Who Bears the Burden? Understanding the Socioeconomic Patterns of Educational Debt in Orthopaedic Surgery Residency Candidates.

BACKGROUND: Educational debt is commonly observed among applicants to orthopaedic surgery residency programs; however, an understanding of the debt burden among minority and nonminority applicants is not well established. Thus, this study aimed to fill these knowledge gaps by examining the extent of and factors shaping educational debt among orthopaedic surgery applicants. QUESTIONS/PURPOSES: (1) What is the educational debt burden among orthopaedic surgery residency applicants? (2) After controlling for relevant confounding variables, what factors are independently associated with increasing levels of educational debt? (3) After controlling for relevant confounding variables, are individuals classified as an underrepresented minority or those with educational debt and socioeconomic disadvantage less likely to match in orthopaedic surgery? METHODS: A retrospective evaluation of orthopaedic surgery residency application data from the American Association of Medical Colleges was analyzed from 2011 to 2021. The American Association of Medical Colleges database was selected because every residency applicant must register and apply through the American Association of Medical Colleges. Therefore, these data exist for every residency applicant, and the sample was comprehensive. Self-reported data including premedical, medical, and total educational debt burden as well as classification as socioeconomically disadvantaged and application fee waiver use were collected. Applicants were dichotomously categorized as an underrepresented minority or a not underrepresented minority based upon self-identified race and ethnicity. Monetary values were reported in USD and inflation-adjusted to 2021 using the Consumer Price Index. We performed t-tests and chi-square tests for continuous and categorical variables, respectively. Significance was considered at p < 0.05. In all, 12,112 applicants were available in the initial cohort, and 67% (8170 of 12,112) of applicants with complete data were included from 2011 to 2021 in the final study cohort. Of these, 18% (1510 of 8170) were women, 14% (1114 of 8170) were classified as underrepresented minorities, and 8% (643 of 8170) were classified as socioeconomically disadvantaged. Sixty-one percent (4969 of 8170) of applicants reported receiving at least one scholarship, 34% (2746 of 8170) had premedical school debt, and 72% (5909 of 8170) had any educational debt including medical school. Among all applicants, the median (IQR) educational debt was USD 197,000 (25,000 to 288,000). Among those with scholarships, the median amount was USD 25,000 (9000 to 86,000). RESULTS: After controlling for the potentially confounding variables of gender and socioeconomic disadvantage, classification as an underrepresented minority applicant was independently associated with higher scholarship amounts than applicants characterized as not underrepresented minorities (ß = USD 20,908 [95% confidence interval (CI) 15,395 to 26,422]; p < 0.001), whereas underrepresented minority classification was not independently associated with a difference in total educational debt (ß = USD 3719 [95% CI -6458 to 13,895]; p = 0.47). After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with higher scholarship amounts (ß = USD 20,341 [95% CI 13,300 to 27,382]; p < 0.001) and higher total educational debt (ß = USD 66,162 [95% CI 53,318 to 79,006]; p < 0.001) than applicants not classified as socioeconomically disadvantaged. After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with decreased match rates (OR 0.62 [95% CI 0.52 to 0.74]; p < 0.001). CONCLUSION: These findings underscore the need for comprehensive scholarship initiatives to ensure equitable financial accessibility for applicants from all backgrounds. CLINICAL RELEVANCE: In the future, orthopaedic surgery may benefit from research comparing the effectiveness of various initiatives aiming to improve fairness in the burden of debt among applicants to orthopaedic surgery residency programs.

Editorial Commentary: Improved Operating Room Efficiency Is the Best Way to Control Orthopaedic Costs.

Current procedural terminology codes and assigned relative value units associated with arthroscopic hip surgery lag behind other joints in accurately describing, and often undervaluing, what surgery entails. Hip arthroscopy is expensive, and, to address inequity, procedural cost drivers require review. Consumable implants and operating room (OR) time drive the costs associated with the procedure. Hospitals, healthcare payors, patients, and surgeons all benefit from increasing OR efficiency and reducing equipment cost. However, the patient loses if financial strategy supersedes care delivery, and it is wrong to cut necessary use of consumables to save money. Fewer anchors is not the answer (yet we should use reusable, nonimplantable supplies when feasible). The greater opportunity to lower costs is improved OR efficiency, requiring a team approach with buy-in from perioperative, anesthesia, surgical staff, and administrators. OR time is a consistent driver of cost across every type of orthopaedic surgery. Studies evaluating strategies for OR efficiency in hip arthroscopy will benefit the field. By leading this effort, surgeons could be best positioned to address inadequate relative value units.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons.

