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Surgeons weigh in on the supply of orthopedic surgeons in the United States

Practice patterns, patient demographics and other factors make it difficult to ascertain the demand for orthopedic surgical services.

Issue: November 2012

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I have had an opportunity to travel and lecture to many large and small groups around the United States for the past 2 years and have been impressed by the large number of orthopedists serving relatively small populations in urban and rural areas compared to 5 years or 10 years ago. Some of the orthopedist-to-resident population ratios have been as low as 1 orthopedist to 4,000 people in a given area. In many desirable urban areas, there are virtually no private practice or hospital employment orthopedic jobs available as older orthopedists work longer and postpone retirement. Yet, articles continue to be published about a predicted shortage of specialists in the future.

In this Orthopedics Today Round Table, panelists discuss if there are any data to support the contention of an orthopedic specialty shortage.

Jack M. Bert, MD
Moderator

Jack M. Bert, MD: What has been the role of the American Academy of Orthopaedic Surgeons (AAOS) regarding the assessment of orthopedic surgical workforce needs in the future?

Joshua J. Jacobs, MD: The AAOS has had a longstanding history in evaluating workforce issues in our specialty. In 1995, the AAOS commissioned the Rand Corporation to investigate future orthopaedic surgical workforce needs. During that era, managed care was becoming popular leading the Rand Corporation to conclude that by 2010, there would be a surplus of 4,122 full-time equivalent orthopedic surgeons. With the advantage of hindsight, we now know that this conclusion was erroneous since, if anything, there is currently a perceived shortage of orthopedic surgeons.

The Rand Study illustrates the difficulty in performing workforce projections. The AAOS, through its Department of Research and Scientific Affairs, regularly surveys and catalogues the orthopedic workforce by state. This and other information gives us a good handle on the supply of orthopedic surgeons. However, the demand for orthopedic surgical services is much more difficult to ascertain given changes in practice patterns, patient demographics, availability of physician extenders, new technology and new payment models.

The current conventional wisdom is that there will be a shortage of orthopedic surgeons in the future, based on the aging of the baby boom generation, increasing life expectancy, the epidemic of obesity and the maintenance of high levels of activity in a growing subset of patients of advanced age. The demand for orthopedic surgical services will likely further intensify as more of the U.S. population obtains health insurance via the Patient Protection and Affordable Care Act (PPACA).

Bert: Is there any data to support the contention that there will continue to be a shortage of specialists in coming years?

A. Alex Jahangir, MD: While I understand your observation that there seems to be a recent increase in the number of orthopedic surgeons treating relatively smaller populations of people, I would propose that this phenomenon is temporary as it is possible that many older surgeons have delayed retirement and will begin to retire once the economy improves and retirement becomes more financially stable. This will once again open positions in the potentially more desirable urban setting for new surgeons finishing training. Furthermore as more surgeons retire, the potential shortage of orthopedic surgeons to treat the increasing number of older Americans, projected to be more than 71 million, will indeed become a real problem. I make this statement with the caveat and assumption that there will be no change to the American health care delivery system in the future, which may decrease the current demand patterns for orthopedic services.

Nicholas A. Sgaglione, MD: Observations remain consistent in the New York City metropolitan region where increasing trends have been noted toward hospital-based employment of orthopedic surgeons. In contrast, a reduction in private practice-based positions has been observed. Many factors may be responsible, including geographic phenomenon, economic uncertainty, health care reform and changing practice paradigms. In addition, the emphasis on specific subspecialty pursuits, and the reduction in the number of “generalists” in a fellowship-centric rich subspecialty medical society have been noted to impact workforce job availability.

Despite these observations, current orthopedic surgeon workforce illustrations in the New York region where I practice are far from consistent with the shortages described in July’s New York Times front page article, which spotlighted Riverside and San Bernardino counties in California.

Bert: Have you noticed a shortage or overabundance of orthopedic surgeons in your respective areas?

Jacobs: I practice in a large urban center. I am not aware of either a shortage or overabundance. Graduates of our residency and fellowship programs seem to be able to obtain a position in the geography of their choosing, although the main growth of new orthopedic surgeon jobs seems to be in suburban and exurban areas.

Jahangir: As I look at the southeastern United States, my home for most of my life, the shortage of orthopedic surgeons is real. According to the April 2010 AAOS report on the state-level changes in AAOS orthopedic fellows, three of the eight states with a relative low number of orthopedic surgeons per population were southern states: Arkansas, Florida and Louisiana. More concerning is that Arkansas and Florida were the only states in the country identified as having a relative low number of orthopedic surgeons with a trend of fewer surgeons entering the market resulting in a potential future shortage of orthopedic surgeons in these states.

