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Dr. Zuckerman is chairman of the Department of Orthopaedic Surgery at NYU Hospital for Joint Diseases and the Walter A.L. Thompson professor of orthopaedic surgery at the NYU School of[…]

Doctors have a lot to lose and gain in the healthcare reform debate. As president of a trade organization representing 20,000 surgeons, Dr. Zuckerman outlines their agenda.

Question: What does healthcare reform mean to you?

Joseph Zuckerman: So, today is November 25th, 2009. We are not probably six months into the healthcare reform debate. In the next two months, will be critical in determining what healthcare will look like in the future. As President of the American Academy of Orthopedic Surgeons, we have been actively involved in the healthcare debate because we represent our members. There are 18,000 orthopedic surgeons practicing in this country.

There are some basic tenants, some basic principles of healthcare reform that we think are important. The first is, patients should be able to have access to physicians that they want to see. And for us, that means specialists. As orthopedic surgeons, we believe, and we know that we're the experts in the orthopedic and musculoskeletal problems. And we think, in this country, patients should be able to see specialists who can provide the care that they need.

So a system that allows them to do that is a good one. A system that makes it difficult to do that, or decreases access to a specialist would be one that we couldn't support because you're taking a step backwards from the development of medical care in this country, which has developed to such a great extent and really is at some of the highest levels in the world. And I do believe that the medical care provided in this country is the most up-to-date, innovative found any where, and that's important.


Then you get to the issue of coverage of those Americans that aren't insured and we also think that's important. The uninsured in this country should have insurance. But it has to be in a system that can support it. So, it should be affordable with the appropriate access. One of our concerns is that the system, as it is currently constructed in this country, doesn't make it easy to add 20, 30, or 40 million new patients to the system. Medicare is a good example of it.

 Medicare, when it was introduced in 1965, was a new program, there was a lot of resistance to it, but it's proven to be a very important healthcare insurance program for the seniors, people over the age of 60 or 65, depending on eligibility. That's very important. One of the issues is that each year we hear that Medicare is getting closer and closer to being insolvent, bankruptcy right? Because there are so many people who have Medicare now and there is only a limited number of funds available and Congress has not been able to enact a long-term solution to the Medicare problem.

Now, if you add, as I said, 20, 30, or 40 million more people for healthcare coverage in this country, you're stressing a system that's already been excessively stressed. And I know that current legislation in the House and the Senate has ways that they are going to pay for this and such, but my concern is that on paper, it looks good. Five years from now, it may not work out exactly as they envisioned. Just like Medicare didn't work out exactly as they envisioned way back when, when they first started it. So, I think that's also a concern.


Another area that we think is particularly important is in the area of liability reform; doing something about the explosion of liability cases, malpractice cases in this country, frivolous cases. It's gotten to the point where any physician, not just orthopedic surgeons, any physician, practices medicine in a defensive way, so called "Defensive Medicine." Do I really need to get that CAT scan? Do I really need to get an X-ray on this patient? Well, probably not, but you know there's a small chance it could be there and if I miss something, there could be a suit against this and such. So, that's what we've come to and so much of that adds to the cost of healthcare and it's very disconcerting and disheartening to us, our organization, that in the two main pieces of legislation, the House and now the one that is going to be introduced into the Senate, that there is no meaningful liability reform, which is astounding to me because the Congressional Budget Office, a non-partisan group said that at the very least, over 10 years, we would take away $54 billion from the cost of healthcare in this country with some very limited liability reform issues. So, that's another very important one that I thing we're just missing in this.


Question: Why is healthcare reform so contentious?

Joseph Zuckerman: Well, we do have different types of coverage for different parts of the population. We are one in this country where most of it is employer-based coverage and all employer-based insurance that is provided is different. The level of coverage is different, the deductibles are different, and the out-of-pocket insurance is different. So, I guess if you’ve seen one health insurance plan, then you've seen on health insurance plan because they are not the same.

Then you have Medicare, which insures, I think at last count 50 or 60 million people in this country. That's a very big program. That's a government program. That also has undergone some changes, but it does not have the oversight or the monitoring that you see in the private insurances, the HMO's, the managed care companies.

Medicaid, as you know is the insurance that is provided for the indigent patients. People that are at a certain level below the poverty line that's federally supported or state supported, that's a different level of coverage. So, you've got this amalgamation of different types of coverage that together insures, you know, 180 or 200 million people in this country. Then there's the uninsured, which again, have another -- no insurance, but tend to go to the Emergency Room, or pay out of pocket for these things.

So, even in countries that have had national health insurance, government induced across the board, what develops in those countries is a private insurance system that allows people to augment their coverage, you know, have access to different doctors, better coverage, maybe different hospitals, all those things. We don't have that here because we don't have one consistent system. That's why it's so hard to reform healthcare because you're not reforming one thing. You're reforming a system that has multiple different parts. Very challenging.


Healthcare, being a physician, can be a small business. Right? And that's what it is for the vast majority of the physicians in this country. You have an office, you have expenses, you have to generate revenue to pay your expenses, and that's different than a Kaiser Permanente, or a large healthcare system like the Mayo Clinic, or others like that that are all encompassing. And if you consider an episode of healthcare from the time a patient decides to go to see their physician, or comes to the Emergency Room, until they're now cured, or no longer a problem, they will see multiple practitioners along the way, physicians, non-physicians, physician extenders, therapists, pharmacists, a whole variety of healthcare providers.

In most systems in the country, each one of those providers could be part of a different system, so there's the lack of coordination. A place like Kaiser manages all the episodes of care, the entire episode of care and all the different pieces to it. You can certainly do that more effectively and more efficiently. The question is, can you extrapolate that, or build that into all different communities in this country, and that's hard to do because it's not set up that way.


Question: Why aren’t doctors well represented in the healthcare debate?

Joseph Zuckerman: Well, physicians have organized themselves to a certain extent, but they haven't organized themselves as much as they should. So, if you look at this current healthcare debate, if the government considers the American Medical Association as their spokes group for American medicine, right? Well, what does that mean? I'm not a member of the AMA. I think only 17% of physicians in this country are members of the American Medical Association. So, do they represent the physicians in this country? Probably not. And that's why there has been such push back, and sometimes significant decry about some of the positions the AMA has taken.

Thirty years ago, when the AMA was "the" medical organization in this country, it was more reasonable, expected, anticipated that they could be the spokes group for American medicine. But now it's changed. There are large physician organizations, the American College of Surgeons with I think 60,000 members. Our organization with almost 20,000 members. But not only do we have large numbers of physicians represented based upon the specialty involved, but in addition, every group has a legislative office. In our organization, we have 14 full-time people working our in our Legislative Affairs office. We are actively involved in the legislative process, pushing for the principles of practice and reform we think are important. So many groups have that because they are large enough and they have the resources to do it. Now, what you really effectively need is coalitions of groups to work together. One of the groups that we are involved in with the American College of Surgeons is, a coalition of surgical societies representing surgeons and other specialists trying to pursue a common agenda in this healthcare reform debate.

So, the fact is, it's very hard to organize physicians because the physician groups are now so well-represented within their own specialty and they have lobbyists, or legislative affairs office in Washington D.C. that they can go it alone, so to speak. So, is there a need for organization, probably because you can speak with a louder voice, but we've learned that, what worked 30 years ago when there was one organization, the AMA, is not the case any more because other organizations want to speak up and be heard because they're opinions, or their needs and priorities are different than other organizations.