Why Are Orthopedic Societies Contradicting The Literature On VA Provider Equity?

Representatives Brad Wenstrup, DPM (R-OH), Julia Brown­ley (D-CA), Ralph Abraham, MD (R-LA), and Raul Ruiz, MD (D-CA) reintroduced the VA Provider Equity Act (HR 1058) in the 115th Congress on Feb. 14. The bill originally passed in the House in 2016. However, the United States Senate Committee on Veterans’ Affairs opted not to adopt the Senate companion bill.

The American Association of Orthopedic Surgeons (AAOS) and the American Orthopedic Foot and Ankle Association (AOFAS) lobbied against the bill in the 114th Congress via a letter to Senate VA Committee Chair Johnny Isakson (R-GA) and then ranking committee member Richard Blumenthal (D-CT). The American Podiatric Medical Association (APMA) objected to the letter due to its numerous inaccuracies regarding podi­atric physicians’ training, education and experience. The AAOS and AOFAS are already lobbying against HR 1058.

Our orthopedic colleagues have published articles that seem in contradiction to their stance on this legislation. Augusto Sarmiento, MD, lamented the shortage of orthopedic surgeons in the U.S., writing in the Journal of Bone and Joint Surgery: “[C]ertain trends that sprouted in the orthopaedic field in the recent past probably have been important contributors to the potentially serious problem of a shortage of orthopaedists. … However, if all newly graduated orthopaedists are subspecial­ists, the situation created by the saturation of surgeons in the subspecialties will simply be made worse.”¹

Dr. Sarmiento offered solutions to the imminent crisis but noted: “If the orthopaedic workforce is not sustained in ade­quate numbers, others will move forward and provide care for conditions traditionally the purview of orthopaedics.”1 He continued: “[P]odiatrists, who for generations had limited their work to minor surgeries of the toes, managed, over a very short period, to become doctors/surgeons who currently care for patients with all types of musculoskeletal conditions below the knee. They treat traumatic injuries as well as de­generative, infectious, and congenital diseases with clinical and surgical means. They perform internal fixation of frac­tures of the tibia, ankle, os calcis, hindfoot and forefoot. In addition, they perform total ankle arthroplasties and tendon transfers. In the process, they have become experts in the field to the point that it is ludicrous to argue that their qualifications do not allow them to cover such a wide territory” (italic emphasis added).¹

Charles S. Day, MD, and colleagues stated the following in a Journal of Bone and Joint Surgery AOA Critical Issues article: “Estimating the musculoskeletal workforce need is a critically important but challenging topic. The [U.S.] population is growing, and some predictions suggest that it may reach 400 million by 2040. Moreover, the population at least 65 years of age will increase … to an estimated 70 mil­lion Americans by 2030.”²

The shortage in orthopedics is more significant in the foot and ankle, according to Kamran Hamid, MD, and James Nun­ley, MD, in Foot and Ankle International 2016 Foot Forum.³ They stated: “Though the 2016–17 AOFAS Fellowship Match con­sisted of 75 available positions—a 44 percent increase over that a decade prior—this growth is comparatively outpaced by other disciplines. Between 2005 and 2015, there were 515 graduates of AOFAS-sponsored foot and ankle fellowships as compared to 547 graduates from podiatry programs in 2015 alone. Despite competitive salary, ubiquitous job opportuni­ties, and high career satisfaction, foot and ankle fails to draw the eye of many orthopedic residents. Only 6 percent of U.S. orthopedic residency graduates plan to apply to a foot and ankle fellowship program, second only to orthopedic oncolo­gy (2 percent) as the least sought-after specialty.”³

The AOFAS fel­lowship data substantiate the paucity of fellowship-trained foot and ankle orthopedic surgeons.⁴ Hamid and Nunley mention a disturbing fact regarding the fellowship training of foot and ankle orthopedic surgeons: “Of the 48 programs of­fering fellowship positions, 6 incorporate a relative amount of standardization and oversight by the Accreditation Council for Graduate Medical Education.”³

In summary, orthopedic surgeons admit to a severe shortage of orthopedic surgeons, particularly foot and ankle orthope­dic surgeons. The need for more foot and ankle specialists is particularly great within the VA, where foot and ankle care is among the most commonly outsourced specialty referrals. The orthopedists also acknowledge that it is “ludicrous to ar­gue that [podiatrists’] qualifications do not allow them” to provide the full scope of foot and ankle care. The AAOS and AOFAS’s pub­lished research calls into question the motivation of their op­position to the VA Provider Equity Act.

Veterans deserve accessible, timely lower extremity healthcare. The current VA system struggles under a widely known set of difficulties for which HR 1058 would be an effective solution to the shortage of well-trained foot and ankle care providers.

Editor’s note: This DPM Blog was originally published in the March/April 2017 edition of APMA News and has been adapted with permission from the APMA.

References

1. Sarmiento A. The projected shortage of orthopaedists may be our fault. J Bone Joint Surg. 2012; 94(14):e105.

2. Day CS, Boden SD, Knott PT, et al. Musculoskeletal workforce needs: are physician assistants and nurse practitioners the solution? J Bone Joint Surg Am. 2016; 98(11):e46.

3. Hamid KS, Nunley JA. Quo vadis? Perspec­tives on the future of foot & ankle fellowship training. Foot Ankle Int. 2016; 37(10):1146-1148.

4. Available at www.aofas.org/medical-community/resident-fellow-opportunities/Documents/Fellowship_Match--Previous_Stats.pdf . Accessed March 10, 2017.