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Keeping up with future demand for joint arthroplasty will prove challenging
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An impending convergence of growing patient demand, plummeting reimbursement rates and fewer orthopedic residents entering the field of joint replacement may create havoc for the U.S. health care system in the coming years, unless measures are taken, according to several trend observers interviewed by Orthopedics Today.
“We find that total joint replacement is increasingly being accepted in society,” said Steven M. Kurtz, PhD, a corporate vice president at the Philadelphia office of Exponent, a scientific and engineering consulting firm. “More and more people are receiving joint replacements and walking around with joint replacements. Generally, these people have good experiences and tell their friends. People, especially in the United States, want to maintain a more active lifestyle, rather than being satisfied in limiting their lifestyle based on arthritis pain.”
But how many surgeons will be available to serve to this increasing patient demand for total joint arthroplasty (TJA)? Two variables are how rapidly joint replacement surgeons can be trained and at what age existing surgeons retire, according to Kurtz, who was lead investigator of an international survey of primary and revision total hip replacement.
Furthermore, in 2008, between 52% and 54% of primary TJA cases were paid for by the government through Medicare.
“Many joint replacement surgeons express dissatisfaction with the trends in their reimbursement by Medicare,” Kurtz said. Compared to other orthopedic specialists, “it appears that generally orthopedic surgeons are having to work more for less money,” which sways many residents to pursue other subspecialties such as spine or sports medicine.
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Image: UCSF Medical Center |
Kevin J. Bozic, MD, MBA, an associate professor and vice chair of orthopedic surgery at the University of California, San Francisco, envisions a shift in cost to the patient, in response to a growing consumer-driven/market-driven health care system. As a result, “patients seeking health care will have better information on both the cost and the quality of care being provided, therefore becoming more savvy consumers of health care services and more wise on how they spend their health care dollars,” he said.
Care will also need to be delivered more efficiently, so an increased number of patients can receive joint replacements. “This will occur through improved processes of care, and probably better alignment and collaboration between the various stakeholders: surgeons, hospitals, device companies, health care plans, purchasers of health care — and most importantly — patients,” Bozic said. Other requirements include more judicious use of expensive, and in some cases unproven new technologies, as well as delivering care in more efficient settings, such as specialty hospitals or even ambulatory surgery centers, without sacrificing quality.
‘Perfect storm’
Kurtz forecasts that the joint arthroplasty market could be headed toward a “train wreck” within the next decade or so, unless, for example, the Medicare reimbursement schedule becomes more favorable, or at least stable, to orthopedic surgeons. “Every year, surgeons who treat Medicare patients worry that their fees are going to be whacked by 30%,” he said. Kurtz also believes there will be no new therapies emerging over the next 5 years to reduce the demand for TJA.
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“Anytime you predict an annual patient-case shortfall in the range of 500,000 to 1 million for hip and knee replacement there is a big problem,” said Thomas K. Fehring, MD, co-director of the hip and knee center at OrthoCarolina in Charlotte, N.C., who was also lead author of a December 2010 Journal of Arthroplasty study on joint replacement access in 2016 being a supply-side crisis.
“I was surprised by how severe the shortfall will likely be. This will result in delayed care for joint replacement patients. Even if our predictions are off by 50%, there will still be a huge number of patients who will not receive treatment in a timely fashion,” he told Orthopedics Today.
The graying of the baby boomer generation, more people living longer and the obesity epidemic “create the perfect storm” as catalysts fueling the increased demand for TJA. According to Fehring, “There is a direct correlation between obesity and arthritis,” he said. “At our specific practice, in the 1990s the number of patients who were obese was low. But now about 50% of the patients we operate on are obese.”
In addition, the number of orthopedic residents interested in pursuing joint replacement as a career “has declined significantly over the last 10 to 15 years, as reimbursement has gone down, while the demand for total joint replacement has risen exponentially, Fehring said.
Revision rates
Assuming revision rates for TJA, now in the range of 1% to 2%, remain the same in the coming years, the sheer number of revision cases will also grow as the number of primary surgeries increase. “A general orthopedic surgeon is usually reluctant to perform revision surgery because it is much more complicated and much more time-consuming, plus it is not reimbursed very well,” Fehring said. “For these reasons this revision burden will be borne by a diminishing work force resulting in further delays in treatment for patients requiring revision surgery.”
Like Kurtz, Fehring is unaware of any new therapies on the horizon that might reduce future TJA demand. Conversely, with the success rates with current technology, he is at a loss to identify any new therapies that could potentially increase demand.
