Remember the old Schoolhouse Rock ditty that tried to educate us on how a bill became law? “I’m just a bill…sittin’ on Capitol Hill.” Well, say our experts, that may be the last that most of us—including orthopedic surgeons—ever learned about the inner workings of our government.
Concerned about the future of the field, and the fact that an increasing sophistication is needed to promote the health policy issues that affect orthopedists and patients alike, the American Association of Hip and Knee Surgeons (AAHKS) got to work and established an unusual program: The AAHKS Health Policy Fellowship.
Dr. Brian Parsley, the third vice president of AAHKS, and the past chair of the organization’s health policy committee, states, “AAHKS is deeply interested in developing young leaders who will have a thorough understanding of how to advocate for our field. We saw that the American Academy of Orthopedic Surgeons (AAOS) was having great success with its health policy fellowship, and thought, ‘This would be a worthwhile effort for a specialty society as well.’”
Those behind the effort got to practice advocacy before the program even got off the ground. “We had to prove that the fellowship deserved to be financially supported by our membership. After about two years of consideration, we brought the idea to the board for discussion in 2004 and then formally proposed the program shortly thereafter.”
Orthopedists coming up through the ranks are increasingly interested in having a seat at the health policy table, says Dr. Parsley. But before they sit down, they have to understand what is on the menu: a word salad of abbreviations. “Orthopedists working in this arena need to be able to pick up a journal and readily absorb the health policy text. This is not something that they are going to get in medical school or residency.”
To better comprehend the meaning behind the acronyms, the AAHKS arranges for its fellows to have substantial exposure to the legislative side of things. Dr. Parsley: “The fellows attend a national orthopedic leadership meeting where we review which laws are coming through Congress. We also examine what is anticipated during the current legislative session and what are the hot points for orthopedics.”
Something that really drives many points home is the day that the fellows spend on ‘the Hill’ with legislative staffers. Over the two years of the fellowship, they begin to develop a level of comfort interacting with those in the legislative realm.
This is also helped along by the “meet and greet” events where the fellows spend time with those who make the laws. “We often have legislators speak at the national leadership meeting, providing a perfect opportunity for them to meet briefly with the AAHKS fellows.”
So who are these orthopedists who want to swim in these unfamiliar, but vital, waters? Dr. Parsley states, “The fellowship is open to residents with an interest in adult reconstruction and who have been accepted into a fellowship in this area. It is also open to current fellows in an adult reconstructive program or recent graduates of an Adult Reconstructive Fellowship. Each fellow is paired with a mentor within the AAHKS leadership to facilitate their experience; also, fellows participate in at least one health policy research project and present their findings at the AAHKS annual meeting upon the completion of their fellowship.”
AAHKS makes other opportunities available as well. “Fellows participate in the AAHKS health policy committee meetings and board meetings; they also have exposure to the AMA Relative Value Utilization Committee and CPT Committee meetings and the National Orthopaedic Leadership meetings.”
Summarizing his vision for the program, Dr. Parsley notes, “The number one advocate for patients is their physician. This means that we need to have a strong presence in health policy arena.”
As for the “doors” of the fellowship, they first opened to Harvard-trained Dr. Sanaz Hariri, who is double fellowship trained in arthroplasty and sports/arthroscopy. She states, “I was thrilled to be chosen to be the first AAHKS health policy fellow in 2008. It was a stellar opportunity to develop relationships with leaders of the organization. Getting to know these accomplished orthopedists gave me an invaluable portal into the health policy world.”
No sooner had Dr. Hariri shaken hands than she got down to gathering data. “The subject of my health policy research thesis was workforce issues…clinical fellowships in adult reconstruction are not being filled and I wanted to know why. My research revealed that this projected workforce shortage will most severely affect patient access to revision surgery. Being part of the fellowship meant that I could connect with individuals who could assist me with this research. For example, the AAOS survey division emailed the survey directly to residents, something I could not have done without their assistance.”