Interestingly according to the AAOS report, Tennessee, my home state, has a relative high number of surgeons per population. However, similar to most states, many surgeons practice in larger cities leaving many rural areas without orthopedic care. According to a recent report on the impact of health reform in Tennessee and the implications on health care manpower, it was estimated that of the 910,215 Tennessee residents who are currently uninsured, 558,044 will receive coverage under the PPACA, reducing the uninsured from 16.7% to 6.5 %.2 This is predicted to place “substantial burdens on regions in Tennessee that are experiencing health manpower shortages.” This study also noted that 44 of the 95 counties in Tennessee have an inadequate amount of primary care and specialty physicians. Finally, this report projects that there will be an annual increase of 175,226 visits to surgical specialist in the state of Tennessee as a result of the PPACA. With this potential increase of people requiring surgical specialists and the fact that many of the rural areas have no access to musculoskeletal care, the predicated future shortage of orthopedic surgeons is a potential problem in the Southeast again assuming that there is no change in the American health care delivery system.

Bert: Is it possible to develop an accurate methodology in 2012 to determine if an orthopedic surgeon shortage exists in a specific area of the United States that can benefit graduating fellows in the future? If so, how could it be accomplished?

Jacobs: The determination of the supply side of the workforce equation is relatively straightforward. However, the determination of the demand side of the equation is fraught with difficulty, particularly in the era of health care reform. In a published summary of a workforce symposium held at the American Academy of Orthopaedic Surgeons meeting, Michael Simon, MD, concluded in 1998 that “I am of the opinion that we are not smart or wise enough to predict accurately the workforce needs in the future.” I tend to agree with Dr. Simon.

Jahangir: The question of whether there will be a surplus or shortage of orthopedic surgeons in the future is a question of what will the demand for orthopedic services be in the future. As I noted previously, there will indeed be an increase in the number of older Americans who, under our current health care delivery system, will result in an increased demand for orthopedic services such as arthroplasty. However, as the American health care system continues to evolve, one potential result may be that more of the financial burden for health care services will be shifted to individual patients rather than third-party payers. I believe that if this shift of financial responsibility were to occur, then the demand for orthopedic services will decrease compared to today as a person who might have received an arthroplasty if it was paid for by Medicare may forego this procedure if he or she had to pay thousands of dollars out of pocket. This change in the health care delivery system that would place more of the financial burden of health care on a patient would result in a decrease in the number of needed orthopedic surgeons as a percentage of the population of a community compared to the situation today.

Obviously, I am making a bold assumption that the health care delivery system will change drastically, but I believe it is prudent for us as a specialty to be aware of the impact of all potential scenarios as we enter a new reality that focuses on the increasing costs of health care delivery and initiatives to reform health care.

Unfortunately, the ability to develop a methodology to accurately predict shortages in orthopedic care so that future orthopedic surgeons can position themselves best for successful practice after training is difficult. The difficulty is because of many uncertainties regarding the future, including the impact of the PPACA as well as the state of the U.S. economy in the future. While a full discussion of the PPACA is beyond the scope of this Round Table discussion, the law will certainly impact the demand for orthopedic services, patient access to services, physician reimbursement and regulations in the practice of medicine.

Additionally, the future of the U.S. economy impacts predictions for future workforce issues as the health of the economy impacts whether older physicians retire, as well as the demand for care. Specifically, economic models have demonstrated that for each 1% increase in gross domestic product, the demand for specialty physicians, including orthopedic surgeons, increases by 0.75%.

Finally, one must consider that any projections about future workforce needs must be able to predict 5 years to 20 years in the future, as people entering orthopedic residencies today are committing themselves to a career that will not begin for at least 5 years after their commitment.

Sgaglione: Developing a methodology to precisely predict shortages in practicing orthopedists can be challenging due to the many moving targets and contributing factors, but nonetheless may have value. Identifying regional or specific geographic physician shortages or clinical subspecialty gaps (arthroplasty subspecialists) can be meaningful to help clinical physician leadership as well as medical students, residents and fellows better identify and target job opportunities. The impact of such measures may better address the potential shortages and/or surpluses that may be realized in the short and long term. Clearly the laws of supply and demand may apply, but may not be directly predictive.

Bert: If it was determined that a shortage or oversupply of orthopedic surgeons exists in the United Sates, how difficult would it be to adjust residency positions nationally to either train more orthopedic surgeons or reduce the number?