One slight bright spot noted in Fehring’s study is that statistics were collected before the current economic downturn; therefore, some surgeons may be delaying retirement by up to 5 years (age 65 instead of 60). “But this shift in retirement age is not going to make a huge difference in the number of procedures expected,” Fehring said.
Fehring believes it is important that health care economists and government “be aware of this looming crisis before it becomes a crisis. That was my motivation to write the paper. I’m concerned about access for my arthritic patients. Can we train more orthopedic surgeons in the short term? Not really. There has to be some long-term stimulus for more people to enter this field.”
Fewer orthopedic specialists
Richard Iorio, MD, director of adult reconstruction at the Lahey Clinic in Burlington, Mass., pointed out that the nation’s economic downturn has resulted in the number of total joint replacements being relatively level.
“We’ve actually had a couple years of flat growth,” he said. “However, as the economy recovers, we expect those numbers to increase.”
Iorio also confirmed that fewer orthopedic residents are entering the specialty of adult reconstruction, “so we foresee fewer specialists in the future to accommodate the really complicated joint replacements.”
He added his concerns over decreasing reimbursements. “In absolute dollars, reimbursement for joint replacement was more than $2,000 in 1991, whereas it now hovers around $1,300,” Iorio said. CMS has targeted DRG 544 and 545 for cost reduction because “these are two of the costliest DRGs in the Medicare program.” Iorio also expects reimbursement rates for total joint replacement to continue to deteriorate in the coming years.
Also, most residents are between 25 and 35 years old. “This is a different generation,” Iorio said. “They want to have some lifestyle considerations. Doing joint replacement is hard work. It requires having patients in the hospital. The obesity epidemic also means that these patients we operate on are increasingly more difficult to take care of.” Long-term relationships are also established with joint replacement patients, “where you take care of these people for years and years and years.”
Some of the other orthopedic specialties, like sports medicine or foot and ankle surgery or even trauma surgery, have more predictable and set hours. Plus, the reimbursement for spine surgery “remains very high, so there is no lack of spine fellows,” Iorio said. “Still, joint replacement is the single most quality-of-life improving intervention in medicine today.”
Without a quick fix to reimbursement issues, “I believe we are rapidly approaching that point where it will be difficult for the complicated patients to easily find a qualified joint replacement surgeon to help them. This is a shame,” Iorio said.
New payment scenarios
Bozic conveyed that episode-of-care (bundled) payment programs are being tested in several U.S. markets. “This is essentially a single lump-sum payment that is distributed among all the physicians and the hospital that provides care, over the entire episode of care,” he said. Instead of every entity being responsible and accountable for its own piecemeal of the care and being paid accordingly, “going forward they will be responsible for coordinating care among the various providers, and thereby look for ways to improve quality and reduce the overall cost of care. Entities are more incentivized to work as a team for the benefit of their patients.”
Hence, these various stakeholders could each have their compensation increased by interacting in a collaborative fashion to reduce cost; for instance, eliminating duplicate tests, not ordering unnecessary hospital lab tests and X-rays, and avoiding costly readmissions to the hospital.
On the other hand, the federal government’s Patient Protection and Affordable Care Act of 2010 will likely have little effect on TJA demand. “This legislation is certainly not insurance for all, but there are provisions to provide basic government sponsored health insurance to approximately 30 million additional Americans,” Bozic said. “While this provides people some basic coverage for preventative and primary care services, it does not necessarily guarantee access to elective care such as total joint replacement. For elective orthopedic procedures like joint replacement, you need a willing provider of care. We’ve already seen a significant decrease in the number of physicians who accept Medicaid, and these patients will have essentially Medicaid insurance.” – by Bob Kronemeyer
Reference:
- Fehring TK, et al. J Arthroplasty. 2010; 25(8):1175-1181.
- Kevin J. Bozic, MD, MBA, can be reached at 500 Parnassus Ave. MU-320W, San Francisco, CA 94143; 415-476-3900; e-mail: BozicK@orthosurg.ucsf.edu.
- Thomas K. Fehring, MD, can be reached at OrthoCarolina, 2001 Vail Ave., Suite 200-A, Charlotte, NC 28207; 704-323-2564; e-mail: thomas.fehring@orthocarolina.com.
- Richard Iorio, MD,can be reached at Lahey Clinic, 41 Mall Road, Burlington, MA 01805; 781-744-8227; e-mail: Richard.iorio@lahey.org
- Steven M. Kurtz, PhD, can be reached at 3401 Market St., Suite 300, Philadelphia, PA 19104; 215-594-8851; e-mail: skurtz@exponent.com.
