Value Challenge: A Bottoms-Up Approach to Minimizing Cost and Waste in Orthopaedic Surgery.

Astronomical increases in medical expenses and waste produce widespread financial and environmental impacts. Minor changes to minimize costs within orthopaedics, the most used surgical subspecialty, could result in substantial savings. However, few orthopaedic surgeons are educated or experienced to implement cost containment strategies. This study aims to investigate cost containment opportunities and provide a framework for educating and incorporating residents into cost-saving initiatives. Methods: Orthopaedic surgical residents from an academic program with a Level I trauma center were queried during 2019 to 2022 regarding suggestions for cost containment opportunities. Based on feasibility and the estimated impact, 7 responses were selected to undergo cost-saving analyses. Results: The proposed initiatives fell into 2 categories: minimizing waste and optimizing patient care. Eliminating nonessential physical therapy/occupational therapy consults led to the greatest estimated savings ($8.6M charges/year), followed by conserving reusable drill bits ($2.2M/year) and reducing computed tomography scans on lower extremity injuries ($446K/year). Conclusion: Current medical training provides limited formal education on cost-effective care. Efforts to mitigate the growing financial and environmental costs of health care should include encouraging and incorporating resident feedback into cost reduction strategies. This tactic will likely have a positive impact on the behavior of such resident surgeons as they enter practice and have more awareness of costs and value. Level of Evidence: V (cost-minimization study).

The economic impact of gunshot wounds on an urban level 1 trauma center.

INTRODUCTION: Firearm-related injuries impact the healthcare system, taxpayers, and injured patients due to lost productivity and reduced quality of life. The goal was to quantify the economic costs related to hospitalization for gunshot wounds (GSWs) at a single urban level 1 trauma center. MATERIALS AND METHODS: 941 patients over 27 months were treated for GSW. Elements related to hospitalization including length of stay, surgical procedures, medications and therapies, and subsequent readmission were identified, and costs were determined, inclusive of fixed and variable direct and indirect costs of facility care. Costs were classified based on body region: abdominal, chest, soft tissue, extremity or pelvic girdle, and head/neck/face. RESULTS: Mean age was 30 years, with 94% male. Most patients (81%) were admitted, and 8% sustained fatal injuries. Overall, 12% were seen previously or subsequently for additional, unrelated GSWs. Mean costs per patient were: $66,780 for abdominal GSWs; $3,986 for chest; $3,509 for soft tissue; $19,875 for extremities; $64,533 for head or neck, and means of $25,249 for two regions and $26,638 for three regions. Over the prospective period, 941 individuals sustained GSWs (approximately 35 per month). 37% were to the extremities, 23% were within the skin/subcutaneous tissue, 7% to the abdomen, 7% to the chest, 6% to the head or neck, and 20% to two or more body regions. Total facility costs for these 941 GSWs was $18.9 million, or $698,960 per month. 55% of the patients had Medicaid, and 33% were uninsured, resulting in substantial uncompensated expenses for the trauma center. CONCLUSION: Firearm-related injuries generate considerable expense. Our data underestimated cost, as professional services and indirect costs associated with lost economic productivity of patients and caregivers were excluded. No objective assessment of the disastrous personal and social impact was projected. Moving forward, interventions to prevent initial injury and recidivism in this high-risk population are crucial. LEVEL OF EVIDENCE: Level III.

Patient Satisfaction Is Improved With Exposure to Trauma Recovery Services.

INTRODUCTION: The purpose of this study is to assess the impact of Trauma Recovery Services (TRS), a program facilitating engagement and recovery on satisfaction after orthopaedic trauma. METHODS: Two hundred ninety-four patients with surgically managed extremity fractures were prospectively surveyed. Satisfaction was assessed after 12 months using a 13-question telephone survey, rated on a Likert scale from 1 to 5 (with five being excellent). TRS resource utilization during and after hospitalization was recorded. Eighty-eight patients (30%) used TRS. RESULTS: Overall satisfaction was high with a mean score of 4.32. Although no differences were observed between the control group and patients with TRS utilization in age, sex, race, insurance, smoking history, or employment status, TRS patients sustained more high-energy mechanisms (81% versus 56%) and had more associated psychiatric illness (33% versus 17%), both P < 0.01. Multivariable regression indicated general exposure to TRS to be an independent predictor of higher overall care ratings (B = 1.31; P = 0.03). DISCUSSION: Utilization of TRS was the greatest predictor of better overall care ratings. This study builds on existing evidence demonstrating the positive impact of Trauma Survivor Network programming. We conclude that a hospital-wide program supporting patient education and engagement can effectively increase patient satisfaction after traumatic injury. LEVEL OF EVIDENCE: Prognostic Level II.

Variations in Revenue Generation for the Care of Orthopaedic Trauma Patients.

BACKGROUND: In the background of increasing competition between trauma centers, this study investigated the relative reimbursement of trauma care provided in an urban trauma setting, comparing patients previously unknown (new) to the system, representing potential sources of new revenue, and those who were known (established), having received medical care previously in the same system. METHODS: A retrospective review of 440 patients with high-energy fractures at a single level 1 trauma center was conducted. Payment to charge (P/C) ratios for professional and facilities services within 6 months of injury were calculated. RESULTS: Mean professional charges per patient were $35,522 and $30,639 (P = 0.11), between new and established patients, respectively, whereas mean professional payments were statistically different, $7,894 and $4,365 (P < 0.001). Mean differences in P/C for facilities payments for new and established patients were not statistically significant, but professional P/C was higher in new patients (P < 0.001), consistent with better insured patients. DISCUSSION: Insurance companies reimburse for professional or facilities services with statistically different P/C ratios. Treating new patients at our institution likely benefits our institution by offering exposure to a more favorable payer mix and more complex patients. LEVEL OF EVIDENCE: Retrospective level III.

