Time to Face the Healthcare Challenge

The Affordable Care Act is upon us. The success, extent, and quality of the resulting care is not fully under our control. That is surely an understatement. Healthcare is one-fifth of the United States' Gross National Product, and it is no longer ours to control. Nonetheless, we have all taken an oath, the Hippocratic Oath, and in 2012, that oath includes being advocates for our

It is clear that the method of reimbursement for healthcare will move away from paying for individual care (á la carte) to a blended method of paying for individual lives and health (prix fixe). Along with this, there are initiatives from all sectors to measure and pay for quality.

In healthcare, quality represents treatment and strategies that use resources to restore or maintain health. The present attempts at measuring quality include initiatives and protocols that are associated with better outcomes and reduced complications. Some examples include, The American Academy of Orthopedic Surgeons' (AAOS) “sign your site” initiative, use of surgical “time out” to insure that operations proceed smoothly, and making sure prophylactic antibiotics are administered preoperatively when indicated. Admittedly, these are great initiatives, but they represent only the “tip of the iceberg” in terms of guiding clinical decision-making.

Appropriate use of resources, such as tests and surgery, is a much more difficult question to answer. The paucity of level 1 studies demonstrates this all too well. Evidence–based guidelines have very limited utility, as demonstrated by the recent AAOS initiatives. The push is now toward “appropriate use” criteria.

There is an understandable reluctance in the medical profession to get involved. Why should we develop guidelines that will restrict our ability to provide customized care for our patients? Will we not be hurting ourselves?

The reason to get involved is because others are already doing so. If we do not do it, others will. Proprietary guidelines that are not transparent are already being used by the insurance community. For example, the American College of Occupational and Environmental Medicine weighed in on musculoskeletal conditions and appropriate use guidelines they developed have been adopted by the Workman’s Compensation Board in the State of California. These guidelines now dictate what orthopedic surgeons can and cannot do, and what they must do to get approval for their planned treatment of patients, since there are no orthopedic surgery guidelines.

At the National Orthopaedic Leadership Conference this past spring in Washington, DC, there was much discussion regarding pay-for-performance, quality measurement initiatives, Medicare demonstration projects, and use of proprietary clinical guidelines by insurance companies to approve or deny patient care and surgery.

Many details on how medicine moves forward with bundling of payments, assessment of quality, appropriate use, and the composition and conduct of Accountable Care Organizations remain to be worked out. Physicians’ interests on behalf of patients need to be heard. Many impediments are in the way; total joint replacement registries, like those that exist in Northern Europe, are long overdue in the US. However, HIPAA rules and other legal issues remain strong deterrents for individual institutions to participate fully in a pooled entity that would give important information about the efficacy of these treatments and complications.

As imperfect as many of the circumstances are surrounding the delivery of health care in the US today, I think our main opportunity to improve the situation would be to mobilize physician engagement and involvement. I encourage orthopedic surgeons to participate in the Orthopaedic PAC and the National Orthopaedic Leadership Conference. Be involved in your State Societies and Specialty Societies. We cannot change what has happened in the past, but having a less than maximally effective health care policy was the result. There are many “stakeholders” in health care now and change will not be easy. However, with these daunting challenges come new opportunities. We will only have ourselves to blame if we fail to act for the future of our profession and our patients.

Author's Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.