AAOS’s Identity Crisis?

"As private practice physicians, we are nowhere. Who represents us?"

That's what Pete Sallay, M.D., a private practice orthopedic surgeon from Indianapolis asked panelists at the recent meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego. His colleagues attending a session titled: "AAOS Quality Initiatives, Health Care Reform and You, " applauded enthusiastically.

Only moments before, panelist Michael Goldberg, M.D., spoke of the "Schizophrenia of Advocacy" as the Academy struggles to decided if it is a professional society or trade union in a dramatically changing healthcare environment where hospital employment of orthopedic surgeons has grown by around 70% from 2004 to 2008.

Salley's question and Goldberg's observation strike at the heart of almost every public policy issue confronting orthopedic surgeons in a new healthcare world. Members are pushing the Academy to reconsider what it stands for, who it represents and how it will engage with industry.

Private Practice, ACOs and Collective Bargaining

The following day at the full AAOS Open Meeting session titled: “Healthcare Reform Bill: Past, Present and Future, ” Academy leaders were asked again if private practices were still relevant. “What is the likelihood that private practice is going to survive future changes?” asked Ned Wilson, M.D., of Kalispell, Montana.

2011 AAOS Meeting“Nobody knows the answer to that, ” responded Pete Mandell, M.D., the Academy’s Council on Advocacy chair. “I think there will always be a role for private practice in rural areas, but I think in big cities and higher density areas, the accountable care organization (ACO) approach is what legislators are looking at. They have to get costs down, and if they can’t do that, we’ll see more medical tourism, with patients going to Asia and Europe for treatment.”

“ACOs will result in a tremendous cultural shift, ” he continued. “In the Kaiser model, doctors still have some autonomy, but they’re also grouped together. It’s not exactly private practice but may be the best we can hope for, ” added Mandell.

No Collective Bargaining for Physicians?

Michael P. Connair, M.D., in private practice in North Haven, Connecticut, asked Academy leaders about the so-called Campbell/Conyers Bill, which, if enacted, would allow physicians to bargain collectively without violating antitrust laws.

Connair said that one of the shortcomings of the Affordable Care Act was the failure to address the rights of physicians to collectively bargain with payers.

All of the other countries that have a hybrid or socialized system accept the right of physicians to have input as to the terms of their employment, their reimbursement, and the care that patients receive, ” said Connair. “The contracts that we have with private payers and Medicare regulate not only our fees, but access and quality as well. We are legally castrated from protecting our patients’ care, because we don’t have the right to bargain collectively.

Connair told OTW that AAOS won’t get involved in this issue because the Academy is afraid of the Department of Justice. He believes AAOS should become more "guild-like" as their colleagues in Europe where societies make sure members are getting a fair shake from payers.

A New President’s Challenge

Daniel Berry, M.D.With Academy members pressing their leaders to look out for their best interests in a manner and intensity we hadn’t seen before, we wondered if the Academy was undergoing an identity crisis.

We posed that question to the Academy's new president, Dan Berry, M.D., head of orthopedics at the Mayo Clinic in Minnesota.

"That's an interesting question, " said Berry. "Medicine and orthopedics are changing fast. Orthopedics may be changing even faster and that's why it’s been a successful specialty." Berry noted that the Academy is based on important foundations beginning with outstanding education and being good advocates for research and patients.

"We'll need to change with the times in education, research and with changing regulations."

What about the role of the private practice member? How will AAOS remain relevant to those members?

The Academy is fortunate to have members from many backgrounds, ” said Berry. “We'll continue to represent diverse interests. Private practice physicians are the biggest part of AAOS, so the Academy will be responsive.

If not going through an identify crisis, is there a "Schizophrenia of Advocacy" as Goldberg suggested? Berry said he didn't hear Goldberg's comments personally, but said the Academy's interests are to represent the best interests of their member's patients. "Keeping the profession dynamic is an important part of doing that."

