In the past, not being able to get an appointment with Dr. X for three months said something about the good doctor’s talents and/or popularity. No more, say our experts. The economics of the recession—both now and for a long time to come—may just mean that not getting prompt treatment by any adult reconstructive specialist isn’t about caché…it’s reflective of a stark new reality.
In 2009, the American Association of Hip and Knee Surgeons (AAHKS) set out to assess the effects of the recent recession, with an eye towards the years to come. Of the 953 AAHKS members surveyed, a full 458 (48%) responded to questions regarding issues such as surgical and patient volume, hospital relationships, total joint arthroplasty cost control, potential impact of Medicare reimbursement decreases, and attitudes toward retirement planning.
The study’s lead author was Dr. Richard Iorio, the director of adult reconstruction at the Lahey Clinic Medical Center and professor of orthopaedic surgery at Boston University Medical School. He told OTW, “Because of the economic downturn, plummeting reimbursements, and total joints being an area open to significant legal risk, adult reconstructive surgery is not something that is appealing to up-and-coming orthopedic surgeons. Combine this with the fact that a multitude of reconstruction specialists will reach retirement age in the next few years, and we are headed for a crisis—patients will just not be able to be seen in a timely fashion…and they will suffer.”
Commenting on the study findings, Dr. Iorio says, “Due to the economic downturn, 30% of surgeons surveyed reported that their surgical volumes decreased and 29% reported that outpatient visits also decreased. The changing economic realities of today’s retiree were also apparent in the study, with a mean loss of 29.9% of retirement savings and a reported planned retirement age that has increased to 65.3 years from 64.05 years. These more difficult economic realities have decreased demand for adult reconstruction services. As the economy improves, demand for adult reconstruction services will again outpace the supply of surgeons willing to supply these services.”
A co-author, Dr. Mary O’Connor, associate professor of orthopedics at Mayo Clinic in Jacksonville, Florida, also waded through the disconcerting data. She notes,
The time is on the horizon when patients are going to have to wait longer and longer to see a total joint specialist; when they can’t get the care they need, most likely it is only then that the reasons for the delay in care will (hopefully) be addressed.
“We are trying to address this workforce shortage with efforts to recruit more young surgeons into adult reconstructive fellowships. It really is a great specialty. But the problem is multifactorial and I’m skeptical that substantial improvement will occur until there is a real patient access crisis. At present there is no clear recognition on the insurer level that reimbursements for total joint surgery should be increased, particularly for revision procedures. Those of us who do revision surgery, which is especially complex, do it because we are deeply dedicated to our patients.”
On this point, Dr. O’Connor adds, “These are difficult surgeries that involve a lot of time and effort, in addition to a substantial risk of litigation. So if you wanted to be a productive surgeon with less stress and better reimbursement, you would not do revision joints. Again, these are very complex cases; I tell my staff not to put more than one revision surgery a day on my schedule because revisions simply take more out of me…they are more physically and mentally demanding.”
Digging into the political fundamentals, Dr. Iorio states, “The government must come to a conclusion as to how healthcare will be funded; part of this is taking a hard look at how much of our Gross Domestic Product they are willing to commit to it. Total joint replacement is one of Medicare’s most expensive Diagnosis-Related Groups, a cost that will only increase if patients are not treated and then become disabled. Politicians understand that these services are desired by their constituents, but the way government resources are distributed at present means that we don’t have enough money to pay for them. We need a new funding mechanism for healthcare.”
Photograph by Jocelyn Augustino / Wikimedia Commons
Of the data, Dr. O’Connor says, “Although we saw a slight increase in the planned retirement age it is unlikely that this is enough to offset the access problem. Even though the surgeons (on average) said that they would work one year longer than before the economic downturn, we can’t assume that they will do the same volume of work. In their preretirement year in particular they won’t be doing as much surgery. We also found that there is a reimbursement threshold at which point our members will say ‘Enough. I won’t operate on patients if you’re going to pay me less than XYZ amount.’ At least 50% of the orthopedists in our survey said that they are no longer operating on Medicare patients…the population that is most adversely impacted by declining reimbursements.”
Surgeons aren’t the only ones watching this tumble…hospitals as well are taking note of where exactly the money is leaking out of their institutions. Of the doctor/hospital relationship, Dr. O’Connor says, “As providers and hospitals become even more aligned there may be an increased recognition by hospital administrators regarding the cost of performing revision joints and caring for infected joint patients, particularly those with Medicare. The trend could be that hospital administrators will say, ‘Dr., if one of your surgical patients returns with an infected knee, you can do the revision surgery. But I don’t want you doing these surgeries on patients who had their now infected joints put in at other institutions.’ In fact it would be interesting to ask providers in a future survey, ‘Has your hospital’s administration raised concerns about/or attempted to regulate your practice of revision joints?’”
Bringing the implant manufacturers into the picture, Dr. Iorio advocates for consistency and clarity.
One way to control costs is for hospitals to put a ceiling on the amount that they will pay for implants…perhaps using a system whereby hospitals choose one implant system and manufacturers bid for the contract.
“The problem in joint replacement is that there are a lot of technologic innovations that require an incremental cost increase. But, we need to figure out what a good implant is, i.e., one that lasts a long time and cuts down on the complication rate. Also problematic for hospitals is that manufacturers aren’t transparent. For example, hospital X in Chicago doesn’t know what hospital Y in a neighboring city is paying for the same implant. Complicating the situation is that if all doctors in a hospital want a different company’s implants then this lessens the institution’s purchasing power.”
Dr. Iorio adds, “We conducted this survey before President Obama’s new healthcare initiatives were signed into law. Once we figure out where all of this is going, then we will have a better sense of how to respond. The fact is that if we extrapolate nationwide from what has been done in Massachusetts—my state—the system will likely go broke.”
And, says Dr. Iorio, the average person—understandably—isn’t shedding any tears over orthopedic surgeons’ situation. “What gives me hope is that joint replacement surgeons delivery quality care day in and day out. Although our patients are our strongest advocates they usually don’t understand the inadequacies of the funding mechanisms…and no one is crying for surgeons. Yet we have to acknowledge that we accumulate—on average—14 years of extensive training before we can begin to work. Once in practice we are working with patients who tend to be heavy, whose problems require a high degree of skill, and—unlike many other subspecialties—must be followed for 15 to 20 years. But change will not come from doctors as we are a small portion of the population. There are about 20, 000 orthopedic surgeons in the U.S. doing close to a million joint replacements each year. Only 2, 000 of those surgeons perform more than 50 total joint surgeries per year…change will come from the patients.”
Dr. O’Connor: “To help facilitate that change, I have seen some orthopedists in private practice distributing educational handouts on Medicare reimbursement and issues of access. We clearly need to educate the public better than we have. Last year Dr. Neil Sheth surveyed patients in Chicago to understand what they think their surgeon was paid to perform a total joint and then if they felt the Medicare reimbursement level was appropriate. Most patients felt the reimbursement was too low. This paper has been submitted for publication. My fellow, Dr. Joel Tucker, and I are partnering with Dr. Sheth to perform a similar survey at our institution which will provide a broader base of data. In addition to education, we need both surgeons and patients to become and remain politically engaged. Fortunately, the AAHKS is particularly advocacy oriented: we have the highest donations to the orthopedic political action committee of any specialty group. But this is going to be a long haul—for everyone.”
