AAOS Chastises Obama | Orthopedics This Week
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AAOS Chastises Obama

Caption: "I was a neutral.", "Illustration of the Franco-Prussian War " (1871), Thomas Nast

This is a story about Joe, the orthopedic surgeon, and Barack, the leader of the free world.

Joseph Zuckerman, M.D., and Barack Obama, J.D., are the respective presidents of their organizations, the American Academy of Orthopaedic Surgeons and the nation of the United States of America.

    During recent rebellious town hall meetings about healthcare reform, President Obama urged all parties to stick to the facts and avoid overheated hyperbole. But then the president made some inaccurate statements about orthopedic surgeons that did not go over well with Dr. Zuckerman and the AAOS.

    A Presidential Gaffe

    First the president made a remark about surgeons taking out tonsils because it was more lucrative than preventive care.

    Then came a comment about amputations, and the AAOS officially entered the fray over healthcare reform.

    At a town hall meeting on August 11, President Obama was answering a question from a nurse practitioner about controlling healthcare costs.

    "One of the things we can do is to reimburse doctors who are providing preventive care and not just the surgeon who provides care after somebody is sick.”

    Obama knew he was wading into trouble because he immediately added:

    Nothing against surgeons…I don't want to be getting a bunch of letters from surgeons now. I'm not dissing surgeons here. – President Obama

    Then he continued, "All I'm saying is let's take the example of something like diabetes, a disease that's skyrocketing, partly because of obesity, partly because it's not treated as effectively as it could be. Right now if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance.

    But if that same diabetic ends up getting their foot amputated, that's $30, 000, $40, 000, $50, 000―immediately the surgeon is reimbursed. Well, why not make sure that we're also reimbursing the care that prevents the amputation, right? That will save us money. – President Obama


    Up to that point in the healthcare reform debate, Dr. Zuckerman had kept the Academy's powder dry and worked with fellow medical societies through an alliance of specialty groups.

    The president may not have wanted any letters, but he got his facts wrong and the challenge to surgeons had been issued. Dr. Zuckerman and the AAOS fired back swiftly.

    Surgeon Response

    In an August 13 letter to the president, the surgeons made their points:

    • The Academy was "profoundly disappointed" with the president's comments.
    • The president was "blurring the realities" of physician reimbursements.
    • It was a "mischaracterization" to suggest that physicians are reimbursed immediately.
    • The president was urged to "disengage from hyperbole."
    • The most expedient way to accomplish healthcare reform is to ensure that the debate is based in fact and reflects the value of the services that all physicians, including orthopaedic surgeons, provide.

    "Surgeons are neither reimbursed by Medicare, nor any provider for that matter, for foot amputations at rates anywhere close to $50, 000, $40, 000 or even $30, 000. Medicare reimbursements to physicians for foot amputations range from approximately $700 to $1, 200, which includes the follow-up care the surgeon provides to the patient up to 90 days after the operation, ” stated the letter in correcting the president’s amputation remarks.

    “We implore [the president] to disengage from hyperbole and acknowledge that healthcare delivery can only be improved by recognizing that health care is a system in which orthopaedic surgeons play a crucial role. With $849 billion of our national economy impacted by musculoskeletal conditions, orthopaedic surgeons provide care that improves lives and puts people back to work.”

    Chastising a President

    In comments to Orthopedics This Week late on Sunday night, August 23, Dr. Zuckerman (who was seeing 35 patients the next day) said that the amputation comment presented itself as an opportunity to speak up for members of the Academy. He hoped the AAOS letter would be a first step in having some dialog with policymakers and requested a meeting with the White House.

    Earlier this year members of the Academy met privately with a group from the Obama administration that included Ezekiel Emanuel, M.D., brother to White House Chief of Staff, Rahm Emanuel. But since that time no other meaningful dialog has occurred between the AAOS and senior administration officials.

    Dr. Ezekiel Emanuel is Special Advisor for Health Policy to Peter Orszag, the Director of the Office of Management and Budget.

    A Complicated United Surgeon Front

    As an individual society, the Academy has not had a seat at the main table of the healthcare reform debate. The Academy has not endorsed any of the various proposals that have come from the White House or passed congressional committees in the House.

    The American Medical Association and the American College of Surgeons have each endorsed reform proposals in some form. This leaves the AAOS with a problem if it wants a united surgeon/physician front on healthcare reform. The College of Surgeons' position presents "a little complication" for the AAOS, said Zuckerman.

    "We know the AMA took the position they did to have a place at the table. The Academy took a different approach.” The Academy believes that the real action in Washington will not start until September and chose to keep its powder dry until then.

    The Academy’s Position

    "The Academy and I represent orthopedic surgeons, " said Dr. Zuckerman. He said the president had simply gotten his facts wrong, thereby offering surgeons an opportunity to educate the president, legislators and the public about the contributions orthopedic surgeons make in keeping the nation healthy and working.

    Peter Mandell, M.D., AAOS’ Advocacy Chair, provided us with the organization’s position statement regarding healthcare reform.

    The current health insurance and healthcare delivery system is not sustainable and the Academy believes some of the factors leading to increased and inefficient healthcare spending include:

    • High administrative costs.
    • A broken liability system.
    • An increased prevalence of chronic disease.
    • A shift in costs from the uninsured to the insured.
    • A predominant third-party payer system.
    • Unnecessary patient care.

    The position papers states that the Academy believes that the demand upon physicians, providers, and payers “is infinite, ” but can be contained through incremental changes to the system. For example, altering the allocation of federal and state resources or increasing the portability and availability of healthcare coverage can increase the number of individuals with health insurance.

    As healthcare reforms are considered, the Academy believes policymakers should:

    • Make certain that patients are empowered to control and decide how their own healthcare dollars are spent.
    • Ensure unencumbered access to specialty care.
    • Make healthcare coverage more affordable.
    • Improve the quality of care.
    • Extend both coverage and access for the uninsured and under-insured.
    • Avoid establishing new unsustainable programs.

    Opposes Single-Payer

    While the Academy believes that expanding healthcare coverage and access should be implemented through a public-private partnership, it strongly opposes proposals that create a federal healthcare authority or move healthcare further in the direction of a single-payer healthcare system.

    To ensure portability and continuity of care, the Academy believes that a newly reformed healthcare system should allow individuals or employers to “assert social responsibility” when purchasing additional services or insurance as part of a structured or packaged offer. Open market approaches similar to the Federal Employees Health Benefits Program (FEHBP) are cited as an example.

    The Academy supports providing physicians with tax initiatives to defray the cost of uncompensated care. It also thinks that federal and state governments should provide adequate long-term sustainable funding for existing government healthcare programs.

    Reigning in Insurance Companies

    The Academy also believes that administrative expenses in private healthcare plans should more closely mirror those of public programs, ensuring that a more significant portion of spending is dedicated to medical care.

    The Academy’s position statement concludes:

    “As we approach the great public debate on healthcare reform in America, the AAOS believes preservation of the autonomy of the physician-patient relationship to be of the highest priority.”

    The entire position statement of the AAOS can be read here:


    The End Game

    But back to Joe and Barack.

    Healthcare reform has emerged as one of the most urgent and debated political subjects in decades. Now that the Academy has entered the fray, its strategy of keeping its powder dry will be tested.

    Whether or not a reform package actually gets passed this year is still unknown. But perhaps in the final hours of the debate, Barack will need Joe to tip a vote or two in Congress. Dry power could be a valuable commodity in the end game.


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