“The year 2010 was huge for orthopaedics, ” wrote S. Terry Canale, M.D., in the December issue of AAOS Now, the American Academy of Orthopaedic Surgeons’ monthly publication. Canale is the publication’s editor-in-chief.
S. Terry Canale, M.D.“It started with a bang—the massive earthquake in Haiti that made heroes out of ordinary orthopaedic surgeons. As the year progressed, we had to contend with healthcare reform, clinical guidelines that could actually change clinical practices, and increased scrutiny on orthopaedic practices—from the use of pain pumps and platelet-rich plasma to the increase in SLAP [superior labrum from anterior to posterior] surgeries and a drop in the use of metal-on-metal hip implants, ” wrote Canale.
Canale, in AAOS NOW named the top ten orthopedic developments of 2010, also noted special attention paid to surgeons who neglected to disclose their ties to industry and the shift in ownership of orthopedic practices.
Here is Canale’s list (with our paraphrasing):
Helping Haiti
Financial and other disclosures
Off-label (physician-directed) treatments
Farewell to the independent physician?
“Obamacare”
Pain pumps and the chondrolysis controversy
SLAP repair scrutiny into possible procedural overuse
Platelet-rich plasma efficacy debate
Clinical practice guidelines for periprosthetic joint infection of the hip and knee and vertebroplasty
Red flags regarding metal-on-metal (MoM) hip implants
In detail, then, here are our picks for the top five orthopedic news stories for 2010.
Haiti
“Who wouldn’t be proud of the hundreds of orthopaedic surgeons who…went down to the Caribbean, not to vacation, but to work under some of the most appalling conditions imaginable, ” wrote Canale
He noted that within 48 hours of the earthquake in January, AAOS fellows were either on their way to Haiti or had contacted the academy about volunteering.
More than 500 AAOS members traveled to the island to provide immediate care. Many physicians, hospitals, and manufacturers donated supplies. “In the aftermath of the earthquake, surgeons operated wherever they could, including performing surgery outdoors using car headlights to illuminate the operating field, ” Canale added.
One news report noted that almost a third of patients at one makeshift hospital would die of “Crush Syndrome” without surgery. Patients were dying of sepsis from untreated wounds. Large numbers of those patients needed amputations.
But perhaps no story about the difficulties encountered by the surgeon volunteers was as graphically demonstrated as the efforts led by David Helfet, M.D., and Dean Lorich, M.D. from New York’s Hospital for Special Surgery.
Within hours of the quake, Helfet’s team was on its way to Haiti in a Synthes plane. They were joined by physicians from New York-Presbyterian Hospital and began working round the clock.
The day-by-day account and graphic photos taken and shared by Lorich brought the orthopedic disaster home in a very visceral way to our readers.
Lorich and Helfet didn’t mince their words upon their return to New York when they publicly criticized the U.S. government for not acting quickly and effectively enough to provide security and logistical support to the volunteers racing to the disaster.
The call for help from Haiti was unprecedented and immediate. Those in the orthopedic community that answered the call, shined brightest in the moment of greatest need.
Disclosure
“None of us enjoyed reading headlines such as ‘Doctors given millions fail to disclose device-industry ties, study shows’… Even if the relationship is totally legitimate and, in fact, may be beneficial to patient care, the fact that it wasn’t revealed created problems, ” wrote Canale.
It wasn’t just the failure of full disclosures by some surgeons as they took to the podium at society meetings and authored papers for medical journals that created problems. It was actual disclosures that, by the end of 2010, resulted in sensational stories in the Wall Street Journal and Bloomberg News about surgeon payments. Medtronic began to voluntarily disclose annual payments in May and disclosed that it paid more than $15.7 million in royalties and consulting fees to U.S. physicians in the first quarter of the year.
Those disclosure provided fodder to some news organizations as they attempted to connect the dots between spine surgeon income and volumes of “questionable” spine surgery. As we pointed out in OTW (Reclaiming the Patient Outcome Argument, January 4, 2011), in response to the articles, a lack of a “batting average” for individual surgeons’ success rates leaves patients and payers guessing if surgeries are likely to be successful.
Off-Label (Physician-Directed) Use
Canale wrote that off-label use made headlines this year, particularly in the pharmaceutical area, where big cases were decided and hefty fines levied against manufacturers accused of promoting drugs for unapproved uses.