BACKGROUND: A survey was conducted at the 2021 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to evaluate current practice management strategies among AAHKS members. METHODS: An application was used by AAHKS members to answer both multiple-choice and yes or no questions. Specific questions were asked regarding the impact of COVID-19 pandemic on practice patterns. RESULTS: There was a dramatic acceleration in same day total joint arthroplasty with 85% of AAHKS members performing same day total joint arthroplasty. More AAHKS members remain in private practice (46%) than other practice types, whereas fee for service (34%) and relative value units (26%) are the major form of compensation. At the present time, 93% of practices are experiencing staffing shortages, and these shortages are having an impact on surgical volume. CONCLUSION: This survey elucidates the current practice patterns of AAHKS members. The pandemic has had a significant impact on some aspects of practice activity. Future surveys need to monitor changes in practice patterns over time.

Is There An Association Between Bundled Payments and "Cherry Picking" and "Lemon Dropping" in Orthopaedic Surgery? A Systematic Review.

BACKGROUND: The goal of bundled payments-lump monetary sums designed to cover the full set of services needed to provide care for a condition or medical event-is to provide a reimbursement structure that incentivizes improved value for patients. There is concern that such a payment mechanism may lead to patient screening and denying or providing orthopaedic care to patients based on the number and severity of comorbid conditions present associated with complications after surgery. Currently, however, there is no clear consensus about whether such an association exists. QUESTIONS/PURPOSES: In this systematic review, we asked: (1) Is the implementation of a bundled payment model associated with a change in the sociodemographic characteristics of patients undergoing an orthopaedic procedure? (2) Is the implementation of a bundled payment model associated with a change in the comorbidities and/or case-complexity characteristics of patients undergoing an orthopaedic procedure? (3) Is the implementation of a bundled payment model associated with a change in the recent use of healthcare resources characteristics of patients undergoing an orthopaedic procedure? METHODS: This systematic review was registered in PROSPERO before data collection (CRD42020189416). Our systematic review included scientific manuscripts published in MEDLINE, Embase, Web of Science, Econlit, Policyfile, and Google Scholar through March 2020. Of the 30 studies undergoing full-text review, 20 were excluded because they did not evaluate the outcome of interest (patient selection) (n = 8); were editorial, commentary, or review articles (n = 5); did not evaluate the appropriate intervention (introduction of a bundled payment program) (n = 4); or assessed the wrong patient population (not orthopaedic surgery patients) (n = 3). This led to 10 studies included in this systematic review. For each study, patient factors analyzed in the included studies were grouped into the following three categories: sociodemographics, comorbidities and/or case complexity, or recent use of healthcare resources characteristics. Next, each patient factor falling into one of these three categories was examined to evaluate for changes from before to after implementation of a bundled payment initiative. In most cases, studies utilized a difference-in-difference (DID) statistical technique to assess for changes. Determination of whether the bundled payment initiative required mandatory participation or not was also noted. Scientific quality using the Adapted Newcastle-Ottawa Scale had a median (range) score of 8 (7 to 8; highest possible score: 9), and the quality of the total body of evidence for each patient characteristic group was found to be low using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. We could not assess the likelihood of publication using funnel plots because of the variation of patient factors analyzed in each study and the heterogeneity of data precluded a meta-analysis. RESULTS: Of the nine included studies that reported on the sociodemographic characteristics of patients selected for care, seven showed no change with the implementation of bundled payments, and two demonstrated a difference. Most notably, the studies identified a decrease in the percentage of patients undergoing an orthopaedic operative intervention who were dual-eligible (range DID estimate -0.4% [95% CI -0.75% to -0.1%]; p < 0.05 to DID estimate -1.0% [95% CI -1.7% to -0.2%]; p = 0.01), which means they qualified for both Medicare and Medicaid insurance coverage. Of the 10 included studies that reported on comorbidities and case-complexity characteristics, six reported no change in such characteristics with the implementation of bundled payments, and four studies noted differences. Most notably, one study showed a decrease in the number of treated patients with disabilities (DID estimate -0.6% [95% CI -0.97% to -0.18%]; p < 0.05) compared with before bundled payment implementation, while another demonstrated a lower number of Elixhauser comorbidities for those treated as part of a bundled payment program (before: score of 0-1 in 63.6%, 2-3 in 27.9%, > 3 in 8.5% versus after: score of 0-1 in 50.1%, 2-3 in 38.7%, > 3 in 11.2%; p = 0.033). Of the three included studies that reported on the recent use of healthcare resources of patients, one study found no difference in the use of healthcare resources with the implementation of bundled payments, and two studies did find differences. Both studies found a decrease in patients undergoing operative management who recently received care at a skilled nursing facility (range DID estimate -0.50% [95% CI -1.0% to 0.0%]; p = 0.04 to DID estimate: -0.53% [95% CI -0.96% to -0.10%]; p = 0.01), while one of the studies also found a decrease in patients undergoing operative management who recently received care at an acute care hospital (DID estimate -0.8% [95% CI -1.6% to -0.1%]; p = 0.03) or as part of home healthcare (DID estimate -1.3% [95% CI -2.0% to -0.6%]; p < 0.001). CONCLUSION: In six of 10 studies in which differences in patient characteristics were detected among those undergoing operative orthopaedic intervention once a bundled payment program was initiated, the effect was found to be minimal (approximately 1% or less). However, our findings still suggest some level of adverse patient selection, potentially worsening health inequities when considered on a large scale. It is also possible that our findings reflect better care, whereby the financial incentives lead to fewer patients with a high risk of complications undergoing surgical intervention and vice versa for patients with a low risk of complications postoperatively. However, this is a fine line, and it may also be that patients with a high risk of complications postoperatively are not being offered surgery enough, while patients at low risk of complications postoperatively are being offered surgery too frequently. Evaluation of the longer-term effect of these preliminary bundled payment programs on patient selection is warranted to determine whether adverse patient selection changes over time as health systems and orthopaedic surgeons become accustomed to such reimbursement models.

Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location.

BACKGROUND: As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent "secret-shopper" study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access. QUESTIONS/PURPOSES: (1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs? METHODS: An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution's IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC. RESULTS: Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements. CONCLUSION: It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center's affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective. LEVEL OF EVIDENCE: Level II, prognostic study.

Are There Nationwide Socioeconomic and Demographic Disparities in the Use of Outpatient Orthopaedic Services?

BACKGROUND: Although disparities in the use of healthcare services in the United States have been well-documented, information examining sociodemographic disparities in the use of healthcare services (for example, office-based and emergency department [ED] care) for nonemergent musculoskeletal conditions is limited. QUESTIONS/PURPOSES: This study was designed to answer two important questions: (1) Are there identifiable nationwide sociodemographic disparities in the use of either office-based orthopaedic care or ED care for common, nonemergent musculoskeletal conditions? (2) Is there a meaningful difference in expenditures associated with these same conditions when care is provided in the office rather than the ED? METHODS: This study analyzed data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS). The MEPS is a nationally representative database administered by the Agency for Healthcare Research and Quality that tracks patient interactions with the healthcare system and expenditures associated with each visit, making it an ideal data source for our study. Differences in the use of office-based and ED care were assessed across different socioeconomic and demographic groups. Healthcare expenditures associated with office-based and ED care were tabulated for each of the musculoskeletal conditions included in this study. The MEPS database defines expenditures as direct payments, including out-of-pocket payments and payments from insurances. In all, 63,514 participants were included in our study. Fifty-one percent (32,177 of 63,514) of patients were aged 35 to 64 years and 29% were older than 65 years (18,445 of 63,514). Women comprised 58% (37,031 of 63,514) of our population, while men comprised 42% (26,483 of 63,514). Our study was limited to the following eight categories of common, nonemergent musculoskeletal conditions: osteoarthritis (40%, 25,200 of 63,514), joint derangement (0.5%, 285 of 63,514), other joint conditions (43%, 27,499 of 63,514), muscle or ligament conditions (6%, 3726 of 63,514), bone or cartilage conditions (8%, 5035 of 63,514), foot conditions (1%, 585 of 63,514), fractures (7%, 4189 of 63,514), and sprains or strains (18%, 11,387 of 63,514). Multivariable logistic regression was used to ascertain which demographic, socioeconomic, and health-related factors were independently associated with differences in the use of office-based orthopaedic services and ED care for musculoskeletal conditions. Furthermore, expenditures over the course of our study period for each of our musculoskeletal categories were calculated per visit in both the outpatient and the ED settings, and adjusted for inflation. RESULTS: After controlling for covariates like age, gender, region, insurance status, income, education level, and self-reported health status, we found substantially lower use of outpatient musculoskeletal care among patients who were Hispanic (odds ratio 0.79 [95% confidence interval 0.72 to 0.86]; p < 0.001), non-Hispanic black (OR 0.77 [95% CI 0.70 to 0.84]; p < 0.001), lesser-educated (OR 0.72 [95% CI 0.65 to 0.81]; p < 0.001), lower-income (OR 0.80 [95% CI 0.73 to 0.88]; p < 0.001), and nonprivately-insured (OR 0.85 [95% CI 0.79 to 