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.     

The incidence of fractures and dislocations referred for orthopaedic services in a capitated population

BACKGROUND: The purpose of this study was to determine the annual incidence rates of non-work-related traumatic fractures and dislocations (excluding head and facial injuries) referred for orthopaedic services in a large population enrolled under a capitated insurance contract. METHODS: The number of fractures and dislocations that were referred for orthopaedic services were recorded prospectively from among an average of 135,333 persons per year who were enrolled under a capitated insurance contract during the three-year study period. These data were used to determine the gender-specific and age-specific incidence rates of fractures and dislocations referred for orthopaedic services. RESULTS: A total of 3440 fractures and 422 dislocations were referred for orthopaedic services during the three-year study period. The incidence rate of fractures referred for orthopaedic services was 8.47 per 1000 member-years, with a significantly (p < 0.0001) higher rate among males. Members between the ages of ten and fourteen years had the highest rate of fractures referred for orthopaedic services (21.52 per 1000 member-years). The lifetime risk of a traumatic fracture referred for orthopaedic services to the age of sixty-five years was one in two for both males and females. The incidence rate of dislocations referred for orthopaedic services was 1.04 per 1000 member-years, which did not differ significantly (p = 0.75) between genders. Members between the ages of fifteen and nineteen years had the highest rate of dislocations referred for orthopaedic services (2.75 per 1000 member-years). The lifetime risk of a traumatic dislocation referred for orthopaedic services to the age of sixty-five years was one in sixteen for both male and female members. CONCLUSIONS: Young males had the highest rate of traumatic fractures referred for orthopaedic services. Adolescents of both genders had high rates of traumatic dislocations referred for orthopaedic services. The lifetime risk of a non-work-related fracture referred for orthopaedic services to the age of sixty-five years is approximately equal to that of coronary artery disease.     

Magnetic resonance imaging of the extremities. A critical appraisal of utilization by an orthopaedic service

Summary Objective: To assess the utilization of MRI by the orthopaedic department of a University Teaching Hospital for the investigation of musculoskeletal conditions affecting the extremities.Design: During a 12 month period, all patients referred for MRI of an extremity were enrolled in the study. Clinical details of presentation, surgical management and outcome were prospectively recorded.Patients: 91 patients were included with a mean age of 35 years. The following anatomical areas were scanned; knee (48), shoulder (31), hip (3), soft tissues (6), brachial plexus (2), wrist (1).Results: A significant finding was reported in 56 patients (62%) and surgery was undertaken in 42. With regard to MRI of the knee the sensitivity of the investigation was 95%. Four patients were referred inappropriately for the investigation.Conclusions: Selective referral for MRI for the investigation of the injured knee represents an appropriate use of this scarce resource. It allows arthroscopy to be targetted to those patients in whom the procedure will be therapeutic. Unnecessary diagnostic knee arthroscopy can and should be avoided. The study supports increased orthopaedic access to MRI for non spinal conditions in the future.     

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.     

Editorial Commentary: Understanding the Gap in Clinical Outcomes After Rotator Cuff Repair Based on the Influence of Social Determinants of Health

There is growing recognition and understanding of the important role that social determinants of health and access to care play in surgical outcomes, particularly in the field of orthopaedic surgery and sports medicine. Factors including race, ethnicity, education, income, insurance status, social class, and sex have been identified as important contributors to outcomes after orthopaedic procedures, including rotator cuff repair. Disadvantaged or marginalized patients have been shown to attend fewer office visits and physical therapy sessions, are more likely to present with advanced stages of disease, have delayed surgical interventions, and have poorer patient-reported outcomes after surgery. Virtual visits and telemedicine have the great ability to improve access to medical professionals for disadvantaged patients who have poor access to transportation. However, reliance on telehealth has the potential to worsen access to care for patients with limited access to technology or language barriers. Disadvantaged populations, including those with noncommercial health care insurance, show decreased use of telemedicine.     

