President's Perspective August 2011

Glenn WeinraubThe Ant and the Grasshopper
By Glenn M. Weinraub, DPM, FACFAS, President

One of Aesop’s fables, “The Ant & the Grasshopper,” concerns a grasshopper who has spent the warm months singing while the ant worked to store up food for winter. When the winter season arrives, the grasshopper finds itself dying of hunger and upon asking the ant for food is only rebuked for its idleness.
The story is used to teach the virtues of hard work and saving, and the perils of improvidence. Some versions of the fable state a moral at the end, along the lines of “Idleness brings want,” “To work today is to eat tomorrow,” and so forth. In my own life I always remember a sign that hung over the door of the Mammoth Mountain ski patrol office. It said, “Adapt or Die.” These lessons should be part of our daily philosophy as we prepare for and adapt to the changing face of healthcare.
Although the Patient Protection and Affordable Care Act of 2010 is the law of the land, the fact remains that it will continue to face legal interpretation, such that what lies ahead from a regulatory and administrative standpoint is yet to be defined.
As foot and ankle surgeons we need to be at the forefront of reform and change. Clearly we do not want to be in a position of having to play catch-up with regulations passed by bureaucrats who in reality have no true skin in the game. In short, we need to think like the ant!
Medicare provider payment reform is a key aspect of the Affordable Care Act. This reform allows the Secretary of Health and Human Services to develop new payment methods, such as shared savings arrangements with accountable care organizations (ACOs).
The concept of the ACO is a type of payment and delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated healthcare providers form an ACO, which then provides care to a group of patients. The ACO is accountable to the patients and the third-party payer for the quality, appropriateness, and efficiency of the healthcare provided. There seems to be three core principles for all ACOs:
 1.Provider-led organizations with a strong base of primary care that are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients
 2.Payments linked to quality improvements that also reduce overall costs
 3.Reliable and progressively more sophisticated performance measurement, to support improvement and provide confidence that savings are achieved through improvements in care.
What this means is that future reimbursement will not hinge on the volume of surgical procedures you perform, but rather on the care employed to prevent those procedures and on the outcomes obtained when surgery is truly required. I firmly believe that ABPS board-certified foot and ankle surgeons are best qualified to provide this type of care.
The key to our being able to provide it will be inclusion, and for that we should again think like the ant! We need to recognize that the genesis of most ACOs will lie with large hospital organizations and moderate- to large-size physician groups who join together. Both of these will have at their foundation a strong cadre of primary care representation. In the future we will most likely see the end of “volunteer” physician staffs. Instead we will see hospitals employing large numbers of physicians as they build their ACO teams.
To be included in this will require that we continue to support and participate in research that elucidates the superior value and outcomes of the ABPS board-certified foot and ankle surgeon. It will require that we position ourselves NOW on hospital boards and within academic health centers. It will require that no opportunity to educate a primary care colleague about our unique training and skills ever slips by. And yes, it will require effective legislative advocacy by your ACFAS and the APMA.
In closing I would encourage you to keep abreast of the rapid changes in healthcare reform. You may not like it, but the fact remains that it IS coming. All that remains to be seen is whether you will be the grasshopper or the ant.
Questions for Dr. Weinraub? Write him at

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