0.91]; p < 0.001). Public insurance status (OR 1.30 [95% CI 1.17 to 1.44]; p < 0.001), lower income (OR 1.53 [95% CI 1.28 to 1.82]; p < 0.001), and lesser education status (OR 1.35 [95% CI 1.14 to 1.60]; p = 0.001) were also associated with greater use of musculoskeletal care in the ED. Healthcare expenditures associated with care for musculoskeletal conditions was substantially greater in the ED than in the office-based orthopaedic setting. CONCLUSIONS: There are substantial sociodemographic disparities in the use of office-based orthopaedic care and ED care for common, nonemergent musculoskeletal conditions. Because of the lower expenditures associated with office-based orthopaedic care, orthopaedic surgeons should make a concerted effort to improve access to outpatient care for these populations. This may be achieved through collaboration with policymakers, greater initiatives to provide care specific to minority populations, and targeted efforts to improve healthcare literacy. LEVEL OF EVIDENCE: Level III, therapeutic study.

Men Receive Three Times More Industry Payments than Women Academic Orthopaedic Surgeons, Even After Controlling for Confounding Variables.

BACKGROUND: In 2016, orthopaedic surgeons received nearly USD 300 million from industry, with the top 10% of recipients making more than 95% of the total amount. The degree to which gender may be associated with industry compensation has not been well explored; however, this may be confounded by a number of variables, including academic productivity, experience, and other factors. We wished to explore the variability in payment distribution by gender after controlling for these factors. QUESTIONS/PURPOSES: (1) Do men or women academic orthopaedic surgeons receive more payments from industry? (2) To what degree do any observed differences between the genders persist, even after accounting for identifiable factors, including academic rank, scholarly productivity, regional location of university, subspecialty selection as identified by fellowships completed, and years since completion of residency? METHODS: This study was a cross-sectional retrospective analysis of surgeons practicing in orthopaedic surgery academic departments in the United States. Academic orthopaedic surgery departments were identified using the Fellowship and Residency Electronic Interactive Database. Publicly available data on gender, academic rank, scholarly productivity, regional location of university, fellowships completed, and years since residency graduation were collected from institutional websites. Industry funding data for 2016 were obtained from the Centers for Medicare & Medicaid Services Open Payments Database, and scholarly productivity data through 2017 were collected from Scopus. A total of 2939 academic orthopaedic surgeons, 2620 (89%) men and 319 (11%) women from 126 programs were identified. Men and women surgeons were different in most of the variables collected, and all except region of university were associated with differences in industry payments. RESULTS: The median payment for men surgeons was greater than that for women (USD 1027 [interquartile range USD 125-USD 9616] versus USD 177 [IQR USD 47-USD 1486]; difference of medians, USD 850; p < 0.001]. After accounting for potentially confounding variables like faculty rank, years since residency, H-index and subspecialty choice, women faculty members still received only 29% of payments received by otherwise comparable men orthopaedists (beta coefficient for gender = 0.29 [95% CI 0.20 to 0.44; p < 0.001]). CONCLUSIONS: Women academic orthopaedic surgeons received only 29% of the industry payments received by men, even after controlling for faculty rank, years since residency, H-index, and subspecialty selection. This gender-related disparity may hinder the career advancement of women orthopaedic surgeons. CLINICAL RELEVANCE: Increased transparency by companies can help guide orthopaedic surgeons who wish to receive industry funding.

Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopaedic Sports Medicine: A Matched-Pair Analysis.

PURPOSE: To quantify the cost of resident involvement in academic sports medicine by examining differences in operative time, relative value units (RVUs) per case, and RVUs per hour between attending-only cases and cases with resident involvement. METHODS: A retrospective analysis of common sports medicine procedures identified by Current Procedural Terminology code was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2015. Matched cohorts were generated based on demographic variables, comorbidities, preoperative laboratory values, and surgical procedures. Bivariate analysis examined mean differences in operative time, RVUs per case, and RVUs per hour between attending-only cases and cases with resident involvement. A cost analysis was performed to quantify differences in RVUs generated per hour in terms of dollars per case. RESULTS: A total of 14,840 attending-only cases and 2,230 resident-involved cases were used to generate 2 matched cohorts (N = 4,460). Resident cases had greater mean operative times than attending-only cases, with operative time increasing as residents became more senior (P < .01). Residents participated in cases with larger mean RVUs per case (P < .01). Cases with lone attendings showed greater RVUs per hour (P < .01). The cost of resident involvement increased nearly 8-fold from postgraduate year 1 to postgraduate year 6 residents ($25.70 vs $200.07). CONCLUSIONS: In academic sports medicine, the involvement of resident physicians increases operative time. The associated decrease in attending physician efficiency in RVUs per hour equates to an average cost per case of $159.18, with costs increasing as residents become more senior. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

[Economic aspects of digitalization in orthopedics and trauma surgery]. / Ökonomische Aspekte der Digitalisierung in Orthopädie und Unfallchirurgie.

INTRODUCTION: In addition to the advantages for patients and physicians, the progression of digitalization will also have economic implications for healthcare systems in toto worldwide. The integration of digital innovations enables healthcare institutions to transform their current activities and processes and to create a new form of patient care. IMPORTANT ECONOMIC TOPICS OF DIGITALIZATION: Using digital applications process optimization can be achieved by increased efficiency and therefore a reduction in costs in the healthcare system. Improved processes can in turn achieve an increase in quality in the treatment of patients. Simultaneously, a duplication of investigations can be avoided through digital interfaces and the communication among the healthcare professions involved can be improved, which would result in a conservation of resources. Finally, these influences can lead to more precision in medicine, acceleration of healing processes and represent an advantage for all parties involved. PERSPECTIVES: Economic redistribution due to digitalization of medicine will become increasingly apparent in the future. Ethical considerations as well as data protection will be important topics. At the same time investments and digital innovations must be sponsored by the government and industry. Scientific studies are necessary to secure the evidence of new methods for practice in orthopedics and trauma surgery.

Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial.

BACKGROUND: Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. OBJECTIVE: The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. METHODS: An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. RESULTS: This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. CONCLUSIONS: This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. TRIAL REGISTRATION: ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX).

Industry Payments to Pediatric Orthopaedic Surgeons Reported by the Open Payments Database: 2014 to 2017.

