income of the orthopaedic community at a level that is the envy of many other specialties.

He cited the fact that neurosurgeons could see a 30 percent reduction in their reimbursement. Having worked closely with several neurosurgeons in the recent past, I have very little sympathy for them. The neurosurgeons in our community are charging fees that deserve to be cut back. I recently saw a fee of $11,000 for a lumbar laminectomy for a recurrent HNP. I think there is no reason for anyone charging a fee like that for such an operation.

When I was in active practice my fees were always on the low end of the scale in Portland, but I still made a very respectable income and have had no regrets that I didn't charge more.

John W. Thompson, MD
Portland, Ore.

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