Zuckerman to Callaghan

We heard more than once that the recent meeting of the American Academy of Orthopaedic Surgeons (AAOS) in New Orleans had nothing dramatic to offer. We heard complaints that no new blockbuster scientific advances or groundbreaking devices were announced or introduced.

Those looking for the trees would have missed the forest.

A Pivotal Moment for Orthopedics

This year's meeting of the AAOS and the passage of leadership from departing President Joseph Zuckerman of New York to the new President, John Callaghan of Iowa, comes at a pivotal moment for orthopedics as a national health care debate rages, a national device registry is on the cusp of creation, and new standards of proof for coverage and reimbursement loom on the horizon with the arrival of comparative effectiveness.

Departing AAOS President
Joseph Zuckerman, M.D.The passage of leadership melds Zuckerman's nimble handling of the Academy's engagement in the health care debate with Callaghan's hope for a steady focus on quality and research.

In an exclusive interview with OTW on March 9, Drs. Zuckerman and Callaghan stressed that a change in presidents does not change the current mission or path of the Academy. "We're all playing from the same sheet of music, " said Callaghan.

Balancing Interests

As stakeholders in the health care debate seek to protect their own interests, Zuckerman said physicians have to balance their own interests with the concept that the commodities physicians deal with are human beings with orthopedic problems.

"It’s not like those other [stakeholders]. We always have to find the balance between the two [interests of patients and physicians]. That’s why the health care issues, government regulations, the restriction on things, practice difficulties, all become important because they interfere or complicate the ability of orthopedic surgeons to provide the care that we want to provide for our patients in a manner in which we feel it should be provided."

"Physicians are no different than any other profession or field, " said Callaghan. If physicians can do something better or more cost effective, he feels physicians are then truly helping the [healthcare] system by getting people through in a better and sometime, safer way.

Focus on Quality

Incoming AAOS President
John Callaghan, M.D.Callaghan will be focusing on the quality movement during his term. "For us [AAOS] that means we want to make sure that we understand what the important quality issues are and that there are appropriate quality measurements. Then we want to help our members and our patients understand what those measurements are and to help our members take better care of the patients." And, continued Callaghan, to do it in a more cost effective and efficient manner.

"We think that is all part of the quality movement, but we are a little bit concerned that some in government may not have their eye on the right target. We want to try to help them redefine that, " said Callaghan

Zuckerman's focus, before having to pile deep into the health care debate and marshal the Academy’s resources on the Haitian orthopedic catastrophe, was on practice management.

"Why is practice management important?" asks Zuckerman,

Because you have to run a business efficiently. There are ways that you can do things that make it run more efficiently and decrease your overhead. At the same time, government regulations are adding more overhead like requirements for electronic medical record or other things. So, you know, it is harder to actually do that.

"So as an organization, we’re trying to provide our members with help in that area. At the same time, if health care reform goes through, there will be many more patients that we are going to have to be taking care of. If the plan is to ensure another 30 million Americans with more ready access to care, they will have to be taken care of. They’re going to require more care.

So when John [Callaghan] talks about the ability to do things effectively over large populations of patients, consistently and effectively, that's important. We also need to take a closer look at what we do, how we do it and what works regarding comparative effectiveness.

Callaghan asked, "With the numbers Joe [Zuckerman] noted, there are going be 3.6 million total joints that will need to be done. Who is going to do it? We are not training enough people because they do not want to go into this because they are concerned about reimbursement." 

Callaghan’s Passions: Quality and Research

Callaghan is ready to integrate his life long passions of research and quality into his term. He told attendees during his inauguration speech that the Academy went through a restructuring process six years ago and the Council on Research was changed to the Council on Research, Quality Assessment, and Technology.

He noted the Obama administration's call for comparative effectiveness initiatives and its injection of $1.1 billion dollars into NIH funding. "With the stimulus package, quality has come front and center, " said Callaghan.

American Joint Replacement Registry Project

On another front, Callaghan told his colleagues that the Academy, through the American Joint Replacement Registry Project team led by David Lewallen, M.D., has made headway in making an independent voluntary non-regulatory hip and knee replacement registry a reality in the U.S.

Callaghan said,

It will dwarf all the other registries in the world with the potential for 750, 000 entries in the first year.

Callaghan said this model for a registry, as demonstrated in countries throughout the world, has been shown to markedly improve the quality of care by behavior.

“Although it has taken us over nine years, I am convinced that this registry will come to fruition. We intend for it to represent a jewel for all of medicine to see the seriousness of our orthopaedic profession."

Implants of Interest

Henrik Malchau, M.D., one of the fathers of the Swedish registry and architects of the U.S. registry, said survivorship information gained from revision surgeries will identify "Implants of Interest."

CIGNA's Medical Director, David Mino, M.D., another architect of the U.S. registry told an audience that CIGNA will not use information from the registry to make coverage or payments decisions.

Some in the audience found that hard to believe.

Health Care Town Hall Meeting

The Academy offered its own version of a health care Town Hall Meeting presided over by President Zuckerman. The evidence of the important role advocacy took this past year at the Academy was noted in that the Academy’s number of full-time equivalent employees went from 2.5 employees to 15. The Academy opposed the reform package proposed by Congress.

It was clear from Zuckerman’s review of Academy advocacy efforts during the year that a schism developed between the traditional voice of physicians—the American Medical Association—and the surgeon societies.

Zuckerman didn't sugarcoat problems with the AMA over its support of the President's health care plan. "Many of us have been disappointed in the AMA, " said Zuckerman. But he cautioned about a fragmentation of the physician voice, citing a "Divided We Fall" theme. "There has to be some cohesiveness to succeed, " said Zuckerman.

AMA Schism

The schism with the AMA is particularly tricky for specialty societies because the AMA houses the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The RUC makes annual recommendations regarding new and revised physician services to CMS (Center for Medicare and Medicaid Services). This proprietary tool makes the AMA a little like the Catholic Church before Luther spawned the Reformation.

Perhaps nothing highlighted the role Zuckerman and the Academy played in the health care debate more than Zuckerman’s highly publicized spat with President Obama over comments the President made about surgeons quick with the scalpel. After the spat, Zuckerman was invited to a meeting at the White House with senior administration officials.

"We met in the Treaty Room in a building near the White House, " said Zuckerman. "I thought maybe we could get a casino deal out of the whole thing to pay for the costs of the health care bill, " joked Zuckerman. His humor will be missed.

One courtly elderly physician from Kentucky asked his leadership panel what the official position of the Academy was on universal access to health care for all citizens. "You mean socialized medicine?" responded Peter J. Mandell, M.D., chair of the Council on Advocacy. That answer did not seem to go over well with some attendees as they admonished their leadership that they can't loose sight of the fact that they are patient advocates and not businessmen.

Zuckerman noted that the Academy did not have a detailed plan for universal access.

Joseph Zuckerman gave the Academy a clear and powerful (and often irreverent) voice as the nation went through a very loud public debate over access to health care. With the shouting out of the way, John Callaghan sets a course to makes sure that clear quality standards will define how that access will be served by physicians and paid for by government and private payers.