BACKGROUND: The Open Payments Database (OPD), mandated by the Sunshine Act, is a national registry of physician-industry transactions. Payments are reported as either General, Research, or Ownership payments. The current study aims to investigate trends in OPD General payments reported to pediatric orthopaedic surgeons from 2014 to 2017. METHODS: General industry payments made to pediatric orthopaedic surgeons (as identified by OPD) were characterized by median payment, payment subtype, and census region. As fewer Research and Ownership payments were made, only payment totals for these categories were determined. General payment data were analyzed for trends using the nonparametric Mann-Whitney U test. RESULTS: For General payments, there was an increase in the number of compensated pediatric orthopaedists from 2014 to 2017 (324 vs. 429). Of those compensated, there was no significant change in median payment per compensated surgeon ($201 vs. $197; P=0.82). However, a large percentage of total General payment dollars in pediatric orthopaedics were made to the top 5% of compensated pediatric orthopaedists each year (average 71% of total General industry compensation). For this top 5% group, median General payment per compensated surgeon increased from 2014 ($14,624) to 2017 ($32,752) (P=0.006). A significant increase in median subtype aggregate payment per surgeon was observed in the education (P<0.001) and royalty/license (P=0.031) subtypes; a significant decrease was observed for travel/lodging payments (P=0.01). Midwest pediatric orthopaedists received the highest median payment across all years studied. Few payments for research and ownership were made to pediatric orthopaedists. Four-year aggregate payment totals were $18,151 and $3,223,554 for Research and Ownership payments, respectively. CONCLUSIONS: Many expected payments to surgeons to decrease when put under the public scrutiny of the OPD. Not only was this decrease not observed for General payments to pediatric orthopaedic surgeons during the 2014 to 2017 period, but also the median General payment to the top 5% increased. These findings are important to note in the current era of increased transparency. LEVEL OF EVIDENCE: Level III.

Artificial Intelligence and Arthroplasty at a Single Institution: Real-World Applications of Machine Learning to Big Data, Value-Based Care, Mobile Health, and Remote Patient Monitoring.

BACKGROUND: Driven by the recent ubiquity of big data and computing power, we established the Machine Learning Arthroplasty Laboratory (MLAL) to examine and apply artificial intelligence (AI) to musculoskeletal medicine. METHODS: In this review, we discuss the 2 core objectives of the MLAL as they relate to the practice and progress of orthopedic surgery: (1) patient-specific, value-based care and (2) human movement. RESULTS: We developed and validated several machine learning-based models for primary lower extremity arthroplasty that preoperatively predict patient-specific, risk-adjusted value metrics, including cost, length of stay, and discharge disposition, to provide improved expectation management, preoperative planning, and potential financial arbitration. Additionally, we leveraged passive, ubiquitous mobile technologies to build a small data registry of human movement surrounding TKA that permits remote patient monitoring to evaluate therapy compliance, outcomes, opioid intake, mobility, and joint range of motion. CONCLUSION: The rapid rate with which we in arthroplasty are acquiring and storing continuous data, whether passively or actively, demands an advanced processing approach: AI. By carefully studying AI techniques with the MLAL, we have applied this evolving technique as a first step that may directly improve patient outcomes and practice of orthopedics.

A Novel, Synergistic Model in Total Joint Arthroplasty: A Report of 2 Specialty Hospitals With Joint Ownership Between Physicians and Healthcare Systems.

BACKGROUND: In 2010, the Affordable Care Act introduced new restrictions on the expansion of physician-owned hospitals (POHs) due to concerns over financial incentives and increased costs. The purpose of this study is to determine whether joint ventures between tertiary care and specialty hospitals (SHs) allowing physician ownership (POHs) have improved outcomes and lower cost following THA and TKA. METHODS: After institutional review board approval, a retrospective review of consecutive series of primary THA and TKA patients from 2015 to 2016 across a single institution comprised of 14 full-service hospitals and 2 SHs owned as a joint venture between physicians and their health system partners. Ninety-day episode-of-care claims cost data from Medicare and a single private insurer were reviewed with the collection of the same demographic data, medical comorbidities, and readmission rates for both the SHs and non-SHs. A multivariate regression analysis was performed to determine the independent effect of the SHs on episode-of-care costs. RESULTS: Of the 6537 patients in the study, 1936 patients underwent a total joint arthroplasty at an SH (29.6%). Patients undergoing a procedure at an SH had shorter lengths of stay (1.29 days vs 2.23 days for Medicare, 1.15 vs 1.86 for private payer, both P < .001), were less likely to be readmitted (4% vs 7% for Medicare, P = .001), and had lower mean 90-day episode-of-care costs ($16,661 vs $20,579 for Medicare, $26,166 vs $35,222 for private payers, both P < .001). When controlling for the medical comorbidities and demographic variables, undergoing THA or TKA at an SH was associated with a decrease in overall episode costs ($3266 for Medicare, $13,132 for private payer, both P < .001). CONCLUSION: Even after adjusting for a healthier patient population, the joint venture partnership with health systems and physician-owned SHs demonstrated lower 90-day episode-of-care costs than non-SHs following THA and TKA. Policymakers and practices should consider these data when considering the current care pathways.

