I have been a practicing orthopedic surgeon for 40 years. I have observed profound changes in my profession since the advent of Medicare, changes that have affected patients’ access to care. As reimbursements plummeted, internists abandoned hospital care to the new specialty of hospitalists, created boutique practices and stopped participating with health insurance companies. Physicians in all specialties have been retiring at earlier ages than ever before. In my own office, our staff has doubled over the past 40 years to enable us to handle the growing stream of government and insurer mandates. Our reimbursements continue to drop — with no ability to pass on these costs. We are not the Mayo Clinic. There is no foundation to provide computers and electronic medical records or research grants to supplement salaries. Everything we do must come out of the reimbursement we receive for the care we provide to each patient.
Total joint replacement surgery for an arthritic hip and knee is a prime example of the difficulties physicians face and of the implications of health-care reform as envisaged by Congress and academic “experts.” In 1971 I was paid $1,000 for a total hip replacement. Today, I would be paid approximately $1,600 for the same service. There is no multiplier — a surgeon can only do one patient at a time. We continue in our practice for the immense satisfaction we receive from knowing that this surgery does more to restore a high quality of life to patients than any other surgery, and for the gratitude patients show. We implant devices because we believe, based on medical literature, that they are the best choices for patients. The overwhelming majority of surgeons have not received fees from implant manufacturers — many times lowering the profitability of our hospitals.
Consider the implications when a global fee will be paid to the hospital: Then hospital and physician incentives will be aligned, and patients will bear the cost of the search for ever-cheaper implants and techniques, such as a return to cemented total hips. Forget metal-on-metal bearings, resurfacing, rotating platforms, high-flex knees, navigation systems or bilateral replacements. And if our hospitals are financially penalized for occurrences such as infection and deep-vein thrombosis after surgery, who will operate on the obese, the hypertensive or the diabetics among us? Experience with government funding reveals a never-ending spiral of decreased reimbursements in the name of restraining costs. In the end, this will come out of the care we all receive.
At your next visit to your specialist, take a tip from the drug company ads and “ask your doctor”: Does he or she plan to retire early if reform legislation passes close to its present form? Does he or she plan to continue to participate with Medicare/Medicaid or participate with insurers that will not reimburse adequately? How does your doctor think health-care reform will affect the care you receive in his or her specialty? Access to a waiting list is not access to health care. Let’s stop pointing fingers and start considering the real flaws and strengths of our system and how to improve it.