There are many reasons for us to be concerned about the changes in the health-care system and how they are affecting us. At the federal level, we have the impending reforms of the Medicare and Medicaid programs, the proposed cuts in funding for research and graduate medical education, and the continuing regulatory constraints from the Federal Trade Commission, the Food and Drug Administration, 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 changes are having a significant impact on our ability to deliver quality care because of the overriding focus on the bottom line, the loss of physician control of clinical decision-making, the limitations in the 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, that we as individuals or as an Academy can do about them. The changes are being cost-driven by forces of immense power—the federal and state governments and big business. Individual orthopaedists are vulnerable if they directly attempt to address problems associated with managed care. We have concerns that too many orthopaedists are being produced, but antitrust laws and the Federal Trade Commission 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 as merely trying to preserve our incomes.
Certainly there are reasons for concern, but I do not believe that there is reason for despair. There are things that can be done that can make a difference. Before turning to those initiatives, I want to emphasize a few things that have not changed. First, we must remain dedicated to keeping the needs of our patients as our highest priority. Second, we need to remember that we possess great expertise in the care of the musculoskeletal system, and although others also treat these problems many of the things that 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.
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Enhanced Ability to Serve
Along those lines, first I want to be sure that you are aware that your Academy has been working hard to enhance its ability to serve. During the last two years, we have increased our commitment to the strategic planning process, which articulates what we stand for and what we are striving to accomplish. I want to emphasize that it is not my plan, the plan of the Presidential line, or even the plan of the Board of Directors. It is truly The Academy's plan.
Initially drafted each year at our March workshop by the Board of Directors, the Council Chairs, and the senior staff, the plan 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 it is 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 that we believe are the most important.
Second, the Presidential line has an ongoing and strong commitment to the concept of the continuity of leadership. We realize that few worthwhile projects can be conceived, developed, and executed in the short span of one year, and we have buried the old tradition of one-year presidential agendas. Instead, all three Presidents now fully participate in the planning and implementation discussions that feed into the strategic planning process. This helps to ensure a smooth transition from year to year without abrupt and disruptive changes in direction, which could be particularly disastrous in these perilous times.
Third, during the past three years we have strengthened our financial position through a major fiscal responsibility initiative, which has enhanced revenues while reducing costs throughout The Academy and has resulted in a swing of nearly three 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 the initiatives that support our strategic priorities.
I want to single out four things that we can do to make a difference.
Education
First and foremost is education, which, quoting from the Strategic Plan1, remains "the fundamental endeavor of The Academy which allows us to deliver the highest quality and most 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 of us must remain committed to our own continuing medical education. For The Academy, education continues to dominate our strategic priorities, as ten of the top twenty-nine objectives in the new Strategic Plan relate to educational initiatives. The Council of Education and its committees will be continuing to offer outstanding educational opportunities to upgrade our clinical skills and to help us to keep abreast of practice-management issues.
Document Quality and Value
The second thing that we can do is provide better documentation of the quality and value of our services. Although virtually all health-care plans and employers assert the importance of maintaining quality, it is no secret that the changes that have been occurring in both the private and the public sector 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, led by Bob Keller, has given The Academy a long-standing interest in the emerging field of patient-oriented outcomes research. While the increasing need for valid data of this type was being monitored, it became clear that we were hampered by the fact that few outcomes instruments addressed musculoskeletal conditions and the few that were available were not practical for the office setting. In addition, we realized that measurement of outcomes of care with valid instruments before and after treatment (outcomes assessment) could 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 program on outcomes. First, in collaboration with several Council of Musculoskeletal Specialty Societies, we developed and extensively tested four generic instruments for musculoskeletal outcomes—one each for the upper extremity, the lower extremity, the spine, and pediatric orthopaedic problems. Only sensitivity testing remains to be completed.
Second, an Academy task force chaired by Jody Buckwalter began development last year 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 transmit data successfully to a central database.
I am pleased to announce that draft versions of our four instruments are now available for general use so that we all can begin to measure quality in our daily practices. At the same time, I want to emphasize that we realize that it is no longer enough to consider quality of care alone. It is also necessary to take into account the costs associated with providing that care. In the coming year, our Outcomes Data Management Program will begin to collect cost data and will be expanding its capacity so that additional practices will be able to participate.
By the time of the Annual Meeting next year, we fully expect to have completed the testing of the instruments and to 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 that we provide. At the same time, it will enhance our ability to negotiate individually with insurance companies.
