Orthopaedic surgeons do not increase surgical volume after investing in a specialty hospital.

BACKGROUND: The number of surgical specialty hospitals with physician investors in the United States has increased in the last ten years. Opponents to these hospitals have argued that surgeon investors will perform more surgery in order to maintain the hospital's profitability. The purpose of the present study was to determine whether the surgical volume or the surgical rate increased for a group of ten orthopaedic surgeons after the opening of an orthopaedic surgery specialty hospital in which they held a financial interest. METHODS: We analyzed the practice data for ten orthopaedic surgeons during an interval spanning seven years before and eight years after the opening of an orthopaedic surgery specialty hospital in which they held a financial interest. The average rates of change in the number of surgical procedures per year for each period were computed and compared with use of regression analysis. The percentages of patients who underwent surgery before and after the opening of the specialty hospital were also compared. RESULTS: The ten orthopaedic surgeons did not increase their surgical volume or surgical rate after the specialty hospital opened. The ten surgeons performed an average of 4399 surgical procedures per year before the hospital opened and 4542 surgical procedures per year after the hospital opened. The rate of change in the number of surgical procedures per year (19.1 compared with 8.9 procedures per year) did not increase after the specialty hospital opened. The annual patient volume (16,019 compared with 15,982 patients) and the percentage of patients who underwent surgery (27.5% compared with 28.4%) did not significantly change after the specialty hospital opened. CONCLUSIONS: The opening of an orthopaedic surgery specialty hospital did not increase the surgical volume or the surgical rate for ten orthopaedic surgeons who held a financial interest in the facility.

Utilization of orthopaedic services for hand and wrist conditions in a capitated population.

BACKGROUND: The utilization of orthopaedic services (office visits and surgery) to treat hand and wrist conditions is not well known. In this study, we report the utilization rates for patients referred for orthopaedic treatment of hand and wrist conditions in a large population of individuals enrolled in a capitated insurance plan. METHODS: The study population consisted of individuals enrolled, between January 1998 and December 2001, in a capitated insurance plan that had an annual average membership of 135,188 during that period. This plan was serviced by an independent physician association of sixty-two orthopaedic surgeons who were responsible for all orthopaedic care. Data were collected prospectively in a centralized database as patients with various hand or wrist conditions were referred for orthopaedic services. Odds ratios were used to compare gender-specific and age-specific utilization rates. RESULTS: Overall utilization rates were 18.06 office visits and 6.47 surgical procedures per 1000 members per year. The most frequent hand or wrist conditions were fractures, carpal tunnel syndrome, tendinitis or tenosynovitis, and ganglion or synovial cysts. These four diagnoses accounted for 70% of all office visits and 71% of all surgical cases. Across all age groups, males had a significantly higher rate of utilization of office visits (p < 0.001). Between the ages of thirty-five and fifty-five years, utilization of office visits and surgery increased approximately linearly with age. CONCLUSIONS: A comparison of these data with those of previous reports indicates that approximately one of every ten patients who are referred for orthopaedic services has a hand or wrist condition, and nearly half will require surgery.

The effect of payer type on orthopaedic practice expenses.

BACKGROUND: Orthopaedic practice expenses are the costs associated with providing treatment that are incurred by a physician's practice. Certain payer types are thought to increase orthopaedic practice expenses by increasing paperwork and other administrative activities. Our study investigated the hypothesis that orthopaedic practice expenses would vary significantly by payer type. METHODS: With use of the method of activity-based costing, data on the orthopaedic practice expenses for 518 consecutive patients (286 men and 232 women) who had a sports-related knee condition were collected. For each patient enrolled in the study, all employees recorded the actual amount of time that they spent on each of seventeen specific activities previously shown to be associated with orthopaedic practice. The seventeen activities were categorized as either a value-added activity, which adds value to the services provided to the patient, or a nonvalue-added activity, which does not add value. The total orthopaedic practice expense was the sum of the value-added and nonvalue-added activity expenses. To capture all practice expenses associated with a particular episode of care, data collection continued until the patient was discharged and the financial account had been settled. We evaluated the differences in orthopaedic practice expenses among six payer types: self-pay, indemnity plan, Medicare, health maintenance organization/point-of-service plan (HMO/POS), preferred provider organization (PPO), and Workers' Compensation. RESULTS: The differences among payer types with respect to orthopaedic practice expenses were significant (p = 0.0000000004). The total orthopaedic practice expense per episode of care was $123 for self-pay, $195 for an indemnity plan, $148 for Medicare, $178 for PPO, $208 for HMO/POS, and $299 for Workers' Compensation. These differences among payer types persisted even after accounting for patient age, gender, treatment type (nonoperative versus operative), and number of office visits. Nonvalue-added activity expenses differed to a greater degree among the payer types than did value-added activity expenses. CONCLUSIONS: The payer type was found to be an important factor affecting orthopaedic practice expenses, particularly with respect to nonvalue-added activity expenses.

