8 Defining Issues for Spine & Orthopedics Surgeons Today

The roundtable included Board of Director Chairman for Surgical Management Professionals R. Blake Curd, MD; Director of MUSC Health Sports Medicine David Geier, MD; Carlos Roman, MD of Arkansas Specialty Orthopaedic Surgery Center and Pain Care Center; and Congressman Tom Price, MD. The panel was moderated by Scott Becker, JD, partner at McGuireWoods.

1. Physician employment. In many markets, hospitals employing physicians is the biggest issue, especially for specialists who wish to remain independent. "The hospital's thrust into private practice aims to institutionalize us all," said Dr. Roman. "At this juncture, it isn't impacting my patient base, but the competing hospitals in my economy and local market get exclusive payer contracts so they have a monopoly on the services with those companies."

While the same consolidation is happening in his market, Dr. Curd hasn't seen a change in referral patterns yet at his Midwestern practice. "We are thriving," he said. "There has been quite a bit of practice acquisition in my region, but there are a limited number of practices to acquire, and I think most of the activity has already occurred."

2. Physician productivity. The trend toward hospemployment and pay-for-performance instead of fee-for-service has some worried physicians will be less productive now than in the past.

"The challenges for physicians are increasing, and I have friends who were independent physicians and didn't want to become employed, but the compliance and data was so onerous that they spent days doing it or hiring other people to do it, which grew their overhead," said Dr. Geier. "I think physicians in private practice have more incentive to succeed because their practice reflects them."

At hospitals, surgeons often don't market themselves and must comply with hospital executive directions. "When physicians become employees of some other entity completely, there are no pressure valve outlets for them," said Dr. Price. "You get less productivity. It's not that physicians were doing bad things, but when 5 p.m. comes they are ready to leave."

3. Survival of private practices. Entrepreneurial opportunities for physicians exist, but increased regulations make it more difficult for private practices to survive. More commonly, physicians rejecting hospital employment must join a larger group for economies of scale.

"I think it's important for physicians to appreciate there are people in decision-making roles that don't want private practice to survive," said Dr. Price. "The sense of bundling payments, large systems and governments wanting to write one check and not a dozen threatens private practice. Some would like to see every physician and system to be in a larger group, but every patient is different and needs personal care. You can't get that in big health systems; you get impersonal, bureaucratic care. It violates the kinds of principles we hold dear as it relates to healthcare."

4. Physician burnout. A recent study from the American Medical Association shows physician burn-out rate at around 64 percent, which poses a big problem for access to healthcare.

"There's a frustration and fear with healthcare reform," said Dr. Geier. "We didn't go into medicine for these reasons; we went in to help patients. There's a burden and frustration that grows as all these changes occur. Sixty-four percent of physicians feel burnt out and a third of surgeons are expected to retire over the next few years. Can we attract new surgeons? The money isn't there, and this industry isn't as attractive to young people."

5. Health insurance exchanges. States are at various stages of implementing health insurance exchanges and it's unclear how they will impact physician practices. There are both grim and hopeful prognoses.

"Physicians are running small businesses, and many of the new insurance plans coming out are high-deductibles," said Dr. Roman. "With the exchanges, many employees will only be able to afford the high deductible plans, but they'll be saddled with a $5,000 bill they can't afford."

As mega healthcare systems develop that are dependent on federal funding, institutions won't be able to turn away patients with the low-reimbursing government insurance plans. "For patients who are self-insured or have high-deductible plans, private practices may be able to cater to them," said Dr. Curd. "The big systems won't be able to turn on a dime, so I think there are opportunities for private practice there. I think physicians with an entrepreneurial mindset will find ways to negotiate this new market."

6. Two-tiered health systems. While independent practice may be sustainable for the future, the landscape and patient base may change. "I think it's almost inevitable that we will end up with a two-tiered health system," said Dr. Roman. "The rich are not going to be denied a total knee or total hip replacement. I think rich people will pay the penalty on Cadillac plans or pay out of pocket, and that will be more like the free market. However, it will be only a small portion of the population."

Dr. Price disagreed — he feels a two-tiered system won't develop given the current political climate. "The United States is unique and exceptional, and the court system is egalitarian," he said. "I don't think the courts will allow for a two-tiered system. Some believe the ACA precludes a two-tiered system and people won't be able to contract outside of the ACA for services."

7. Political activism. Physicians traditionally haven't been politically active on the local or national level, but as current healthcare policy is developed, more surgeons are rising to the challenge. "Physicians aren't usually politically active and we tend to be non-confrontational," said Dr. Curd. "We're so busy taking care of people that we've lost sight of the bigger picture with people who enforce the laws."

Whether it's calling lawmakers, contributing to campaigns or running for office themselves, physicians are finding ways to become more active while still maintaining a busy and successful practice.

"The folks that are taking care of patients have to believe that the people who are making policy decisions would do the right ting and allow surgeons to take the best care of the patients possible," said Dr. Price.

8. Medical marketing. There is an opportunity for surgeons, especially in independent practice, to market themselves to patients. Physicians haven't traditionally engaged in big marketing efforts, but as medicine becomes more institutionalized surgeons can use the desire for personalized medicine to their advantage.

"When you call a hospital they say they'll send you to Orthopedics, a nameless and vast thing, instead of a particular surgeon," said Dr. Curd. "The opportunity for private practice is to personalize the surgeon and put a face on patient care. We don't want medicine to be a faceless bureaucracy. When patients come to see a physician, we need to restore that relationship."

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