Public Education and Advocacy
The third thing that we can do to make a difference is maintain and enhance our public education and advocacy programs. During the past two years, Nick Cavarocchi and our Washington office have been instrumental in putting together the Patient Access to Specialty Care Coalition, which currently has 119 members, including fifty-five professional organizations and forty patient organizations. The coalition is a voice that is being heard in Washington and is pressing Congress to include its major points in Medicare and Medicaid reform legislation. During the past year, we have also worked with state orthopaedic societies to develop similar coalitions to address these issues more effectively at the state level. So far, there are active or developing coalitions in nineteen 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 there are substantial differences between the various parties on other issues. We have also learned that, even though we have the support of a large number of professional organizations and we have valid messages that are in the best interests of the public, the federal and state legislators pay little or no attention until we also have the support of organizations that provide the voice of the public. Involving the public is the 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 managed-care programs that provide quality, cost-effective care and in which the administrators, patients, and physicians are satisfied.
However, there are also onerous aspects of managed care that profoundly impact quality. Individual orthopaedic surgeons and practices are vulnerable if they attempt to address these issues because by doing so 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 the government. Three particularly onerous aspects that need to be addressed are the outrageous profits that are being made by some plans at the expense of providing appropriate care, the continuing economic incentives for physicians to withhold care, and the provider gag rules. It is encouraging that the tide of opinion that holds that managed care can do no wrong is beginning to turn, as evidenced by the increasing number of reports, on television and in the print media, that focus on one or more of these problems. However, more needs to be done.
Through our Council of Health Policy, we are making it a high priority to delineate the specific onerous aspects of managed care that are part of some programs and to begin collecting individual stories of the problems that have been encountered by patients. The Committee on Health Care Delivery will analyze these problems, and when they are due to managed-care restrictions they will be passed on to the media and the Committee will develop position statements. This information will also be available to the national and state coalitions to support their legislative efforts and to The Academy members to support negotiations with local managed-care organizations.
Influence on Future Musculoskeletal Health-Care Delivery
The fourth thing that 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 the current health-care delivery systems has been taken during this past year by a work group chaired by Doug Jackson. The group surveyed twenty-eight managed-care organizations that they believed were representative of the managed-care model most likely to be dominant in the marketplace. 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 patient-care decisions, but the bad news is that to do it we have to change.
The major strategy for influencing the future of health-care delivery is to work with other organizations that represent physicians who provide musculoskeletal health care, reinforcing the importance of the bridge-building concept that was articulated by Jim Strickland in his First Vice-President's 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 per cent of the physicians in the United States, and it is estimated that only 25 per cent of the musculoskeletal health care in the United States is currently being provided by orthopaedic surgeons. Alone, we have limited clout. The goal of the bridge-building effort is the joint development of models for providing coordinated care for populations of patients who have musculoskeletal problems—models that will address patient needs, emphasize a team approach, ensure physician control of clinical decision-making, and provide high-quality and cost-effective care.
During the past few months, we have had very encouraging initial meetings with the leadership of key organizations representing family physicians, internists, pediatricians, physical medicine and rehabilitation specialists, and emergency medicine physicians. Each of these organizations has agreed to join with The Academy to form a steering committee to work toward a musculoskeletal summit to be held later this year. The summit concepts are to be inclusive and to promote and develop cooperative efforts in research, outcomes studies, guidelines, education, patient-care models, and advocacy. An indication of the tremendous interest out there is that twenty-three professional organizations have accepted our invitation to participate in a one-day forum in Chicago on musculoskeletal outcomes.
Clearly, we have an extraordinary opportunity to move beyond traditional territorialism and to work toward a united house of medicine for musculoskeletal problems. Jointly developed and jointly endorsed models for the delivery of health care, for education, and for guidelines, backed up by common outcomes data that reflect both quality and costs, will give us far more compelling messages for our public information and advocacy programs and will provide us far greater leverage with government and health-care organizations. Although we, as orthopaedists, will be only one of the players in a musculoskeletal house of medicine, we do have a legitimate leadership role because of what I emphasized earlier—we possess great expertise in the care of the musculoskeletal system and we do many things that are not done by anyone else. In addition, The Academy is well positioned among these other organizations, as we have already developed viable programs in most of the areas that will be addressed by the group.
The four things that I have chosen to emphasize today are by no means the only ones that we are actively pursuing. Believe it or not, in the interest of time there are many others that 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 we 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 as our first priority, I believe that 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 be cost-effective I believe it will return to its 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 that we want. Even when we are unable to have something go our way, we might well have helped to prevent something even worse from happening. That too is an accomplishment and should be recognized as such.
In closing, I return to the place 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 I urge all of you to stay with us. No matter how bleak things may appear to be, there are things that we can do!