Cue bluesy background saxophone. Fade in image of Chicago’s rough and tumble streets: cars rolling by, steam spewing from manhole covers and rundown storefronts littering the landscape. Toss in some medical jargon and you’ve got yourself the makings for a primetime network drama.
Except this scene isn’t a Hollywood set and the characters are real people with real orthopedic problems. And that’s where this drama really begins.
Welcome to Dr. Daniel Ivankovich’s world. The orthopedic surgeon and team leader of “The Bone Squad” and founder of the Chicago Musculoskeletal Initiatives has made a career treating the uninsured of the Windy City.
Source: Steven Wallace
Windy City Orthopedic Blues
Chicago’s health care problems are like those of many other U.S. cities. But the need for care extends beyond the stereotype most have of the uninsured. Middle class and working class people comprise a big chunk of Chicago’s growing Medicaid population. Orthopedic-related problems are a major reason this population seeks care. “Back pain, obesity-related knee osteoarthritis in women, and alcohol and sickle-cell related hip osteonecrosis is quite common, ” explains Ivankovich. “Pediatric and adult fractures are seen in the clinics and ERs on a daily basis. Hip fractures are quite an epidemic in this community as well…And there are more gunshot-related injuries than I’d like to acknowledge. It’s very sad.”
But Ivankovich says it also puts orthopedics front and center in the delivery of comprehensive musculoskeletal medicine, especially if you take into account diabetes and vascular-related wound issues and limb compromise. “Orthopedic issues are responsible for 20-45% of what many primary care providers are seeing in these communities.” Ivankovich adds that the biggest obstacles to orthopedic in his opinion are:
Access to care
Transportation to care
Education about care and preventative medicine
Failure to treat orthopedic problems early can have a snowball effect which not only hurts the patient but can have even larger consequences in the community. For example, when an arthritic and painful knee deteriorates and prevents the patient from working their standard of living deteriorates. Among the Medicaid population, lack of care, poor diet and exercise increases the risk of a disability and ultimately becoming fully dependent on government for support. “When you’re handicapped and can’t walk, it’s very hard to live in an impoverished area. You get victimized in a multitude of ways.” In Dr. Ivankovich’s world, orthopedic care is much more than a life style decision but rather a key part of the economic and life saving fabric of his community.
The Mark of Medicaid
Could conditions improve for the uninsured when Health Care Reform is ushered in? It’s not that simple according to Ivankovich. “Health care reform won’t make much difference at all. Reform will cover uninsured patients via Medicaid. We’re pretty much the only clinicians accepting Medicaid. Until there’s a vehicle to make care more inclusive, the status quo will remain.”
Covering the uninsured through Medicaid won’t make specialists see them. Although he specializes in spine and large joint care, there are few orthopedic surgeries that Ivankovich turns down, from amputations to arm and hip issues. His pay for working with this particular population is, he estimates several hundred thousand dollars less than his colleagues at the larger hospitals or private clinics.
But Ivankovich is quick to point out that you can reap special rewards from this kind of practice. Results are more dramatic for the patients he treats. They aren’t just looking to get back to better golfing, they are leaving a wheelchair to walk again.
But the issues of the inner-city are complex and other problems contribute to the challenge of working with the Medicaid population:
Poor compliance with medication instructions, either because of finances or home situation
Low rates of compliance with post-operative follow-up treatments or physical therapy
Poor living conditions, including homelessness, physical or other abuse, drug use and obesity all can contribute to poorer overall outcomes and subsequent health problems.
To counter these issues, Ivankovich works with hospital social workers and rehab therapists who are, like him, working with the Medicaid population. A silver lining for surgeons is that there is plenty of real medicine to do and the competition is low. In terms of market opportunity, the Medicaid field is wide open for the right surgeon.
And the Bone Squad Is Born
“Dr. Vietta Johnson and I worked together for the Cook County Bureau of Health at Provident Hospital. It’s always been a multi-cultural group of health care providers: African-American, Caucasian, Hispanic, Indian, Slavic, etc. We wanted to be perceived as cool and contemporary doing positive things.
