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We have a responsibility to promote healthy lifestyle programs
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The epidemic of obesity and how it affects orthopedic care are well-recognized problems. A self-centered view raises concerns about our ability to successfully manage common orthopedic conditions, as outcomes after routine orthopedic procedures can be negatively affected by obesity.
Orthopedic surgeons have evidenced, as written about in this month’s Cover Story, that operative results are not always the same for patients with obesity compared to non-obese patients. The technical aspects of surgery are more challenging and procedures take more time. Additional staff members are often needed to transport as well as place and secure obese patients on operative tables. Implants are more expensive because of the added materials. Dressings and durable medical products are larger, and larger surgical incisions, unique instruments and retractors may be required. Anesthesia risks are also greater as it takes more time to manage airways and the commonly associated obstructive sleep apnea. Post-anesthesia recovery room time is often longer due to the retention of anesthetic agents in a higher percentage of body fat, and postoperative rehabilitation may be longer as well.
Anthony A. Romeo
With all these known challenges, there is an unrecognized comorbidity in the health care system in terms of supporting orthopedic surgeons who manage patients with obesity. There is an ICD-9 code for obesity, 278.0, which can be included in the description of a patient’s various disease conditions, however, there is no clear method to define the impact of obesity on a surgical procedure in the CPT coding system for procedures. We can also state in operative notes that additional procedures and larger equipment were required for the care of an obese patient.
Orthopedic surgeons also may chose to amend the CPT code with a 22-modifier, which is appropriate to “report or indicate that a service or procedure which has been performed has been altered by some specific circumstance but not changed in its definition or code.” Unfortunately, third-party payers do not recognize the added difficulty in all aspects of care for patients with obesity. In fact, in at least two orthopedic-based studies, adding the 22-modifier for obesity positively changed the reimbursement in less than 5% of cases. In some cases, the addition of the modifier led to decreased reimbursement.
Value-based care
As orthopedic surgeons are more responsible for their own outcomes, which define their ability to provide value-based health care, there will be an increased disincentive to manage patients with obesity. Overall reimbursement is the same as that of non-obese patients despite the added complexity. This means less financial benefit per unit of time spent with the patient. We also will be penalized in the overall system because outcomes will be worse in this patient population. We have already seen an increase in the referral of “complex patients” where the only obvious comorbidity to a relatively routine orthopedic condition is obesity. For many orthopedic surgeons who receive significant referrals from other orthopedic surgeons, we accept the challenges as leaders in the profession. However, as this cost increases and affects our partners or employers, we are more likely to restrict the opportunities to help manage these complex patients.
This microcosm reveals a number of concerns about the health care system, which is not a true system, but a patchwork of various concepts and incentives put together to provide health care to as many people as possible. Many other developed nations have instituted national health care systems for their entire population, but the United States has been reluctant to accept this method of health care delivery. Statistics would suggest that other countries have done an overall better job in management of common medical conditions in terms of access to care and overall cost.
From a financial standpoint, the health care system is incentivized toward providing high-cost treatment for patients with chronic conditions. This is often not provided in a methodological way, but instead by each episode of medical care crisis. It is not surprising that 75% of U.S. health care dollars are spent to treat chronic illnesses, such as heart disease, diabetes and hypertension – all of which are either caused by or exacerbated by obesity. Most of these illnesses are lifestyle-related, which means the consequences are potentially preventable or can be managed more successfully with healthier lifestyles.
There is often a disconnect between the perception of personal choices and health care. To some degree, orthopedic surgeons also contribute to the problem as we continually improve outcomes of care. The incredible advances in technology, education and surgical technique have led to an explosion of successful procedures. However, we cannot solve every aspect of treatment with orthopedic skills. Patients and third-party payers are often surprised to find out that up to 20% of patients with total knee replacements still have pain and measurable disability. What they fail to recognize is that this group of fair or poor results is likely to be patients with poor lifestyle choices.
There is an illusion that somebody else, such as the government, employers and insurance companies, pays for the cost of health care. This is not true as ultimately, the working and tax-paying American population pays for health care. Every year, trillions of dollars, almost 20% of the gross national product, are directed toward conditions better treated with prevention and healthy lifestyle. The challenge is redirecting incentives to prevent or better manage health problems, including obesity.
Our responsibility
There are three major parts to health care: patients, providers and payers. If we continue to provide sophisticated, episodic, high-expense care for patients’ problems at a level that is unsurpassed by other nations in quality and volume, and we continue to demand increasing support from payers without providing clear value for expensive care, then we are not fulfilling our roles as the ultimate managers of musculoskeletal care. We have a responsibility to support and promote programs that encourage healthy lifestyles, such as the “Exercise is Medicine” program started by the American College of Sports Medicine, and the Sports Trauma and Overuse Prevention (STOP)program started by the American Orthopaedic Society for Sports Medicine. We need to be a loud voice in the movement toward healthier lifestyle choices – both by personal conduct and promotion of preventative programs.
These initiatives will not solve all musculoskeletal problems, but the results and value of our care will be improved beyond technical advances because of improved overall health and lifestyle.
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Disclosures: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.