Critical shortage of orthopaedic services in Ontario,Canada

BACKGROUND: Questions regarding the adequacy of the current orthopaedic workforce in Canada to meet the present and future demands for orthopaedic services raise the need for accurate estimates of the supply and demand for orthopaedic services. The present study provides estimates of current supply of orthopaedic services in Ontario, the largest province of Canada, in order to allow for direct comparisons with data on workforce requirements. METHODS: All identified orthopaedic surgeons in Ontario were sent a self-administered questionnaire in 2000, which was similar to a previous survey in 1997. The age and gender of eligible respondents were obtained from the College of Physicians and Surgeons of Ontario. One full-time-equivalent orthopaedist was assumed to have 2200 annual hours of direct patient contact and to provide forty-four weeks of clinical work per year. RESULTS: The response rate was 94%. The mean age of the 337 active orthopaedic surgeons was forty-nine years, an increase of four years since 1997. Six percent of the respondents were women in both survey years. Approximately twenty-three half days of office and surgery time per 100,000 population were reported, which represents approximately two full-time equivalent orthopaedic surgeons per 100,000 population. On the average, eight half days of combined office and surgery time were reported per surgeon per week. CONCLUSIONS: The estimated supply of orthopaedic surgeons in Ontario (two full-time equivalents per 100,000 population) falls short of the recently calculated requirement in the United States (5.6 full-time equivalents per 100,000 population). These data suggest that there is currently a shortage of orthopaedic services in Ontario, which will be exacerbated by the aging of a profession already working near full capacity.     

Costs associated with potentially unnecessary postoperative healthcare encounters after lumbar spine surgery

BACKGROUND CONTEXTExcessive use of postoperative imaging after lumbar surgery has been documented, becoming a target for cutting costs. This must be balanced with the patient's need for information and allay their postoperative concerns.PURPOSETo determine the incidence and associated costs of patient interactions with the healthcare system, outside the standard follow up routine, in the first postoperative year.STUDY DESIGNRetrospective longitudinal cohort.PATIENT SAMPLEConsecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 from a multi-surgeon single tertiary spine center.OUTCOME MEASURESAll healthcare encounters: phone calls, office and emergency department visits, and additional testingMETHODSA consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 were identified. All non-routine healthcare encounters: phone calls, office and emergency department visits, and additional testing were collected. Direct costs for all healthcare services were determined using the Medicare Allowable rates. Indirect costs were determined using local, median income, length of office visits, and distance from the clinic to the patient's home.RESULTSOf 200 patients, 14 with thoracic fusion were excluded. The mean age of the 186 included patients was 58.26 years and 85 (46%) were male. Forty-seven percent (87/186) had only routine postoperative visits and 24 had revision surgery. Seventy-five patients made a total of 102 phone calls, 55 office visits, leading to 38 diagnostic studies none of which led to an additional intervention. Using Medicare Allowable rates, the mean direct cost was $776 per patient and the using a median income of $16/h the mean indirect cost was $124 per patient. There were no differences in the baseline characteristics among the patients who only had routine post-op encounters, had non-routine encounters or had a repeat surgery.CONCLUSIONSForty percent of the patients undergoing lumbar surgery had a healthcare encounter outside their routine follow up that did not result in additional intervention after their index operation. These potentially unnecessary encounters create additional cost and inconvenience to both the patient and healthcare system. Providing patient reassurance is important and providers should identify ways to reduce associated costs through patient education, virtual visits, or new technologies to monitor patient's postoperative progress.     

Dorsal triquetrum fracture

The patient was a 39-year-old man who self-referred to a physical therapist with a chief complaint of right wrist pain after falling backward onto an outstretched right hand the previous day. Based on the suspicion of a fracture, right wrist radiographs (posterior-to-anterior, lateral, and oblique views) were completed, which revealed a comminuted dorsal triquetrum fracture. The patient was referred to an orthopaedic surgeon who recommended nonoperative management.     