“We wanted to be like a modern day Mod-Squad for musculoskeletal medicine.”
With two-year-long waiting lists for back, knee and hip pain and an average of a five-year wait for a joint replacement, Ivankovich and his colleagues realized this was unacceptable and began to recruit other surgeons to join their pain-busting team. Today the roster, aside from Ivankovich and Johnson includes five other core members: Randon Johnson M.D., Mark Sokolowski M.D., Samuel Cordova, P.A., Thomas Rosen P.A., and Kathy Gillin, RTRM. But there is also a rotating list of string players as well.
Bone Squad Mobile and Dr. Dan Ivancovich examing a patient’s arm/Steven Wallace
“He’s the Really Tall Dude that Plays the Guitar”
That’s how many of Ivankovich ‘s patients know him, his name might be tough to pronounce for them, but his image is perhaps unforgettable. At six feet, ten inches tall, dressed in motorcycle leather and a cowboy hat, Ivankovich doesn’t look like your run of the mill surgeon. And his schedule isn’t standard by any means either.
Performing around 800 surgeries a year (which is double the rate of most surgeons according to Bone Squad stats) Ivankovich bounces between a dozen hospitals in the Chicago area, with around a third of the cases being uninsured patients. That ratio amounts to Ivankovich working twice as hard for around half the pay that most orthopedic surgeons would be netting. “Charity and regular practice is seamless for me I have no idea which patient has or doesn’t have insurance.”
But it appears Ivankovich wouldn’t have it any other way. Rolling between hospitals, through the Chicago inner-city in his supped-up black Dodge Magnum (with its custom seating, oh and under-car lighting) known as the Bone Mobile, the doctor says it’s easy to overlook the population he serves, of “gangbangers, frail old ladies and people who do dangerous work. Healthcare is all about freedom. But how do you just walk and keep going when you see a need?”
It’s on these same streets that Ivankovich’s music can be heard. The Northwestern-trained surgeon who completed his residency at Rush University and is fellowship-trained in Adult Joint Reconstruction, Reconstructive Spine and Traumatology is also a blues guitarist and vocalist whose shared the stage with Bo Diddley and Eddie Taylor. But even his musical career is intertwined with his passion for altruistic orthopedics. His band mates in the Chicago Blues All-Stars were not immune, with Ivankovich operating on the lead singer and giving the uninsured drummer a hip replacement.
In the OR with Dr. Ivancovich and staff/Steven Wallace
The One Patient Philosophy
Ivankovich isn’t trying to change the system, just each patient one at a time.
One of Ivankovich’s patients, Felicia Thomas, is a good example. The Harvey, Illinois 53 year old suffered a hyper-extended knee while gardening. Lack of proper care led to a progressive degenerative change in her knee to the point where she was unable to walk without a walker and had to hop around in what she described as excruciating pain. She couldn’t work or stand for more than a half hour at a time. Ivankovich diagnosed arthritis. “Nobody wanted to do what was necessary, ” he says, “and that was a total knee replacement.” After the surgery and several months of physical therapy Thomas reports that she’s gotten her “Mobility, freedom and life back.”
The Bone Squad went beyond the Chicago city limits to give Reading, Pennsylvania resident Jeffrey Jackson a hip replacement. After paying insurance premiums for two decades the senior couldn’t afford the $1, 600 a month and was left waiting for Medicare to set in, until doctors told him that his hip replacement was needed before then. All it took was an email from Jackson’s daughter to the team to set the surgery into motion.
Beyond Chi-town
But Reading is nothing compared to the other spots the team has ventured. “I’ve been referred to land-mine victims from the former Yugoslavia (my country of birth) and we remain quite connected with the work we did in Haiti after the earthquake, ” says Ivankovich.
Future plans for the team include developing into a full-scale 501(c)(3) not-for-profit to encourage donations and spreading the word to the next generation of surgeons.
“We have a great opportunity to take this work to new graduates and show them how they can profoundly impact people’s lives by bringing quality orthopedic care into the mix. I’d like to get to the point where every safety-net hospitals could have orthopedic surgeons based there.”