The Growing Executive-Physician Wage Gap in Major US Nonprofit Hospitals and Burden of Nonclinical Workers on the US Healthcare System.

BACKGROUND: In an era of increasing healthcare costs, the number and value of nonclinical workers, especially hospital management, has come under increased study. Compensation of hospital executives, especially at major nonprofit medical centers, and the "wage gap" with physicians and clinical staff has been highlighted in the national news. To our knowledge, a systematic analysis of this wage gap and its importance has not been investigated. QUESTIONS/PURPOSES: (1) How do wage trends compare between physicians and executives at major nonprofit medical centers? (2) What are the national trends in the wages and the number of nonclinical workers in the healthcare industry? (3) What do nonclinical workers contribute to the growth in national cost of healthcare wages? (4) How much do wages contribute to the growth of national healthcare costs? (5) What are the trends in healthcare utilization? METHODS: We identified chief executive officer (CEO) compensation and chief financial officer (CFO) compensation at 22 major US nonprofit medical centers, which were selected from the US News & World Report 2016-2017 Hospital Honor Roll list and four health systems with notable orthopaedic departments, using publicly available Internal Revenue Service 990 forms for the years 2005, 2010, and 2015. Trends in executive compensation over time were assessed using Pearson product-moment correlation tests. As institution-specific compensation data is not available, national mean compensation of orthopaedic surgeons, pediatricians, and registered nurses was used as a surrogate. We chose orthopaedic surgeons and pediatricians for analysis because they represent the two ends of the physician-compensation spectrum. US healthcare industry worker numbers and wages from 2005 to 2015 were obtained from the Bureau of Labor Statistics and used to calculate the national cost of healthcare wages. Healthcare utilization trends were assessed using data from the Agency for Healthcare Quality and Research, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey. All data were adjusted for inflation based on 2015 Consumer Price Index. RESULTS: From 2005 to 2015, the mean major nonprofit medical center CEO compensation increased from USD 1.6 ± 0.9 million to USD 3.1 ± 1.7 million, or a 93% increase (R = 0.112; p = 0.009). The wage gap increased from 3:1 to 5:1 with orthopaedic surgeons, from 7:1 to 12:1 with pediatricians, and from 23:1 to 44:1 with registered nurses. We saw a similar wage-gap trend in CFO compensation. From 2005 to 2015, mean healthcare worker wages increased 8%. Management worker wages increased 14%, nonclinical worker wages increased 7%, and physician salaries increased 10%. The number of healthcare workers rose 20%, from 13 million to 15 million. Management workers accounted for 3% of this growth, nonclinical workers accounted for 27%, and physicians accounted for 5% of the growth. From 2005 to 2015, the national cost-burden of healthcare worker wages grew from USD 663 billion to USD 865 billion (a 30% increase). Nonclinical workers accounted for 27% of this growth, management workers accounted for 7%, and physicians accounted for 18%. In 2015, there were 10 nonclinical workers for every one physician. The cost of healthcare worker wages accounted for 27% of the growth in national healthcare expenditures. From 2005 to 2015, the number of inpatient stays decreased from 38 million to 36 million (a 5% decrease), the number of physician office visits increased from 964 million to 991 million (a 3% increase), and the number of emergency department visits increased from 115 million to 137 million (a 19% increase). CONCLUSIONS: There is a fast-rising wage gap between the top executives of major nonprofit centers and physicians that reflects the substantial, and growing, cost of nonclinical worker wages to the US healthcare system. However, there does not appear to be a proportionate increase in healthcare utilization. These findings suggest a growing, substantial burden of nonclinical tasks in healthcare. Methods to reduce nonclinical work in healthcare may result in important cost-savings. LEVEL OF EVIDENCE LEVEL: IV, economic and decision analysis.

Revenue for Initial Orthopaedic Trauma Care: Effects of Patient and Injury Characteristics.

OBJECTIVE: To characterize the charges and collections associated with the initial inpatient management of trauma patients who undergo operative fracture management. DESIGN: Retrospective. SETTING: Level 1 trauma center. PARTICIPANTS: Four hundred forty consecutive, adult, trauma patients. INTERVENTION: Fixation for fracture of the spine, pelvis, acetabulum, and/or femur fractures. MAIN OUTCOME MEASURES: Professional and technical (facility) charges and collections from the initial inpatient management and 6 months of subsequent related care. RESULTS: Patients were predominantly male (74.3%) and white (63.2%) with a mean age of 41 years and mean injury severity score of 18.5. Uninsured (self-pay) patients represented the largest payer class (35.0%), and 34.5% of all patients were unemployed. Professional and technical charges totaled US $12,382,028 (US $28,140/patient) and US $39,682,225 (US $90,187/patient), respectively. Injury severity score, longer lengths of stay (LOS), and the presence of a complication were positive predictors of initial charges (P < 0.0001; adjusted R = 0.799). Professional and technical collections totaled US $2,418,096 (US $5,496/patient) and US $16,921,959 (US $38,459/patient) (percent of charge: 21.5% vs. 41.3%; P < 0.0001). Of the self-pay patients, 34.4% had no collections, resulting in potential lost revenue of US $2,513,988. Greater collections were predicted to occur in females, employed patients, and those with insurance (P < 0.0001; adjusted R = 0.35). CONCLUSIONS: Trauma patients often present without insurance, which compromises hospital revenue. Expectedly, charges are higher in more severely injured patients, those with longer LOS, and those experiencing complications. A bundled model will proportionately decrease reimbursements for a given episode of care in the event of longer LOS or occurrence of complications.