Spring 2020 Issue
By Bradley Butkovich, MD
Head Team Physician, Old Dominion University Sports Medicine and Arthroscopy
Atlantic Orthopaedic Specialists
The year has had many challenges and felt like time was flying by until most recently when everyone’s world came to a screeching halt. It certainly has been a challenging past few weeks for all of us here at VOS, as it has been in all doctors’ lives, families, practices, hospitals and communities. I greet you all with my final President’s Message during a time of great uncertainty. It has been an honor and privilege to serve as President of your Virginia Orthopaedic Society this past year. We continue to serve as your Board at VOS, along with our staff and the ortho PAC, and are working even harder in this unprecedented time to continue to advocate for Orthopaedic Surgeons in the commonwealth.
First and Foremost, the 73rd Annual Meeting scheduled for May 15-17, 2020 has been postponed due to the impact of COVID-19. We are in the process of rescheduling the meeting for July 10-12, 2020 at the Hilton Oceanfront in Virginia Beach. Please hold those dates in the event we are able to finalize plans for July.
In regard to surgeries and COVID-19, at the request of VDH, we have worked with MSV to determine appropriate guidelines for elective, urgent and emergent categories of surgery, as applied to practicing orthopaedic surgeons. The guidelines, which we submitted, can be found on the VOS website HERE and are a culmination of regulations collected from the major hospital systems in Virginia, Ambulatory Surgery Centers and University Systems.
Finally, in light of the State of Emergency, we have complied targeted online resources focused on COVID-19 in Virginia. We are actively monitoring the Commonwealth’s response to COVID-19 and are continuously being updated and informed about issues that affect all of us from a health, legal and economic standpoint.
Outside of the current crisis, I have strived to update our membership and emphasize the policy activities with which the society has been actively involved. This year has been particularly challenging from a political and orthopaedic standpoint in Virginia.
As with past presidents, we are always open with initiative updates and initiatives that we have been working on over the last few months. As Dr Schulman stated in this address last year, “Many times I have heard others say ‘All politics is local’ or ‘If you’re not at the table, then you’re likely on the menu.’" This has not been more apparent than this year with the political climate in Virginia.
Like many of you reading this, as a surgeon, and many of the surgeons on our Board, I had true experience in public policy and political science prior to my introduction to the Virginia Orthopaedic Society. In the seven years I have been active on in VOS, many policy matters, decisions and political decisions that affect each and every one of us every day has been debated and decided upon. One does not have to be on the Board at VOS to understand how politics in Richmond affects us locally. It doesn’t take many years in practice before some policy initiative or regulation leaves each and every one of us feeling slighted with a strong desire to call for change. Ultimately, we must ask ourselves how we want that change to occur. That is done though advocacy and our national and state organizations.
AAOS is extremely supportive of vibrant and active state societies with ongoing grant money for various initiatives. Within the last two years, VOS received AAOS grants in support of our Certificate of Public Need (COPN) reform, physician extenders, and advancement of women in Orthopaedics. However, when it comes to many of the issues that actually effect your practice on a daily basis, implementation occurs at the state level. Quite simply, reaching out to AAOS with your concerns may not be heard with the volume one would hope. On the other hand, the Virginia Orthopaedic Society, like all state societies, is much more approachable and is your voice. Our membership numbers are in the hundreds, not tens of thousands, and a phone call or an email puts you in touch with a real person at our office in Richmond. For those active society members in the Commonwealth, and even for those who are not active members, the society has always been your voice to the Legislature in Richmond, to the AAOS, to payers, and even to Congress. Let me repeat that, member and non-member surgeons alike in Virginia both benefit from our voice because legislators have always looked to us at the society to speak for all orthopaedic surgeons. It should come as no surprise that all of this costs money! All we ask is $300 annual dues for VOS membership, and for those that join as a whole practice, there is a 10% discount. It is a very small price to pay for the access and voice this society gives you, and I promise that the causes fought for on your behalf by VOS over the last few years easily cover that cost. Feel free to visit our VOS website and look at some of the current and past issues. I would call particular attention to the Workers' Comp fee schedule reform and let you imagine what that could have been without our society’s top-notch representation here in Richmond. Please share this message with anyone who will read it. We need their support now and in the future.
One of the state policy initiatives that was on our radar this past year, and is an ongoing prominent issue that will affect all of us as surgeons, is “Surprise Balance Billing.” This was tabled last year and brought to the forefront with a vengeance this legislative session. This issue would not be where it is without a few bad actors within the medical community. All physicians understand the legislative title alone is a propaganda victory by the payer community, where inappropriately small physician networks, reimbursement rates, and routine denials of claims as standard operating procedures are more representative of the widespread, if not uniform, institutional imbalances seen across the medical industry. There was significant debate in the legislature as balance billing metastasized, not only to care delivered specifically in the Emergency Department, but in post-admission care and surgery, ancillary and elective surgery as well. VOS, along with the other Specialty Surgical societies in Virginia in collaboration with MSV, fought against last-minute attempts from insurance payors to railroad doctors into taking insurance industry set rates across the board with no recourse or leverage to negotiate fees or reimbursement. In turn, with MSV’s and VOS’s support, legislation was passed in the Commonwealth that follows an average regional billing model for payment and allows for arbitration in disputes when an out-of-network patient is seen for emergency care. This legislation follows the Washington state model for involved parties. Insurance companies felt less than overjoyed by the final law out of Richmond, which as far as I am concerned, is a good thing. Our long-term concern is that politicians and insurance companies will want to expand the scope of these laws to reach in and control the delivery of care and overtly affect the practice of orthopaedics and medicine in Virginia. On a broader basis, and as a whole, this could be detrimental with all sorts of predictable, as well as unintended consequences. We will be following this closely in the years to come.