“In some ways, physicians may be ahead of regulators in expanding the use of some materials to support patient safety. For example, antibiotic cement has only limited approval for use—in the second stage of a two-stage total knee arthroplasty revision. But in an effort to reduce periprosthetic infections, many surgeons are regularly using it for primary arthroplasties.”
Canale says he believes that the most important aspect of this issue is informed consent. “There’s nothing wrong with physician-directed use of a drug or device to improve outcomes, but the physician ought to know what he or she is doing, ought to share that information with the patient, and ought to keep the [FDA] informed of any problems through its MedWatch system.”
In spine, we saw the off-label use of BMPs (bone morphogenic proteins) continue to be the poster child for regulators, personal injury lawyers, payers and media as an example of surgeons using products because of relationships with manufacturers.
Farewell to the Independent Physician?
Perhaps no issue has the potential to change the landscape of medical delivery more than the trend of the hospital employment of physicians.
The weight of this trend was brought home in September when Medtronic CEO Bill Hawkins told investors, that while the device companies still market to surgeons, hospitals are increasingly becoming the main focus of sales efforts.
More hospitals are acquiring physician practices, have more physicians on staff and are responding to reimbursement pressures associated with healthcare reform legislation. Hawkins said hospital technology committees are starting to work with their physicians to cut costs and at the same time, hold those physicians more accountable for total costs.
Canale wrote that some experts are pointing to younger surgeons “who have different priorities than my generation of surgeons and who don’t want to take night or weekend emergency call, do want to work regular hours, and would rather a hospital shoulder the administrative, regulatory, and medical-legal burdens of running a practice. A recent national survey of 2, 400 physicians found that nearly 3 out of 4 were planning on retiring, working part-time, closing their practices to new patients, becoming employed and/or seeking nonclinical jobs in the next 1 to 3 years.”
“With the demise of fee-for-service payments under PPACA [Affordable Care Act] and the changing demographics of both orthopaedic surgeons and their patients, this is a trend that’s likely to continue, ” predicted Canale.
We saw some surgeons, seeking to maintain their independence, respond by finding new ways to keep control of their practices by starting physician-owned distributorships and physicians from Tyler, Texas, headed to federal court to fight provisions limiting their ability to own and operate their own hospitals.
In a year-end review of the orthopedic sector, BMO Capital Markets analyst, Joanne Wuensch wrote that according to the MGMA Physician Compensation and Production Survey Report 2010, ~55% of responding practices were hospital-owned, from ~25% in 2002, while the share of physician-owned responders declined from ~70% to less than 40%. She noted Boston Scientific management estimated the percentage of hospital-owned practices could eventually level off at upwards of 70%-75%.
Wuensch says there are several downsides for device manufacturers. “Resulting vendor consolidation may limit the arm-wrestling power of a smaller market participant… It also could result in increased pricing pressure: while changes to Medicare reimbursement rates are one direct and quantifiable variable affecting pricing, the creation of accountable care organizations (ACOs) and gain-sharing programs could have long-term effects that may be harder to evaluate and project.”
Introducing “Obamacare”
“Although the healthcare reform act does extend coverage to millions of Americans and contains a number of positive provisions designed to improve patient access to care and increase insurance coverage, many believe that it will do little to stem rising healthcare costs or improve the quality of care, ” wrote Canale.
Canale noted that the act provides funding for comparative effectiveness research, studies into improving quality of care, and the transition to electronic medical records, but fails to address the issue of comprehensive tort reform and does nothing to fix the broken Medicare Sustainable Growth Rate formula.
He also noted the creation of an Independent Payment Advisory Board, restrictions on physician hospital ownership, and mandates participation in the Physician Quality Reporting Initiative.
AAOS opposed the passage of the Act and the academy’s president, Joseph Zuckerman, M.D., got into a very public squabble with President Obama over comments the president made about scalpel-happy surgeons. The opposition by the Specialty Societies was at odds with support of the bill by the American Medical Association and exposed a big split in the physician community over reform.
2011
Looking into the new year, what issues are likely to emerge?
We think that issues relating to disclosure, negotiating with reimbursers over the consensus definition of medical reasonableness or necessity for specific procedures and the increasingly unsettled distribution system for orthopedic implants will make headlines all this year.
To read the entire text of Dr. Canale’s article, click here: http://www.aaos.org/news/aaosnow/dec10/clinical1.asp
