Panel discusses the future of pediatric orthopedics

Health care is changing at a fast pace. Not long ago, our job as a pediatric orthopedic surgeon was to solely take care of the musculoskeletal health of the children in the best possible manner. This is not the case anymore. Now, terms like efficiency, value, quality and accountability dictate health practices. The repeal of the Sustainable Growth Rate formula is not the end of payment reforms, but rather the beginning of the merit-based incentive payment system. Physicians and practices would be rewarded for providing quality services at an affordable value and penalized if they do not. The definitions and metrics used for “quality” and “value” are not fully understood. In this Orthopedics Today Round Table, I asked leaders in the field of pediatric orthopedics about their opinions on the future of the subspecialty.

Shital N. Parikh, MD
Moderator

Shital N. Parikh, MD: How do you think the field of pediatric orthopedics will change with the changes in health care?

James J. McCarthy, MD: Like the stock market, the truth is no one knows. Many trends have come and gone in health care during the past several decades. It is not always easy to determine which changes are trends or simply fads that will go away. When I try to predict future trends, I try to look for long-term historical trends. Within pediatrics and health care in general, there are a few long-term general trends. These include:

• an increase in hospital-base practice by physicians in general, but this also includes orthopedic surgeons and pediatric orthopedic surgeons;
• an increase in the pediatric orthopedic work force. This has been a trend for approximately 8 years. It is unclear whether this will result in too many qualified pediatric orthopedic surgeons, given the older age of our pediatric surgeon population and the continued trend of subspecialization;
• continued drive toward greater subspecialization. My mentors were unique when they decided to choose only pediatric orthopedics and now, even within pediatric orthopedics, most people subsubspecialize either by doing a second fellowship or by focusing their practice further;
• continued push toward using quality- vs. volume-based metrics for reimbursement. This change is clearly tied to the Affordable Care Act (ACA) and legislation, but this trend started well before the passage of that law; and
• relentless progression of technology. About 20% of the procedures I perform now, I learned as a fellow. The rest have been either completely altered or greatly modified. Being able to understand and adapt to new techniques and new technologies is going to be critical. This means staying diversified, and taking the time and effort to feel comfortable with new techniques and technologies. This also means understanding enough about the techniques and indications so you do not adopt the technologies too quickly before the possible risks and complications are known.

Michael G. Vitale, MD, MPH: Moving forward, we will increasingly need to “right size” care. That means making optimal use of physician extenders, from pediatric nurse practitioners and physician assistants to medical assistants and “scribes.” Each member of the team will need to be functioning at the highest level possible to allow the efficiencies demanded by our value-driven system. This also means more subspecialization as a combination of market demand and supply promotes surgeons to do fewer procedures, perhaps more efficiently and better.

John M. Flynn, MD: The ACA and the rapidly changing economic landscape of health care in general were at the forefront of the public discussion leading into my year as Pediatric Orthopaedic Society of North America (POSNA) president, so I commissioned Jeffrey R. Sawyer, MD, to assemble a team and perform the most sophisticated pediatric orthopedic workforce analysis possible. Jeff and his team have reported their findings at our national meetings during the last year, and will publish them in the Journal of Pediatric Orthopaedics. The bottom line: we are training about the right number of pediatric orthopedists, but the future workforce will have a much higher percentage of female surgeons, and the distribution of surgeons does not match where the children are. The changing demographics of the United States suggests young orthopedic surgeons coming out of training should head to the south and southwest.

Pediatric orthopedics, and all of pediatric medicine, will be less affected than adult care by the current medical economic trends. Little that we do in pediatric orthopedics can be commoditized (with the possible exception of some sports medicine procedures in adolescents). This allows us to avoid some of the bundled payments and price competition (at least for now) that are dominating factors for our adult orthopedic colleagues, especially those who do commoditized procedures, such as arthroplasty.

A dominant economic force in pediatric orthopedics during the next decade will likely be Medicaid reimbursement. States with the best Medicaid reimbursement will have children’s hospitals that can recruit and retain the best surgical talent. States with poor Medicaid reimbursement will have hospitals that struggle to break even and cannot pay their surgeons market rates. Because the ACA requires people to purchase services they do not need, health care will become increasingly expensive, and more families will move their children to Medicaid. If Medicaid reimburses poorly, access for these children will be limited.

Alvin H. Crawford, MD: The need for pediatric orthopedists will continue to increase. It is possible the care of simple fractures and longitudinal follow-up of diagnosed growth and developmental conditions under management may be covered in a community practice and not at a children’s hospital because of costs and access. Most community orthopedic groups are being acquired by hospitals, and these groups will either have their own pediatric specialist or will contract a pediatric specialist from a children’s hospital group to see patients in their offices. Cost will determine this change. Industry is interested in containing cost and their employee satisfaction. This will be a determinant in the future as to where the child is treated.