Moving on, last year we finally thought Certificate of Public Need reform was going to happen. The Medical Society of Virginia and VOS has worked diligently with Richmond for several years. After much discussion in Richmond, COPN reform was not going to happen until Medicaid expansion went through. Now that this has happened, the legislature has pulled the rug out from under the medical community and has essentially mothballed any impetus of COPN reform. VOS and MSV thought that when it was voted through last year, our stars were finally aligning. We made our arguments, we bided our time, we waited through changes of office and then we were asked to hold tight again. Medicaid expansion was implemented and we were betrayed by the leadership in Richmond. As anyone who turned on the news during the Virginia legislative session could see, our lawmakers continued to get quite a bit of national attention, like it or not. The political landscape has changed, and we will have an uphill battle as long as it remains as it is now in the Commonwealth. As a non-partisan society, VOS and its members can always be confident that our positions are for the good of the practice of orthopaedics and our patients and will appeal across the political spectrum when we are given a venue.
That said, I wanted to reflect on a few final points that are imperative going forward as Orthopaedists. Now more than ever the politics in Virginia have been slowly turning against us from both sides of the aisle. Insurance companies and hospital systems have more resources, more politicians in their back pockets and more influence over the narrative than ever before. It is imperative that we continue to fight for what we believe in for the good of our patients and our profession. We, as a society of orthopaedists, have tried to minimize that which goes against what we believe. In the past few years, we have been told that it would be good to compromise on Workers' Compensation only to be subject to lower reimbursement. We have come to the table on Medicaid expansion and have been lambasted as bad actors. We have negotiated for and been promised COPN reform only to be turned away while one of the largest hospital systems in Virginia profited over One-Billion Dollars in 2019 as a “non-profit” hospital system. We continue to fight against encroachment into orthopaedics from podiatrists, the naturopathic lobby, and physician extenders for the safety of our patients. We are fighting against insurance companies and their outright dishonesty. They claim they are the heart of healthcare yet they care more about their Board of Directors than the patients they claim to serve. Their profits are up 20% and their CEOs are getting paid millions. We have seen it in denial of services, red tape, out-of-network manipulation, onerous pre-certification processes, higher copays and less service. We physicians have often been looked to as a moral compass by virtue of our training and dedication. It is up to us to carry that role forward in these times, where social justice and equity are rightly earning their proper place in public discourse. Such discussions first start with careful reflection upon our local environments. We need to be more than good surgeons and doctors. We need to contribute to our communities and institutions as mentors, advocates and leaders. As we prepare the next generation of orthopedic surgeons, this should be a top priority. Only then can we work together on a grander scale for the good of our patients as we strive to take back the practice of medicine.
Finally, nothing is more important than reflecting where we are right now in the middle of this crisis. It often seems to me that we are living in a surreal alternate reality as I drive to a more than half empty clinic during what used to be rush hour. There is only a few cars on the road and a couple of people standing at a bus stop with masks placed haphazardly on their grim faces. OR techs, medical assistants and nurses are talking to me about how they have applied for unemployment as our livelihood and theirs have been frozen in time. As doctors, we lament not being able to utilize the skills we have to make people whole and provide for ourselves and those around us. Patients and families are unsure, and maybe afraid, and we have to tackle all of this as we think of our own livelihoods. We wonder if the practices we have built and partnered in are going to be the same or even exist when this is over. We have had to cut salaries of employees, let people go, forego profit and reorganize the way in which we do the business of medicine. None of us really knows how long this will last, but I pray that the end may come soon and we will all be better for it on the other end. Reflect on why you became a doctor and surgeon. When you get the chance to operate, cherish it and understand how awesome an honor and a gift it is to be able to do what we do. Regardless of everything going on in the world, that is your place of solace away from the insanity outside the operating room. Embrace the things around you and spend time with your family. Enjoy the fruits of your labor where you may not have been able to in the past. Look for opportunity around you, in helping those in need, in embracing new technology such as telemedicine and cutting the extraneous distractions in our lives and careers. Remember, we are some of the smartest people in the room, we wouldn’t be orthopaedic surgeons if we weren’t. Lead your hospitals, your practices and your employees through this with compassion and wisdom and do the right thing. We will conquer this together and understand that your Virginia Orthopaedic Society is right there with you.
In conclusion, serving as President and on the Board of VOS, has been one the most rewarding ventures of my entire orthopaedic career, even in times like this. It has been my absolute honor to serve you all this past year, and I look forward to seeing all of you in July 10-12 in Virginia Beach, to put all of this behind us.
Please visit our website at vos.org for updates as they become available.
Tentative New Dates
July 10-12, 2020
The Hilton Virginia Beach Oceanfront