Physician Union

Dr. Connair is vice president of the Federation of Physicians and Dentists and of the National Union of Hospital and Healthcare Employees affiliated with American Federation of State, County and Municipal Employees (AFSCME).

Yes, Virginia, there is a physician’s union. Connair has testified in front of Congress on this topic and spoke in detail with OTW about those collective bargaining efforts and the Department of Justice’s push-back. We will report on those collective bargaining efforts and the role of the AAOS in the near future.

Shifting Economics

The Academy’s relationship with its members is clearly the most important one. However, the relationship with industry is also important when over half of the attendees at the annual meeting are from industry and device companies continue to need surgeons to help design and test new devices. 

When outgoing Medtronic CEO Bill Hawkins declared the end of the era of the surgeon champion as the sole marketing focus of device makers last year, he signaled the rise of the hospital purchasing department. Biomet founder Dane Miller told us at AAOS that Hawkins is exactly right.

We asked Berry if AAOS leadership has discussed this change in market conditions and what it means for the Academy and its members.

Berry said the Academy had not addressed that specifically. “But generally we recognize that market forces continue to be dynamic in how hospitals, healthcare systems and physicians are negotiating pricing.” He says the entire economics of the healthcare system will continue to change over time.

The Annual Meeting and Industry

How those market forces play out at medical society meetings was evident at last fall’s annual meeting of the North American Spine Society. There we saw that Synthes was temporarily absent from the exhibit floor as the company reevaluated its appropriate role in supporting medical societies and marketing to their surgeon customers. Synthes was present at AAOS.

Is this a cause for concern by AAOS?

“The Academy has a committee that looks at the overall experience of attendees and exhibitors. The initial reports from San Diego are very positive. Attendance was good and people seem to value the opportunity to evaluate products, ” said Berry. He has no doubts that over time, companies and physicians will reevaluate how the process of evaluating products at the Academy meeting is working. 

The attendance, exhibitor numbers and square footage from the San Diego meeting show that members and industry continue to value the meeting. As the table from AAOS below shows, while attendance by physicians has dropped slightly over the last two years, attendance by exhibitors has remained steady. 

2009    544 Companies           259, 000 NSF*
2010    591 Companies           261, 290 NSF*
2011    533 Companies           258, 500 NSF*
Source: AAOS

* Exhibitors square footage

SBi’s “Booth-in-a Suite” Strategy

One company absent from this year’s exhibit floor was Small Bone Innovations (SBi). SBi, founded by the Viscogliosi Brothers, made big news during the depths of the Great Recession in 2009 by raising almost $150 million in funding from sovereign funds and private investors.

Anthony ViscogliosiCompany Chairman and CEO Anthony Viscogliosi said the company decided not to spend several hundred thousand dollars in exhibit costs to be on the exhibit floor. “Instead we were there in a hotel (the Omni across the street from the Convention Center) to create a more personal, intimate and in-depth opportunity to build on relationships with surgeons, payers, hospitals and key global distributors.”

He called it the "Booth-in-a-Suite" strategy.

The strategy, according to Viscogliosi, allows for more intense and complex discussions which today's world requires, as opposed to 30 people standing in a booth not doing very much.

“We decided to directly target the payers and hospitals and spend more on education, training, clinical data collection and face-to-face communication. We did that effectively at AAOS and I believe other companies will follow suit, ” added Viscogliosi

He advises AAOS to be proactive about adjusting to the changing environment and make it more economically sensible to participate in an effective way for each type of vendor.

However, Viscogliosi told OTW, it's vital for companies to support the surgeon societies. “The meetings are the venues and tools for relationship development and creation of better opportunities for education and training.”

He still believes that some presence in the exhibit hall is valuable and plans to set up a smaller booth in the future to serve as a launching pad for attendees to get to the "Booth-in-a-Suite."

Dr. Berry inherits a medical society grappling with profound historic changes in science, regulations, reimbursement and economics. Will economic changes push the Academy to become more guild-like and redefine their own identity to remain relevant to members and vendors?