Jacobs: The number of residency positions in a given residency program and the ability to add new or close existing programs is determined by the Orthopaedic Residency Review Committee (RRC) of the Accreditation Council of Graduate Medical Education. The RRC makes their determinations of resident compliment based on the educational environment of the individual institutions. Workforce issues are not a direct factor in these decisions. Thus, correction of an oversupply or undersupply of orthopedic surgeons is not likely to be accomplished in a systematic way by the orthopedic RRC unless a fundamental change in their processes occurred.

Furthermore, even if the number of residency positions is increased to meet a perceived shortage of orthopedic surgeons, then it is unclear how this would be funded since most training institutions are at or above their CMS-designated “cap” on the number of funded residency positions.

Jahangir: Even if one could make an accurate projection of future orthopedic surgery workforce needs, it would be complex to try to correct this problem purely by adjusting the number of residents being trained. Rather, the change would have to occur in the demographics of the residents trained, as well as, the location in which the training is completed. Such changes are difficult without government support including GME Medicare funding to establish programs in communities that may need more orthopedic surgeons as well as incentives to establish practices in underserved areas through funding such as the National Health Services Corps that provides education loan payments for a commitment to work in an underserved area.

Sgaglione: Short-term training program actions to either reduce or increase the number of orthopedic residency positions may not be easily accomplished. Residency complement increases have traditionally focused on the breadth and depth of educational volume rather than solely clinical case volume. In addition, numerous longer-term workforce projections indicate that as our population ages, lives longer and remains increasingly active and healthy, the demand for musculoskeletal care and more practicing orthopedic surgeons will likely increase.

Once again, the clear prediction will be better understood depending upon the extent and degree that cost-cutting regulatory health care initiatives are enacted including expansion of health insurance coverage, a switch to “value-based” medicine, increasing assumed risk models and possibly bundled payment and vertically integrated health care delivery programs. These paradigm shifts will likely have the greatest effect on future workforce trends

References:

AAMC Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. 2008. www.innovationlabs.com/pa_future/1/background_docs/AAMC%20Complexities%20of%20physician%20demand,%202008.pdf

AAOS Department of Research. State Level Changes in AAOS Orthopaedic Fellows. 2010. www.aaos.org/research/orthocensus/2010OrthopWorkforce.pdf

Heckman JD. Orthopaedic workforce in the next millennium. J Bone Joint Surg Am. 1998;80(10):1533-1551.

Lowrey A. Doctor shortage likely to worsen with health law. July 29, 2012. New York Times. www.nytimes.com/2012/07/29/health/policy/too-few-doctors-in-many-us-communities.html?_r=0.

The Methodist Le Bonheur Center for Healthcare Economics. The Impact of Health Reform in Tennessee: An Examination of Changes in Health Insurance Coverage, Use of Health Care Resources, and the Implications on Health Care Manpower. 2012. www.tenncare.org/PDFs/impacts_of_hcr_in_tn_jan12.pdf

For more information:

Jack M. Bert, MD, is Orthopedics Today Business of Orthopedics Section Editor. He can be reached at Minnesota Bone & Joint Specialists, Ltd, 17 W. Exchange St., Suite 110, St. Paul, MN 55102; email: bertx001@gmail.com.

Joshua J. Jacobs, MD, is first vice president of the American Academy of Orthopaedic Surgeons. He can be reached at can be reached at Rush University Medical Center, 1725 Harrison St., No. 1063, Chicago, IL 60612; email: joshua.jacobs@rushortho.com.

A. Alex Jahangir, MD, is an assistant professor of Orthopaedic Surgery and Rehabilitation, Division of Orthopaedic Trauma, Vanderbilt University Medical Center. He can be reached at can be reached at The Vanderbilt Orthopaedic Institute Center for Health Policy, Medical Center East Suite 4200, Nashville, TN 37232, email: alex.jahangir@vanderbilt.edu.

Nicholas A. Sgaglione, MD, is professor and chairman, Department of Orthopaedic Surgery, North Shore Long Island Jewish Health System, and president of the Arthroscopy Association of North America. He can be reached at University Orthopaedic Associates and the Department of Orthopaedic Surgery, North Shore – Long Island Jewish Medical Center, 611 Northern Blvd., Great Neck, NY 11021; email: nas@optonline.net.

Disclosures: Bert, Jahangir and Sgaglione have no relevant financial disclosures. Jacobs receives research funding from Zimmer, Medtronic, Spinal Motion, Nuvasive and has stock options in Implant Protection.