Paul Tornetta III, MD, PhD, has been involved with the American Academy of Orthopaedic Surgeons for more than 25 years, and he's seen how the orthopedic landscape and its challenges have changed.
Now he's at the helm of the AAOS, serving as the organization's president for the 2024-2025 term. Dr. Tornetta spoke with Becker's about the upcoming changes within AAOS and his strategies for the year ahead.
Note: This conversation was lightly edited for clarity.
Question: We're having this conversation before you're officially announced as president of the AAOS. Can you talk about some of your top goals going into this role?
Dr. Paul Tornetta: Our governance structure and our leadership structure has thankfully moved a little bit beyond a year-by-year focus. I've been on the presidential line for two years of a four year commitment, so this is going to be the third year of four. The academy strategic plan ran through last year, and this past year we've done almost a yearlong project resulting in a new strategic plan. A lot of my initial activity and the board's initial activity will be to initiate movement along the new strategic plan as opposed to the old one.
My goal as the chairman of the board is to work with the board to implement the strategic plan. We've also taken a hard look at our governance structure. We started that process last year and this will be ongoing. We are looking at how we might be able to meet the needs of the profession better and how we might be a more effective board because the healthcare landscape changes. Since the last time anyone's really looked at our governance structure, our environment has changed dramatically. There's going to be a lot of effort this year around making sure that we're a well-informed board and trying to make headway in the idea of being a more efficient and effective board.
Q: What's the big difference between the previous strategic plan and what you're going to implement?
PT: Our new plan includes a formal focus on patients and members and also speaks to our desire to partner with others to advocate for patients. We will carry over our goals of fairness and increasing the diversity of our field. We are also planning to be stronger advocates for research money, alongside other organizations. It is important to note that our strategic plan is an initial roadmap that we expect to change as the landscape evolves.
Q: In your time with the AAOS, how have you seen different concerns and issues among your peers evolve from when you started to now?
PT: I have seen too much change to answer this easily as I have been involved with the organization for more than 25 years. On the educational side there's been dramatic change with digital implementation and the many tools we have to teach now. The changes in residency education have also been dramatic. When I was a resident, we had rotations that would have us on call every other night and be in the hospital the next day until we went home for dinner. It wasn't always that bad, but the number of hours you worked and the amount of experience that you got was just night and day greater than what the residents get now. When I was a resident many graduates would go immediately into practice. Now residents all do a fellowship or even two. They don't have as much experience as residents. They can't possibly have the same skill set when they come out as those who trained when I did. But they come out with a broader base of knowledge than we did. More and more surgeons identify as specialists or have a specialty interest. All of our younger members have a subspecialty interest and if you look at those surgeons who are heading into retirement, most of them were general practitioners who might have had a special area of interest, but they were interested in everything. That's been a major shift. Finding ways to partner and work with the specialty societies that are really important to our members is an important part of what we have to do. Our partnerships with other organizations are key to our ability to help patients and our members.
On the advocacy side, things are harder and harder for the physicians. To be clear, orthopedic surgeons make a good living, and they work quite hard to get where they are and in practice. However, there are a lot of people who do a lot of hard work that they don't do as well. That said, the landscape of healthcare continues to change, and this is from every avenue. Financial stresses cause change and regulatory stresses cause change. I think there are pros and cons to many different employment models. Large healthcare systems that have figured out how to be efficient and care well for patients and have an eye on quality can do a wonderful job. Large non-academic health care systems can do that. Small practices and large practices can do that but the way you do it is different. I don't think that any one model is the best model. I think that there are very effective and wonderful physicians and systems in all of the states. I think it comes down to in large part the devotion of the physician to the patient. The physician-patient relationship is the one thing that will always be the constant.
Q: CMS recently put out a new rule on prior authorization going into effect in 2026 which would streamline the process for some claims. What do you make of that and what else do you want to see from CMS?
PT: The academy has been on the forefront advocating for these kinds of changes for many years. If you look at physician burnout rates, they're very high. The primary reason for that is that physicians became doctors to take care of patients and to contribute to the greater good. They didn't become doctors to do paperwork. Of course we have to do some paperwork, but when insurance companies or others use that as a hurdle between the patient and the care they need, it is a problem. Prior authorization should be a very simple thing as long as the physician demonstrates their ability to indicate the right cases. The preapproval process has become a very onerous task for physicians. It takes a great deal of time and it doesn't contribute in any way to patient care. I think that the moves that are being made to help with pre-authorization are going to expedite patient care. It's going to make physicians less burned out. And I think it's going to be a win-win for everybody.
Q: What other changes do you want to see?
PT: There's a lot of changes, and the academy has an advocacy strategy. We all worry about skyrocketing malpractice insurance costs from a business standpoint. Capping or finding other ways to make the legal system more reasonable will help patients. When there are physicians who can't afford to stay in business because malpractice rates are high, and you have people with substantial stress around something they haven't done wrong, it's just not good for patient care.
The other thing that's always on our radar is Medicare reform. Physician reimbursement was decreased last year. For many years that was corrected right before the rule would come. This year the physician salaries went down. Everything else in the world is becoming more expensive. Physicians were paid less. That is a very important piece because not all physicians need to take care of Medicare patients. There are publications that evaluate the viability of a practice that is predominantly Medicare patients. The answer is in some areas of medicine and for us in orthopedics it's not really feasible anymore, and that has a huge effect on patient access. It used to be that everybody took Medicare. But as those rates go down and the return on investment for taking care of Medicare patients drops below zero, people will then elect not to take Medicare. And as our population ages, we cannot afford as a society to bring the Medicare rates so low that surgeons opt out, because that will be a huge challenge for patients. Everything that we do should be focused on them.
Q: How do you feel about the state of value based care in orthopedics right now? What are your predictions for its future? What does it need to thrive?
PT: That's a really complicated question. My crystal ball is probably not any better than yours. Many things have been tried, and every time something is tried it doesn't seem to work very well. As we look 10 years down the line, it may be that orthopedic surgeons have to be in control of a musculoskeletal health program, not just determine who needs surgery. Finding the financial win for patients and society around making sure that everybody gets the care that they need would be a huge step forward. It may come down to condition based care. If you have arthritis, here's how that's going to be reimbursed. It's a model that's starting to be looked at, and I don't know whether it will be successful. But for every model that has come up so far, there's always something good and something bad about it. So it's very difficult to say. We have policy experts who look at all of these things, so my opinion is far less weighty than theirs.
Q: What other healthcare trends have you been following closest?
PT: I'm following how patients wish to interact with the healthcare system and how employers are contracting with non-physicians. It seems like the youngest generation who are seeking healthcare are much more driven by convenience than quality. Not to say that they don't expect high quality. I think they do, but I don't think they see the quality difference as dramatically as someone who's older. Older patients seek out the best person to care for them and are willing to travel and wish to be seen in person. Younger patients are more comfortable with the convenience of virtual visits and immediate access.
There is also a real change occurring as many companies are trying to do portions of orthopedic care with non-physicians, using algorithms and with protocols. There's a lot of money going into this arena, and I worry that that's actually going to decrease the quality of care. Large companies are contracting with firms whose entire platform is to keep the patient away from the doctor. This group of middle-persons may be very bad for patients.