Utilization of orthopaedic services in a capitated population.

BACKGROUND: The utilization rate for orthopaedic services (office visits and surgery) is not well known. The purpose of this study was to determine the utilization rates for orthopaedic office visits and surgical procedures in a large population of captured lives. METHODS: The study population comprised an average of 134,902 persons per month who were enrolled under a capitated insurance plan between January 1999 and December 1999. This plan was serviced by an independent physician association of sixty-two orthopaedic surgeons who were responsible for all orthopaedic care. Data were collected prospectively and stored in a centralized database. All analyses were conducted with use of monthly averages. Poisson regression was used to compare utilization rates and to calculate odds ratios in order to determine whether the utilization rates varied by age and gender. RESULTS: The highest proportions of office visits were due to fractures (21%), osteoarthritis (4%), meniscal tears (4%), and low-back pain or sciatica (4%). Knee arthroscopy (30%), foot and ankle procedures (10%), and spine procedures (9%) accounted for the highest proportions of surgical procedures. The overall utilization rates were 6.96 office visits and 1.99 surgical procedures per 1000 covered lives per month. Across all age groups, males and females did not differ with respect to the utilization rate for office visits (p = 0.42) or surgery (p = 0.09). Increased age was significantly related to increased utilization rates for office visits (p < or =0.0002) and surgery (p < or = 0.002). CONCLUSIONS: These data may be used to determine the size of a capitated population that an orthopaedic practice can accommodate, to determine the number of orthopaedic providers that is needed to provide services for a capitated population, and to estimate the expenses associated with providing orthopaedic services for a capitated population in an orthopaedic practice.

Payer type has little effect on operative rate and surgeons' work intensity.

Does health-care payer type affect the rate of operative treatment and surgeons' work intensity for patients with orthopaedic conditions? We analyzed the clinical and financial data collected during 6 consecutive years (1999-2004) for a group practice of 40 orthopaedic surgeons. We examined the rate of operative treatment and surgeons' work intensity (total physician's work Resource-based Relative Value System units) by diagnosis, patient age, and payer type. The eight payer types were: capitation health maintenance organization, health maintenance organization, preferred provider organization, indemnity, self-pay, Workers' Compensation, Medicaid, and Medicare. There were 230,306 patients with 526 unique primary diagnoses. Diagnosis accounted for most of the variability in operative rates and surgeons' work intensity. After adjusting for differences attributable to diagnosis, payer type had little effect on the rate of operative treatment and surgeons' work intensity.

Clinical breast examination: practical recommendations for optimizing performance and reporting.

Clinical breast examination (CBE) seeks to detect breast abnormalities or evaluate patient reports of symptoms to find palpable breast cancers at an earlier stage of progression. Treatment options for earlier-stage cancers are generally more numerous, include less toxic alternatives, and are usually more effective than treatments for later-stage cancers. For average-risk women aged 40 and younger, earlier detection of palpable tumors identified by CBE can lead to earlier therapy. After age 40, when mammography is recommended, CBE is regarded as an adjunct to mammography. Recent debate, however, has questioned the contributions of CBE to the detection of breast cancer in asymptomatic women and particularly to improved survival and reduced mortality rates. Clinicians remain widely divided about the level of evidence supporting CBE and their confidence in the examination. Yet, CBE is practiced extensively in the United States and continues to be recommended by many leading health organizations. It is in this context that this report provides a brief review of evidence for CBE's role in the earlier detection of breast cancer, highlights current practice issues, and presents recommendations that, when implemented, could contribute to greater standardization of the practice and reporting of CBE. These recommendations may also lead to improved evidence of the nature and extent of CBE's contribution to the earlier detection of breast cancer.