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© 1999 The Journal of Bone and Joint Surgery, Inc.
CorrespondenceTO THE EDITOR: This letter concerns "Commentary. Responding to Change" (80-A: 601-603, April 1998), by Sarmiento. In his statement "When the fees for services were reduced, we responded by complaining about it and increasing the volume of our services," Dr. Sarmiento was referring to the "baseline adjustment," a term that was used in 1991 when the Medicare Fee Schedule based on a Resource Based Relative Values Scale was introduced as the basis for physician payment for services provided to Medicare beneficiaries1. The Health Care Financing Administration had made the arbitrary assumption that every reduction in payment under the Resource Based Relative Values Scale would be offset by the increased volume of services provided by physicians. However, the Physician Payment Review Commission, in its report to Congress4 in 1996, refuted that assumption and stated that "changes in volume do not appear to be correlated with payment rate changes." This report, as well as that from 19975, reveal Dr. Sarmiento's assertion to be erroneous. Dr. Sarmiento's Commentary restates views that he espoused in his First Vice-President's Address7 to the American Academy of Orthopaedic Surgeons in 1991 and again in his Editorial, "Orthopaedics at a Crossroads,"8 in 1993. Now, as he did then, Dr. Sarmiento admonishes orthopaedic surgeons for ordering too many expensive tests and for performing too many operations and addresses the perception that there are too many orthopaedists. In so doing, Dr. Sarmiento does not recognize the activities and accomplishments made in these areas by the Academy, its members, and subspecialty societies. Among medical specialists, orthopaedic surgeons have become leaders in the development of evidence-based practice guidelines and instruments for the collection of outcome data that address proper utilization of resources and appropriate treatment interventions. To address the perception that there are too many orthopaedists, the Academy supported the RAND study by Lee et al.2, which explored the difficult issue of the orthopaedic workforce. Finally, Dr. Sarmiento proposes that subspecialty societies have weakened the cohesiveness of our profession by establishing lobbying offices in Washington, D.C. I would point out that all orthopaedic surgeons have benefited from the fact that the Arthroscopy Association of North America6 has joined the American Academy of Orthopaedic Surgeons in working to effect changes for an appropriate payment policy in the Health Care Financing Administration's Correct Coding Initiative3. In addition, both groups have joined advocacy efforts in Washington, D.C., in the Coalition for Patient Access to Specialty Care and the Practice Expense Coalition.
Alan H. Morris, M.D.: 522 North New Ballas Road, Suite 199, St. Louis, Missouri 63141
Dr. Sarmiento replies I thank Dr. Goldflies, Dr. Thompson, Dr. Roosth, and Dr. Tuli for their positive responses to my Commentary. I invited criticism of my Commentary if appropriate. Therefore, I appreciate Dr. Morris's letter. I met Dr. Morris during my tenure as President of the Academy while he served as a member of an important subcommittee of the Council on Health Policy and Practice. At that time, I was able to appreciate not only his knowledge in the area but also his commitment to the welfare of our profession. He earned my respect. Dr. Morris corrects my statement regarding the increased volume of orthopaedic services. Although I am not denying that the Physician Payment Review Commission's 1996 and 1997 reports to Congress4,5 refuted the Health Care Financing Administration's assumption that the reduction in payments has resulted in increased volume, it is difficult for me to believe that the explosion of technology and the trend toward operative intervention as the first alternative in the treatment of many musculoskeletal conditions have not resulted in increased volume and, therefore, in increased cost of care. How can this fact be denied when the routine use of expensive magnetic resonance imaging and computerized tomography scans has been added to the use of traditional modalities such as radiographs; when spinal instrumentation has experienced the fastest growth of any other operative technique in the orthopaedic field; when arthroscopy is frequently misused by many who perform it at the appearance of the slightest symptoms; when internal fixation is now the prevailing treatment of simple fractures, such as simple metacarpal and metatarsal fractures and uncomplicated distal radial fractures, which until recently were treated nonoperatively, on an outpatient basis; and when the indications for total joint replacement have been relaxed? The need for admission to the hospital for most, if not all, of these procedures obviously represents greater additional volume of services and necessarily increased cost. Dr. Morris makes reference to my long-standing position that, in general, we order too many expensive tests and perform too many operations. I stand by that position. Even the public has identified the epidemic of operative treatment and technology and has clamored loudly and clearly for the correction of the perceived situation. A distinguished academician responded to my Commentary by saying that he was dismayed because his former residents do not see a wrist that does not need to be scoped or an ulna that would not benefit from shortening. In my opinion, this is not an unusual situation. As a student of trends in our profession, not only in this country but also in Latin America, the Far East, and Europe, I am convinced that the position that I took while President of the Academy is still sound. If Dr. Morris and others do not agree with what I am saying and have the evidence to prove me wrong, I will retract my pronouncements and conclude that what I have been observing over the years is merely a mirage. Dr. Morris also accuses me of not recognizing "the activities and accomplishments made in these areas by the Academy, its members, and subspecialty societies." This is incorrect. I am keenly aware of what is going on in our profession. My uninterrupted service on committees of the Academy during the past thirty-five years and, in particular, my eight years on the Board of Directors and my one year as its President have given me the opportunity to observe closely and to analyze carefully the issues that we are now discussing. My experience as chairman of two large departments of orthopaedics for twenty years also allowed me to keep my finger on the pulse of orthopaedic education. Although I respect the decision of some orthopaedic subspecialty societies to have lobbying offices in Washington, D.C., I still refuse to believe that such a move strengthens the cohesiveness of our profession. Orthopaedics represents only 3 percent of the medical profession in the United States, and attempting to effect action in Congress through lobbying offices that represent less than 1 percent of the orthopaedic community is, in my opinion, naive. The officers of the Academy, the Academy representative in the Washington office, and the Board of Councilors and Council Chairpersons can best speak on behalf of the entire orthopaedic fellowship. I have always believed that subspecialization has improved orthopaedic care in many areas, and I have no objection to subspecialty societies. As a matter of fact, I have limited my surgical practice to total hip replacement for the past twenty-eight years and was a founding member of the Hip Society and the International Hip Society, serving for two years as President of the former. What I find objectionable is the exaggerated emphasis on subspecialty fellowships for everyone and the creation of superfluous subspecialty societies. It is going to take a long time for me to be convinced that the proliferation of subspecialty societies, with their different criteria for membership, certificates of special competency, and independent certification boards, does not encourage fragmentation and erode the cohesiveness of our orthopaedic discipline.
Augusto Sarmiento, M.D.: The Arthritis and Joint Replacement Institute, 1150 Campo Sano Avenue, Suite 301, Coral Gables, Florida 33146
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