Stratum-Specific Likelihood Ratio Analysis: An Evidence-Based and Pragmatic Approach to Meaningful Thresholds in Lower Extremity Arthroplasty.

BACKGROUND: With the transition toward a value-based care delivery model, an evidence-based approach to quantify the effect of procedural volume on outcomes and cost presents an opportunity to understand and optimize the delivery of lower extremity arthroplasty. Stratum-specific likelihood ratio (SSLR) analysis has been recently applied to define benchmarks which confer a significant advantage in value at the hospital or surgeon level. MATERIALS AND METHODS: In this report, the role, statistical technique, and future applications of SSLR analysis are described with an example outlined for total hip arthroplasty (THA). RESULTS: SSLR analysis provides multiple significant value-based thresholds, providing an advantage over previous methods used to describe the effects of surgeon and hospital volume. These benchmarks have been developed for THA, total knee arthroplasty (TKA), hip fracture, and several other orthopaedic procedures. Current SSLR analyses are limited by the databases employed, and the study of a national database may provide more generalizable benchmarks, which may be applied by hospitals and orthopaedic residencies to define minimum competency thresholds. CONCLUSION: The use of SSLR analysis provides a pragmatic, data-driven approach to understanding and communicating the volume-value relationship in orthopaedic surgery, particularly lower-extremity arthroplasty.

[Prioritization or unlimited resources in orthopedics and trauma surgery?] / Priorisierung oder unbegrenzte Ressourcen in Orthopädie und Unfallchirurgie?

The development of the healthcare system in Germany is increasingly approaching human and economic limits. A social consensus and a political concept at which point priorities are promoted and for which services the money should be primarily spent, do not exist on the whole. As soon as it becomes clear that resources are limited and that is now, prioritization has to be introduced to avoid the alternative threat of rationing of treatment benefits. The goal of prioritization is to rationally and optimally use the existing but limited resources. Medical progress and the relationship to the demographic development are the variables in the future. The individual care of the patient, patients' needs and dependence on access to treatment are the foundations of ethical actions. They must be at the center of attention for doctors and nurses because, after all they are the patient's advocates in the complex healthcare system. At the same time, unjustified claims for entitlement must be rejected just as a preservation of vested rights. Efficiency and economic considerations in diagnostics and treatment are not mutually exclusive. The physician acts as a mediator between the claims of the patient to be treated, the individual realization and the existing resources in the healthcare system.

The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics. QUESTIONS/PURPOSES: (1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state? METHODS: We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design. RESULTS: There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014. CONCLUSIONS: After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Effects of the Affordable Care Act on Payer Mix and Physician Reimbursement in Hand Surgery.

PURPOSE: To evaluate the effect of the Affordable Care Act (ACA) on the payer distribution and reimbursement rate for hand surgery at our institution. METHODS: We reviewed records of 4,257 patients who underwent hand surgery at our institution between January 2008 and June 2016; 2,601 patients underwent surgery before the implementation of the ACA, and 1,656 patients after. Type of procedure, insurance status, amount of money billed, and amount collected were recorded. RESULTS: After the implementation of the ACA, we performed fewer metacarpal fracture repairs, distal radius fracture repairs, and abscess incision and drainage procedures. We performed more endoscopic carpal tunnel releases. The proportion of uninsured patients decreased significantly (15% to 6.4%), and the proportion of patients on Medicare (15.4% to 20.3%) and Medicaid (9.5% to 17.8%) increased significantly. The overall reimbursement rate did not change significantly (32.3% to 30.3%) between the 2 time periods. CONCLUSIONS: After the implementation of the ACA, we observed a significant reduction in the number of uninsured patients and an increase in Medicaid and Medicare patients. However, this led to no significant change in reimbursement rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and design analysis II.