Dr. John Tongue – AAOS's New Truth Teller

Elected officials are not telling the truth in dealing with the nation's unsustainable healthcare system.

That's the message incoming President John Tongue, M.D., of the American Academy of Orthopaedic Surgeons (AAOS), gave the organization's members gathered at the recently completed annual meeting in San Francisco.

The Academy seems to have a knack for choosing a leader to fit the times.

Leadership for the Times

Dr. Dan Berry,
AAOS President 2011
Courtesy of AAOSThree years ago, the Academy elected the charismatic Joseph ("Broadway Joe") Zuckermann, M.D., of New York to take on the President of the United States for calling into question the motives of orthopedic surgeons as the nation's healthcare debate began to heat up.

Then for the past two years, the Academy picked calm Midwesterners, John Callaghan, M.D., from Iowa and Dan Berry, M.D., of Minnesota to begin plowing the fields of quality and evidence-based data to prepare the organization to make the fight for comparative effectiveness of orthopedic therapies.

Dr. John Callaghan,
AAOS President 2010
Courtesy of AAOSThis year is was no exception to picking the right leader for the times as the presidential line of AAOS came to John Tongue of Oregon. Tongue will be the Academy's voice in taking on directly the question of limited resources to provide every American with basic healthcare and utter the dreaded "R" word—rationing.

Perpetuating the Myth

Tongue wasted no time in his acceptance speech to the gathering of some 15, 000 orthopedic surgeons in accusing elected officials of perpetuating the myth that if we simply improve value—create efficiency and reduce waste—there will be sufficient resources available in the systems.

"Our elected officials are not telling the truth because most voters have yet to accept the need for major change, as painful as it may be." The nation must deal with the truth about our unsustainable healthcare system.

Tongue told his members that AAOS must be at the forefront of this discussion with the mantra of: "Strong on vision, flexible on details" as the organization tackles the critical areas of, "Access to Care; Demonstrating Quality and Value of Orthopedic Surgery; and, Improved Patient Safety."

The Financial Conundrum

Figure 1: Comulative Growth Rates of GDP and Health Care Spending: United States, 1960-2007 and projected for 2008-2018

Source: Office of the Actuary, Centers for Medicare and Medicaid Services, 2008

"American healthcare, at its best, remains unrivaled, " said Tongue. "Yet...we face a conundrum in the delivery of healthcare—we cannot afford the care we are already providing, and yet at the same time millions of Americans have no, or very limited access to basic medical care."

He noted that 51 million Americans have no health insurance resulting in as many as 45, 000 Americans who die each year or are driven into personal bankruptcy.

He wonders why the U.S. is the only developed country in the world without access to basic healthcare for all its citizens.

In stark contrast to the uninsured, Tongue said there is another "more fortunate" group—the 43 million Americans who are covered by Medicare.

However, he pointed out that Medicare recipients entering the program today have paid-in an average of only $60, 000 yet are projected to receive three times that amount in benefits.

"And despite Medicare's continued devaluation of physician compensation; there is also a rising 'Silver Tsunami' of baby boomers who want ever more intensive and expensive medical care."

With fewer young Americans paying into the Medicare Trust Fund, it is projected to be exhausted by 2024.

Rationing Benefits

"So how can we give greater access and still pay the bill?" asked Tongue.

By rationing benefits.

Here is where we were reminded of one of former AAOS President John Callaghan's departing comments from the podium at the previous Academy annual meeting when he said that over 90% of all Medicare dollars spent on beneficiaries are spent in the last year of life. Clearly AAOS leaders are asking if spending limited resources on "life-ending" care is more valuable than spending those dollars on "life-enhancing" care.

AAOS lobbyists at the meeting told us that the Academy was not going to tell policymakers to cut spending on end-of-life care, but that they would be making the case for the effectiveness of orthopedic care.

Oregon Trail

Tongue said a partial solution to the question of access and cost lies with a "courageous" effort by the Oregon Health Plan which has provided care for low-income patients since 1993. The plan is intended to make more healthcare available while rationing benefits.

In 1994 Oregon voters made their state the first in the U.S.  to permit terminally ill patients to determine the time of their own death. The law was challenged by the George W. Bush administration, but was upheld by the Supreme Court of the United States in Gonzales v. Oregon in 2006.

"Oregon is the first American government to explicitly prioritize health services, " said Tongue.

"It has been a difficult journey, physician payments can be below cost, but basic care is available to many more citizens, particularly for children...and research shows they enjoy 'substantially' better health because of that access."

In contrast to these explicit and intentional coverage decisions, Tongue said that we have a national patchwork of complex, inconsistent coverage decision..."often hidden in policies devised by private insurers that patients learn about only when they receive denials of care."

"Meanwhile, " added Tongue, "politicians avoid the 'R' word, rationing, " and perpetuate the "simply improve value" myth.

Quality and Value

Even though improving value by itself will not bring the savings many have promised, Tongue said the Academy must still lead to finding innovative means to add value. In that vein, he cited the Academy's leadership position in research on evidence-based quality measures.

"The Academy must continue these efforts and communicate them to policy makers because new knowledge and technologies will not be accepted and funded if we do not continue to define cost-effective, appropriate treatments."

The Orthopedic Advantage

He warned that during the ongoing debate about healthcare reform, there will be increasing competition for allocating limited medical resources. "Fortunately, orthopedic surgical outcomes are among the best in medicine, " said Tongue.

Companies are also driving research in this area as Zimmer Holding's Inc. Vice President and Chief Science Officer Cheryl Blanchard, Ph.D. showed us on the floor of the meeting's exhibition hall, with biologic innovations that are slowly turning orthopedic companies into "joint preservation" companies.

Said Tongue, "We have compelling stories to tell about getting people back to work, or about allowing older citizens to remain active and independent."

"Unfortunately, payers do not benefit from these long-term social and economic impacts. They increasingly question the cost of all medical care, but particularly orthopedic surgical procedures.

"So, the Academy has been working with health economists to articulate, quantify, and even monetize the social and economic value of our work."

Tongue said the initial research findings will be completed this spring and will cover five common conditions:

• Total Knee Replacement

• Hip Fractures

• Lumbar Discectomy

• ACL Reconstruction

• Rotator Cuff Repair

He noted the need is urgent to get this data into the hands of payers because local coverage decisions in many states are already limiting access to care.

He cites an example from his home state of Oregon where the state's Public Employees' Benefit Board has decreed that any beneficiary receiving a total knee replacement must pay, in addition to deductibles and co-pays, a $500 surcharge.

He says that preliminary data from the Academy's research indicates the value for society of the procedure is worth "far more than the initial medical costs, " and the surcharge makes absolutely no sense.

"We will make our case on value and access to orthopedic patient care through a new public awareness campaign called: 'A Nation in Motion: One Patient at a Time.'"

"We have to take the fight to the public and win the debate for public opinion."

Truth of Numbers

While public officials may not be telling the truth about the need to ration and prioritize treatments in the time of a badly damaged public purse and the coming "Silver Tsunami, " the new leader of AAOS has stepped forward to tell the public, voters and patients a truth born in the numbers that we can't have it all.

Decisions about limiting care to assure access for all will have to be made. The Academy appears to be ready to make the case for care that gets people back to work, increases their ability to stay healthy and perhaps, as in Oregon, give them more say over life-ending decisions.