Is the orthopedic community prepared to handle the proposed increases in TJR utilization in the coming decade?
Committed to averting crisis
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During the next decade, the orthopedic community will be challenged to provide care for patients who need total joint replacements. I fear the setting of a perfect storm: increased demand among older patients for joint replacement surgery due to the aging of the population; increased demand among younger patients due to unwillingness to accept a decline in functional activities; a decreasing number of adult reconstructive surgeons; and the perpetual pressure to lower reimbursement to surgeons. Moreover, I believe it will be even more difficult for patients requiring revision arthroplasty or those with an infected total joint to find appropriate care if the surgeon who performed the primary procedure is not available or capable of managing the revision. Hospital systems may not welcome these patients with the cost of care exceeding the Medicare reimbursement.
The American Association of Hip and Knee Surgeons (AAHKS) remains committed to averting this crisis. We are highly engaged in the training of future arthroplasty surgeons. We have been concerned about the decline in the number of residents interested in arthroplasty as a career and are working hard to reverse that trend. Our second resident course at the AAHKS annual meeting in Dallas in November 2010 was completely full; we are able to offer this course at no cost to residents due to generous unrestricted educational grants from industry partners. We are also developing a new mentoring program and started a match program for fellowships, which went very well. In addition, we have a health policy fellowship to nurture selected individuals and prepare them for an active leadership role in the orthopedic community.
Creating value in the health care system for arthroplasty patients is also a major focus of AAHKS. The health care system must be efficient to accommodate the projected increase in total joint cases. For the past 18 months, we have worked hard on the development of an outpatient knee quality measures set. The American Academy of Orthopaedic Surgeons and the Knee Society will partner with us as we move this measure through various agencies for approval as a quality metric. It is important that surgeons develop such quality metrics for surgical procedures. We are best-positioned to understand how to reach the right outcome for the patient while eliminating waste and lowering cost. All of this, of course, must be done while maintaining safety and quality. This is no small task but we are committed to this effort.
The voice of the patient must be heard over the crashing waves of the storm. Access to specialty surgical care must be preserved. AAHKS feels very strongly that our responsibility is first to our patients and we are very active in such advocacy efforts.
Mary I. O’Connor, MD, is chair
and an associate professor in the Department of Orthopedic Surgery at the Mayo
Clinic in Jacksonville, Fla. She is also president of the American Association
of Hip and Knee Surgeons (AAHKS).
Rely on existing resources
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There is a coming storm that is first based on the need. There is no doubt that there are going to be significantly increasing numbers of patients requiring joint replacement surgery in the future. Not only has the life expectancy of our population been rising, but the expected needs and wants of our patients have also increased over time, in that these patients want to remain active.
However, we are in a crunch because it is unlikely that we will be able to obtain additional resources to take care of those patients. Surgeon fees are not an issue, though, because fees have been somewhat set and have been going down for years. The additional resources required from the health care system for us to deliver this care in a growing number of patients must be identified.
The experience for a joint replacement surgery is much more than the patient’s experience in the hospital. When we look at the entire care experience through a full cycle of care from a patient’s and family’s perspective, there is much more to it. This includes time spent in the doctor’s office, time for teaching and education, time for testing and preparation for surgery, time for exercises (both before and after surgery) and time and resources to deliver care in the hospital (from both the hospital and surgeon’s side). You also have to think about care in the home, such as in-home rehab and nursing, as well as out-patient rehabilitation services.
Sometimes the complexity of the health care system does not allow us to think and do things differently. We need simple solutions. Surgeons have 100% influence over only two variables: our patient’s and family’s care experiences and the resources or overhead. Therefore, we need to evaluate this full cycle of care from the patient’s and family’s perspective, and not merely from the doctor’s and hospital’s perspective. We then need to take existing resources, while not necessarily asking for new ones, and refocus those resources on the needs of patients and families.
By creating a seamless transition of care from the patient’s and family’s perspective, I believe the orthopedic community will be prepared to handle the increase in the projected numbers of joint replacement cases. Such a process fosters high-performing care teams that are innovative and extremely efficient. This approach also results in the best outcomes.
Anthony M. DiGioia III, MD, is an
orthopedic surgeon in private practice in Pittsburgh, Penn. He is also medical
director of the orthopedic program at Magee-Womens Hospital of University of
Pittsburgh Medical Center (UPMC).