The Year Ahead: 9 Biggest Issues for Orthopedic Surgeons in 2011

Industry experts identify nine of the top concerns for orthopedic surgeons in 2011.

1. Healthcare reform law. Over the next year, there will be an increased focus on quality measures and an influx in patients who will be able to receive medical care as a result of healthcare reform, says John Callaghan, MD, a surgeon at the University of Iowa and current president of the American Academy of Orthopaedic Surgeons. "The idea and concept that quality and value of procedures and interventions is going to be important going forward," says Dr. Callaghan. Orthopedic surgeons need to be aware of the data regarding their outcomes and have a clear idea of the measures they take to ensure quality to attract the best reimbursement rates.

An additional concern for surgeons is the lack of meaningful medical liability in healthcare reform, which will have a large impact on students finishing medical school over the next few years. "When you look at medical students coming out of school, they have to protect themselves," says Dr. Hecht. "We may not have enough surgeons to treat all the new patients." Tort reform will continue to be a contentious issue over the next year as lawmakers push forward with healthcare reform.

2. Reimbursement rates.
Declining reimbursement is also a significant concern for orthopedic surgeons and an influx of Medicare and Medicaid patients due to healthcare reform could put an even greater strain on their ability to treat patients. "Everyone is concerned about the declining reimbursements for Medicare," says Andrew Hecht, MD, director of spine surgery in the department of orthopedics at Mount Sinai School of Medicine. "Taking care of Medicare patients is a labor of love for most doctors. It's really underpaid for every specialty, especially for the complexity of needs and the type of patients who are on Medicare."

Reimbursement for Medicare patients hasn't increased in years and more surgeons may need to choose to opt out of Medicare to keep their practice running in the future. "We're going to see more people insured and we need to figure out how to improve access to specialty care," says Dr. Hecht. "The solutions to these problems are going to depend on what the reimbursement rates will be and whether they can cover the cost of care."

3. Evidence-based medicine.
With the reform law focusing on reducing the cost of healthcare and improving quality, more focus will be placed on evidence-based medicine. Medical organizations, such as the AAOS, put forth practice guidelines after extensive review of the literature to help their members practice using the best available evidence. For example, in September, the AAOS released a guideline on vertebroplasty, citing studies that found the benefits for the patients were no different than placebo procedures. The organization also has a guideline recommending against the use of arthroscopy to treat patients with degenerative arthritis in the knee.

Dr. Callaghan believes CMS, in the future, will stop reimbursing for the procedures when professional guidelines recommend against their use. "We think it is important that CMS pays for the things that help people, but if a procedure doesn't help our patients, we don't want CMS to have to pay for it," says Dr. Callaghan. "If we're not willing to invest in these guidelines, there's no way we're going to be able to lower the cost of medicine in this country." David Ott, MD, a surgeon with Arizona Orthopaedic Associates in Phoenix, also feels the payors will be demanding a higher level of proven effectiveness before reimbursing for procedures. "The payors, in an effort to control expenses, will demand this level of evidence to make sure the treatments they are paying for are worth it," he says.

The emphasis on evidence-based medicine means that the FDA 510(k) process will likely be reformed and it will take longer to bring orthopedic devices to the market. "New technology is going to have to be introduced more slowly and there is going to be a need for more evidence before putting these technologies into the field," says Dr. Callaghan. "There is also going to be a paradigm shift in orthopedic surgeons who consider themselves 'high tech.'" The surgeons who are interested in using the newest technology will have to curtail their use until the technology has been proven.

4. Accountability among orthopedic surgeons.
There will be a greater emphasis on accountability of orthopedic surgeons in the coming years, whether the surgeons are working in a hospital or ASC setting. If there are complications with a surgery, such as a failed implant or infections, the surgeons have still been paid. However, Dr. Ott sees payors being weary of working with physicians who have high complication rates. "The most successful surgeons will have data to present to payors showing their results," says Dr. Ott. "I also think the level of service will increase because HCAP scores are going to determine reimbursement levels."

The two phrases that surgeons will be hearing about in the future are "appropriate use criteria" and "process improvement measures," says Dr. Callaghan. Appropriate use criteria involves the incorporation of the relevant research available to determine the appropriate use of a procedure. Process improvement measures are the measures set forth by the National Quality Forum to lower costs while maintaining quality, i.e., providing value to the consumer. Surgeons will need to follow these measures and avoid unnecessary expenditures.

5. Surgeon/device company relationships.
The healthcare reform bill will require full disclosure of the relationship between surgeons and orthopedic device companies in 2013. Device companies will have to publish the names of all physicians who have received a minimum amount of compensation for their consulting work and development of implants, says Dr. Callaghan. "The AAOS has been trying to educate our membership about this and recommending complete disclosure in their relationships with industry," he says. These disclosures could discourage some physicians from working with device companies in the future, says Dr. Ott, because they don't want patients or payors to feel manipulated by the industry connection.

However, Dr. Callaghan says orthopedic surgeons will continue to have a hand in developing devices in the future. "We need orthopedic surgeons to develop devices because they are the ones who know the clinical issues related to the procedures and implants they use. This is important for patient safety and optimization of patient outcomes," he says. "All this work has to be done ethically and professionally. Surgeons should disclose and explain these relationships to patients and follow Stark laws as well as other laws that become enacted."

