At the AAOS 2023 Annual Meeting, Alexandra Page, MD, FAAOS, deputy editor of AAOS Now, had the opportunity to speak with Adam J. Bruggeman, MD, FAAOS, FAOA, the new chair of the AAOS Advocacy Council. Dr. Bruggeman is a spine surgeon from Texas with rich experience in advocacy, including serving as president of the Texas Orthopaedic Association and working with the Texas Medical Association and the AAOS Health Care Systems Committee. During the interview, Dr. Bruggeman discussed his goals as Advocacy Council chair, issues that impact physician burnout, and the council’s new approach to reforming prior authorization.

Dr. Page: Prior authorization has been a high-profile issue for orthopaedic surgeons. What do you see happening with this issue in the near future?

Dr. Bruggeman: Prior authorization is tough for us right now, largely because of the Congressional Budget Office (CBO) score. Remember, every bill gets a “score” when it is written—how much it’s going to cost our country over the next 10 years.

Some legislation obviously saves money, others cost money. If the CBO score comes out too high—too expensive—then it becomes very difficult to pass. Particularly with this session of Congress, there is clear emphasis on reducing the deficit and spending.

We’ve been fighting how the CBO scored our prior authorization bill, [the Improving Seniors’ Timely Access to Care Act]. The Advocacy Council and the AAOS Office of Government Relations (OGR) have historically focused on legislation, but I think we have a new opportunity with a push toward the regulatory effort.

How do legislative and regulatory processes differ?
Getting a bill through Congress and getting it potentially signed by the president is just the first step. Remember the old saying, “I’m just a bill sitting on Capitol Hill.” [The bill] has to go somewhere, and somebody has to actually make it happen. The regulatory side—think the Centers for Medicare & Medicaid Services or the FDA—is what ultimately makes that happen.

What we’re seeing now is that despite the high CBO score, the [regulatory agencies] potentially recognize the benefit of reducing the prior authorization burden. The regulatory route is an avenue that doesn’t require that CBO score.

It uses a different process where the executive branch actually puts forth the rules, then various regulatory entities proceed with action without having to go through the traditional legislative process. It allows priorities to move forward more readily in cases where we have support in the other, noncongressional branches of government.

How might the Advocacy Council address Medicare cuts in the future?
The American Medical Association has probably taken the banner on this one, and they’ve put out some interesting concepts about how to pay for healthcare going forward. AAOS is certainly getting behind cost-saving measures like value-based care. We’re a leader in value-based musculoskeletal care, which may offer some opportunities for savings.

But for long-term solutions, we need orthopaedic—and all medical—care to not be a budgetary item. Currently, physician pay is related to the budget. For a balanced national budget, however much is allowed for Medicare determines our reimbursement. It’s not necessarily how much they value orthopaedic care for patients, but frankly it’s how much Congress allots to Medicare.

All our patients benefit from the advocacy we can do as orthopaedic surgeons, but fewer than a quarter of orthopaedic surgeons participate. How can we make advocacy a more broad-based part of orthopaedics?
The good news is that we are the number one medical specialty with regard to the number of members giving to [the Political Action Committee of the American Association of Orthopaedic Surgeons (OrthoPAC)]. But we can do better.

I look forward to working with Wayne Johnson, MD, FAAOS, FACS, our new PAC chair, to find ways to help surgeons understand the value our advocacy efforts bring to our patients as well as our practices. Those PAC dollars are so important.

The OGR does a great job in D.C. spending every dollar to the best possible utility. Getting more of our members to give small amounts would be great—small amounts win.

Do you have any other thoughts on how you’ll put your mark on the Advocacy Council?
We’re going to continue to work hard. I really must hand it to the AAOS staff in D.C. who support our patients and our membership and ensure that our values are represented.

I think our biggest issue will be physician burden: erosion of autonomy and loss of satisfaction with practice, leading to burnout. Contributors to this issue include the consolidation of hospitals and practices, burdens of prior authorization and nonclinical duties overwhelming patient care, and even workplace violence. Solutions could include meaningful legislation to support the mental health of healthcare workers, the repeal of the ban on physician-owned hospitals, and prior authorization reform.

Our biggest fights are going to be on Medicare reform. We need a long-term Medicare payment overhaul, which ties physician payments to an annual increase based on the cost of providing care to our patients.

Whether we accomplish these goals in the next four years or not is to be seen, but we’re certainly going to fight the fight and work as hard as we can. Hopefully we can get at least one of those two major issues across the table and bring some relief to physician practices.

Alexandra E. Page, MD, FAAOS, is a foot and ankle specialist in private practice in San Diego and the deputy editor of AAOS Now.