The future of orthopedics and the orthopedic surgeon: Bright and challenging
It is well documented in all the projections that the demand for orthopedic surgeons and their services will increase with the aging of our population and the simultaneous desire for individuals to stay functional at all ages. These increased demands will bring greater challenges related to the financing of this increased utilization as well as the technological advances.
These financial challenges will manifest and be compounded by periods of continued unpredictable reimbursement. The increased demand by those seeking care will further stimulate the ongoing scrutiny and reassessment of physician remuneration.
Challenges to how we practice
The funding of Medicare and new federal and state-funded programs will remain the driving force behind setting reimbursements and financing of health care. Our current financing methods are not, and will not be, adequate to meet the increasing costs and demands of more universal coverage.
The debate over funding and implementation will emerge as a major issue in the upcoming presidential elections. Since it appears that we will not move all at once to a single-payer system during the initial transition to more universal coverage, federal and state governments may be the payers of 45% or more of the future universal coverage proposals and will try and set the rules for the others.
The American public, although increasingly supportive of universal health care, remains skeptical that our government can administer health-care-for-all efficiently and in everyone’s best interest via a single-payer system. It will be a challenge for private insurance to meet the medical needs of the public and still take out their profits, which can be up to 31% of the health care dollar for administration in some plans.
Many who buy health coverage are seeking reform because they are not satisfied with what they receive for their premiums and the escalating health care costs that are threatening many individuals and businesses.
Clearly, we have experienced the definite trend within orthopedics and medicine in general to do as much as possible in outpatient settings. Arthroscopy and arthroscopically assisted surgical procedures have led the surge and volume of outpatient cases. Spine procedures and joint replacement are still predominantly done on an inpatient basis, but many new approaches are being explored that may increase the outpatient potential. It may take several years, but, many more orthopedic procedures will be feasible in the outpatient and overnight settings. New technologies, devices, instruments and related advances in navigation, robotics and bone substitutes will lead to less-invasive and more physiologic surgical interventions and will further contribute to these trends.
The trend towards decentralization (outpatient settings) of hospital-based imaging, diagnostic studies and rehabilitation programs will continue and we will see more advances in imaging, rehabilitation and pain management.
Physician-ownership, participation in new facilities and control of ancillary services will be further challenged with increasing intensity in the future. Hospitals will covet this potential profit stream in an effort to survive under the increasing financial burden and decreasing reimbursement for inpatient, emergency and intensive care programs. These challenges will test the relationship of hospitals and orthopedic surgeons.
This will, or already has, lead to head-on battles. The American Hospital Association (AHA) is lobbying heavily and will likely increase the intensity of their fight to control this market on both the national and state levels. Their strategy often employs the “good cop/bad cop” scenario — your hospital administrator is your friend and trying to work with you at the local level, but is your foe at state and national level. The AHA is actively lobbying to limit and restrict physicians’ ability to own and control surgery centers, imaging centers and other ancillary services.
The battle for survival
Hospitals or health plans have hired and will further attempt to hire orthopedic surgeons or bring in younger surgeons to compete with larger practices that own and administer successful ancillary services.
New relationships will evolve with the hospitals that are not able to replace or displace their orthopedic surgeons. In many cases, they will not want to lose orthopedic business and work toward alignments and partnerships with orthopedic surgeons. That will be a business decision based on whether it is more costly to hire or partner and a desire to control all the profits or be happy with only a share.
These will be hard business decisions. The hospital administrators have more time and an organizational structure that supports their efforts and assists them. Their infrastructure contributes to them being effective negotiators and influential in new health policy.
In addition to hospital competition and induced restrictions for ancillary revenue, decreasing reimbursements will further challenge private practice. Private practices, as physician-run small businesses, will have to continue to address many of the same issues as other small businesses including employee health care coverage, workers’ compensation, retirement plans, liability coverage and office administration.
There is a point where business owners say it is not worth the responsibility, liability and stress and decide to give the struggle up and become employees. This is something each of us has to decide for ourselves. I hear from many of you that you would just like to practice medicine and wish to leave the business and financial struggles to someone else.
Physician-employees have it well today because there is competition with alternatives, ie, private practice, to get and retain employees. However, if conditions change in the marketplace, one day there may be no alternatives. It may be fine for the next generations working in a new system, but we have to be careful: Do we get there by choice rather then simply acquiescing?
Outcomes and oversight
It appears the future will bring increasing scrutiny and oversight. Many policy makers and governing bodies outside of medicine feel we are ineffective in policing ourselves. This will require more documentation of our treatment and procedural outcomes as well as more in-depth record keeping of complications and the remedies taken.
There will be more justification required for controlling variable outcomes, the costs incurred in various treatments and the profitability (physician income and incentives).
In the new universal-coverage markets, many question whether the system will allow individuals to pay beyond the generic costs that their insurance covers to have new and the latest technology. This debate will be driven by direct-to-consumer marketing and by the patients wanting the very best for their loved one or themselves.
Physicians will have their motives for industry loyalties examined in greater detail (Click here to read the 4 Questions interview). The direct payments to users of drugs and devices are already being limited. It will impact the new evolving biologics market. What role and what indications will be reimbursed for recombinant growth factors, cell transplantation, gene therapy, stem cells and tissue-engineered products? These treatments will challenge health coverage reimbursements in terms of what is experimental, what is cost effective and if they are better than current or placebo treatments. These issues will delay many of these new technologies’ introductions into the marketplace for years as this data is collected.
The future is bright
In spite of the challenges discussed above, which primarily deal with the financing and costs of future health care, whatever evolves, orthopedic surgeons will continue to provide state-of-the-science treatments. We will continue to have the satisfaction and deep meaning gained from contributing to the quality of our patients’ lives and their maximum musculoskeletal potential.
We are in a profession that will have increasing demands for our services and an exciting evolving future. We need to be involved in shaping it for our patients and our profession.
Douglas W. Jackson, MD
Chief Medical Editor