Transparency in academic and scientific journals regarding surgeon relationships with device makers will also be a big topic in 2011. Over the past year, some physicians have been scrutinized for not revealing industry relationships in the journal articles they published, says Dr. Callaghan. The journals currently do not have a uniform set of rules for disclosure, which exacerbates the problem. "The Academy is working on getting all journal editors together to see if they can come up with a common disclosure," says Dr. Callaghan.

6. National Joint Registry. Next year will mark a big step in joint replacement surgery as the pilot programs for the National Joint Registry will begin in the United States. The registry will compile data from around the country concerning the different surgeries being performed, what implants are used and patient outcomes. The registry can also be helpful in gauging possible deficiencies with prosthetics. This year's recall of the DePuy metal-on-metal ASR hip replacement came only after reviewing data from the Australian and English joint replacement registry, says Dr. Callaghan.

"The National Joint Registry was developed by the Academy, but is independent of the AAOS and consists of a board of many stakeholders, including surgeons, payors, industry and hospitals," says Dr. Callaghan. "None of the other countries have multi-stakeholder boards." He says this aspect of the American registry will help make it a stronger resource for our country as well as other countries.

There has also been some interest in assembling a spine registry, says Dr. Callaghan, but gathering a registry for spine procedures is more difficult because of the greater amount of equipment used during spine surgery. "In spine, you may have 30 different screws and four sets of instrumentation," he says. "In a hip replacement, you only have a cup, a femoral component and a ball."

7. Spine surgery advances. There will be a significant focus on growing biologic treatment in spine surgery and improving the correct dose and formulations for the expanded use of BMP," says Dr. Hecht. Developments in BMP usage will allow for biologic surgery in more parts of the spine than are currently available. "Some of the biologic ages are going to facilitate the improved use of minimally invasive surgery," says Dr. Hecht. He sees a growing interest in cervical disc replacement heading into the next year, while he believes the interest in lumbar disc replacement surgery will wane. More focus will be on decreasing morbidity rates and conservatively treating patients who are able to benefit from pain management.

Much of the new technology developed in spine surgery is designed for less invasive procedures, though these technologies and procedures haven't necessarily been proven effective in the long term. Spine surgery technology is often very expensive, which means there will be more focus on the cost and benefit of spine surgery technologies in the future.

8. Subspecialty-focused orthopedic programs in hospitals. As hospitals scramble for physician contracts and begin hiring more surgical specialists, there will be more fragmentation among physicians, says Dr. Ott. For example, a surgeon with an emphasis on knee surgery will redirect their patient with shoulder problems to another surgeon who has an emphasis in that area. "The surgeons will be pushing patients away when they are out of their comfort zone," says Dr. Ott. "This is already happening at some larger practices and surgery centers."

Thomas Vangsness, MD, chief of sports medicine at the Keck School of Medicine at USC and the LAC/USC Medical Center, says the ability to focus on only the subspecialty at hospitals is one of the attractive aspects of hospital employment for some surgeons. He predicts hospitals will begin contracting more for surgeons in specific services. "I think that the average department will put a lot of different guys in to do different specialties," Dr. Vangsness says. "There will be a lot more subspecialties, especially if you contract with physicians."

Hospitals which want to remain competitive in multi-hospital communities will also begin pursuing opportunities for additional review approval, such as the Blue Cross Blue Shield Blue Certification or The Joint Commission's center of excellence certification, says Dr. Vangsness. Receiving recognition and certification will be used as an advertising tool to distinguish one facility from another and will most likely require physician involvement in the process.

9. Increased need for internet presence. Over the past several months there has been a greater desire by orthopedic surgeons to utilize Internet marketing as an advertisement and communication tool with potential patients. When patients receive referrals for orthopedic specialists, they are now using Internet search engines to find the surgeon before attending the appointment, says Ted Epstein, director of sales with Medical Web Experts. According to a study conducted by Pew Research Center's Internet & American Life Project, 61 percent of adults look for health information online and 60 percent of online users have consulted blog comments, hospital reviews and doctor reviews, listened to podcasts about healthcare and signed up to receive updates about medical issues. More surgeons have begun designing personal websites to supplement their practice or created hospital profiles to provide additional information about the procedures they perform.

An additional 40 percent of patients use social networking websites, according to the Pew research. Surgeons are using social media to connect with their patients, such as creating blogs or Facebook pages with videos and columns potential patients might find helpful. In response to an increasing use of social media among healthcare providers, hospitals and practices are developing guidelines for how their surgeons are able to use that space without running into legal or public relations issues. As children who grew up with the Internet mature, the number of potential patients using online media for healthcare information will continue to increase and it will become more important for surgeons to have a positive presence online, says Mr. Epstein.

Physicians are also now beginning to give patients the option to contact them through e-mail instead of by phone, says Dr. Vangsness. "There's more of a trend for Internet-based communication with orthopedic surgeons," says Dr. Vangsness. "It is really important that if a patient has a question or problem, they can send an e-mail. I think it gives them a sense of security and calm."

Read other coverage on orthopedic trends:

- 11 Biggest Sports Medicine Trends for 2011

- The Future of Orthopedic Surgeon Employment: 3 Core Concepts

- Spine Surgery in 2011 and Beyond: 7 Points About the Future of Spine Surgery

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