Parikh: How can a pediatric orthopedic surgeon better prepare to face practice challenges in the future?

McCarthy: First, I would like to say challenges can also be opportunities. Most great successes started with great challenges. Given the concern for changes though, I think there are a number of ways one could prepare themselves for these, including numerous opportunities for education. I received a Master’s degree in health care management which was a wonderful way to expose me to many different health care perspectives, acquaint myself with accounting and financial principles, and understand administrative vernacular. There are numerous quality improvement courses that can help one understand how to treat patients more efficiently and create a higher quality product.

Consolidating to a larger group has advantages of providing greater market share and potentially the strength that comes with that, as well as the support from multiple partners. The downside to a larger group or hospital-based employment is that you give up some control of your daily practice.

Engaging in a professional society is a wonderful way to understand the practice of health care and often provide multiple resources and/or the opportunity to interface at a higher legislative level. Although I believe physicians typically are not attracted to politics, being involved and advocating for a patient is important. Ultimately, the most important thing one can do is practice high-quality care and to maintain the module of that care.

Vitale: In two words, “arm yourself.” We are living through unprecedented change in our health care delivery model. Skill sets that worked in the past, now will reveal themselves to be outdated. Our job is not just to cut and fix with precision, but to add “extreme value” to your organization. Understand you may have responsibilities to multiple organizations and have multiple people you report to, and think about how to add extreme value to each. “Arming yourself” can take different forms, but includes things like developing skills to compete in getting grants, bringing visibility to the organization through clinical work and national governance, leadership and business savvy, and bringing quality improvement initiatives to your work. Some of this is on the job training, and some might require more formal training and degree work. It is not the same pediatric orthopedic job your grandparents might have had.

Flynn: Going forward, we will likely see a continuing trend of pediatric orthopedists accumulating at the larger children’s hospitals, the most successful of which will merge and expand to create large pediatric health care networks. Surgeons who work at the largest hospitals will sit at the bottom of a giant funnel of patients that aims the orthopedic needs of a large population toward experts. This will fuel the trend toward subspecialization and larger pediatric orthopedic groups. Since I joined the group at Children’s Hospital of Philadelphia in 1996, we have grown five-fold. That trend will continue.

The trend towards increasing bureaucracy, documentation, guidelines and rules will surely continue, as hospitals hire a giant stratum of expensive professionals to create the appearance of standardization for the government, payers, etc. The key for survival will be hiring a team of extenders who can most cheaply populate the elements of an electronic medical record (EMR) necessary for billing and regulations, while still making a passable medical communication, which we used to produce more quickly and cheaply just a few years ago. Pediatric orthopedic surgeons also will need to hire people whose full-time jobs are dealing with other requirements from the bureaucracy. Since none of this added burden will improve care, it should be kept as simple and economically feasible as possible.

Crawford: The primary challenges in the future will be cost and efficiency. As reimbursement continues to decrease and our field becomes more subspecialized, the mid-level provider with pediatric orthopedic training will be an integral part of both hospital- and community-based pediatric orthopedic groups.

In addition to EMRs, I have just completed training in ICD-10 which takes the surgeon’s responsibility of coding to a new level. Efficient time-management courses will become important and popular. The government’s financial outlay for data collection by the EMRs is time-sensitive. These hospitals continuing to purchase, recruit and maintain acquired community practices may undergo a transition. It may be that the initial management of pediatric orthopedic conditions will be initiated by the hospital-based subspecialist and followed by well-trained mid-level providers in the community practice/hospital.

A note from the editors

Read part 2 of this Round Table discussion in the October 2015 issue of Orthopedics Today.

• For more information:
• Alvin H. Crawford, MD, can be reached at 222 Piedmont Ave. #2200, Cincinnati, OH 45219 email: alvin.crawford@uc.edu.
• John M. Flynn, MD, can be reached at Children’s Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104; email: flynnj@email.chop.edu.
• James J. McCarthy, MD, can be reached at Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., ML 2017, Cincinnati, OH 45229; email: james.mccarthy@cchmc.org.
• Shital N. Parikh, MD, can be reached at Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., ML 2017, Cincinnati, OH 45229 email: shital.parikh@cchmc.org.
• Michael G. Vitale, MD, MPH, can be reached at Columbia University Medical Center, 622 West 168th St., PH11— Center, New York, NY 10032; email: mgv1@columbia.edu.

Disclosures: Crawford, Flynn, Parikh and Vitale report no relevant financial disclosures. McCarthy reports he does consulting work with Orthopedics and Philips Healthcare, gives talks for Synthes, has received royalties from Lippincott Williams & Wilkins and is on the board of POSNA.