Dr. Hariri is proud to have conducted a meaningful study—not to mention one that was published in both the Journal of Bone and Joint Surgery and the Journal of Arthroplasty. “I worked with Sally York, an expert in survey development, who guided me in creating and developing a valid survey. As for the all-important funding, AAHKS came through, and I was able to pay for the services of a statistician and the AAOS survey department.”
To those thinking that they have to bring knowledge of purchasing pools or accountable care organizations to the table, Dr. Hariri says, “No worries.” “No prior knowledge of health policy is necessary. But you do need to ensure that you will have enough time for the research project, something that requires at least three hours per week plus time to travel to meetings. Talk to your clinical fellowship coordinator and be up front about the commitment. It was critical that I had the enthusiastic support of my fellowship director, Dr. Andrew Freiberg, and my chairman, Dr. Harry Rubash—otherwise I would not have had adequate clinical coverage for the conferences. It is also critical to have an insightful health policy mentor. I was lucky to have the guidance of Dr. Joseph McCarthy.”
Perhaps the most salient thing that Dr. Hariri learned was that those with good data have a better chance of affecting change. “Through this program I learned the importance of asking relevant policy questions and finding evidence for or against your hypothesis. The strongest advocate is the person who has the evidence. My role model was Dr. Kevin Bozic, who conducts pioneering research and is an exceptionally effective policy advocate.”
“If this fellowship did not exist, ” says Dr. Hariri, “we would miss out on being mentored by the people who do the legwork for the rest of the orthopedic community. The field in general should be especially interested in supporting these fellowships because going forward we will be the ones doing the research and legwork that will enable us to advocate for our—orthopedists’—position with regard to important issues, such as patient access to care.”
Dr. Neil Sheth, an orthopedic surgeon with OrthoCarolina, was the program’s second fellow. Dr. Sheth, who attended the Wharton Business School, also spent two years on Wall Street where he gained an introduction to the healthcare business. Then came the medical career path. “During my residency, my chief resident spoke very highly of the AAOS health policy fellowship. Although tempted to pursue this, I was still learning the language of orthopedics. As my training progressed and I became comfortable with doing cases, I began thinking about the health policy world. I was already enrolled in a joint replacement fellowship at Rush; fortunately, they were very supportive of my pursuing the AAHKS fellowship.”
“During my first year of the program I studied the main issues facing arthroplasty; I also did a lot of networking. The second year was devoted to my research project, wherein I looked at patient perceptions of how much orthopedists are paid for total joint replacement. I surveyed 1, 200 patients and obtained a 72% response rate. I asked how much they thought Medicare should reimburse surgeons for several procedures, including open heart surgery, an appendectomy, and a total hip surgery. On average they thought that surgeons should be reimbursed $25, 000 for open heart surgery, $15, 000 for hip surgery, and $3, 000 for an appendectomy. Then I asked how much they think we actually get reimbursed. They thought that we receive $8, 000 for a total hip; when we revealed the actual amount—$1, 378—they were shocked. This work has been well received and will be published soon.”
Dr. Sheth, who has worked with AAOS to develop a health policy primer, states, “The AAHKS program has many passionate supporters who are spread out all over the country. Over time I hope that we can bring more structure to the fellowship so that we can streamline the manner in which we reach out to orthopedic residents. We have recently added timelines for future fellows as well as more specific goals of what should be accomplished, who they need to meet, and what meetings are mandatory.”
As for a health policy issue that he has worked on, Dr. Sheth states, “An increasing number of joint replacement patients are morbidly obese and may not be surgical candidates due to a very high post-operative complication rate.”
CMS no longer covers gastric bypass surgery for Medicaid patients, an issue that I have discussed with North Carolina senators and congressmen. Denying Medicaid patients access to a non-elective procedure that may confer significant benefits for every organ system, beyond the musculoskeletal system, requires re-evaluation.
“It is a particularly exciting time now in health policy, and there is a lot of room for those who want to get involved. And why should you do so? Because these issues affect you every day.”