Prereferral evaluation of patients with suspected bone and soft tissue tumors

One hundred consecutive patients referred to an orthopaedic oncology practice for evaluation of suspected bone or soft tissue tumors were studied prospectively. There were 76 patients with bone lesions and 24 patients with soft tissue lesions. At the time of initial consultation, information regarding the referring diagnosis, number of prior physician office visits, and prereferral imaging studies obtained was collected. There were 50 patients with benign tumors, 17 patients with primary malignant tumors, 11 patients with metastatic tumors, and 22 patients with nonneoplastic conditions. The average number of physician visits before referral for the entire group was 4.8 visits and was highest for patients with malignant bone tumors (6.2 visits). Imaging studies obtained before referral included plain radiographs, magnetic resonance imaging, bone scans, computed tomography scans, and ultrasound. None of the plain radiographs were thought to be unnecessary; however, 26 of 76 (34.2%) magnetic resonance imaging scans, 17 of 40 (42.5%) bone scans, and 13 of 36 (36.1%) computed tomography scans were excessive and did not contribute to the evaluation of the lesion. Although only 58% of the study group included patients with benign bone tumors and nonneoplastic bone lesions, they accounted for the majority (79%) of unnecessary imaging studies. Primary care physicians and general orthopaedic physicians were equally likely to order unnecessary imaging studies (48% and 52%, respectively).     

Validation of a modern activity hand survey with respect to reliability, construct and criterion validity

This study validates a novel, modern wrist and hand functional assessment: the Modern Activity Subjective Survey of 2007 (MASS07). In total, 326 patients visiting an academic tertiary-care orthopaedic hand clinic (April 2006-April 2007) were recruited to complete the MASS07 questionnaire, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and Patient-Rated Wrist Evaluation (PRWE) to assess construct validity, criterion validity and test-retest reliability of the MASS07. MASS07 correlated strongly with both PRWE (0.81) and DASH (0.85) even when adjusted for age, sex and history of hand problems (P<0.001). MASS07 scores compared for 42 patients with repeated visits indicated no statistically significant difference between MASS07 scores at the patients' first and second clinic visit. We conclude that the newly constructed MASS07 instrument is valid and reliable with respect to the outpatient population with a wide spectrum of hand and wrist pathologies for fast and effective assessment of patient-reported hand function during modern daily activities.     

Determining the incidence of postbariatric surgery emergency department utilization: an analysis of a statewide insurance database

BackgroundPrior studies have found rates of emergency department (ED) visits after bariatric surgery approach 15% with the majority (>60%) not requiring admission. The timeframe for which ED utilization remains elevated postoperatively remains unknown. We hypothesize that ED utilization following bariatric surgery remains elevated for months after surgery with the majority of visits not requiring admission.ObjectiveNo study has determined the impact bariatric surgery has on health care resource utilization in the two years following surgery. The aim of this study is to determine the frequency of ED visitation in the 2 years following bariatric surgery.SettingsDatabase study, single state-wide insurance database.MethodsWe queried the Colorado All Payers Claim Database. Patients with data 1 year before and 2 years after surgery were included. Primary outcomes of interest were ED visits or readmissions during the 2-year period. Bariatric surgeries were identified using CPT codes. Diagnoses for an ED visit or readmission were determined by ICD codes.ResultsA total of 5399 patients underwent bariatric surgery from January 2013–November 2017. Of these, 59% underwent sleeve gastrectomy, 38% Roux-en-Y, 2% gastric band, and 1% another surgery. Median age was 44 (IQR 35–54) years, and 82% were female. Overall, 3103 patients (57%) visited the ED at least once with a total of 12,988 visits, 1267 of which (9.8%) resulted in admission. ED use was highest in the 30 days following surgery (17%) but remained above presurgery baseline for 8 months (7.4% at 8 mo compared with baseline mean 6.4% [95% CI 6.0%–6.8%]).ConclusionsED visits remain elevated for 8 months post bariatric surgery with over 90% of visits not requiring an admission. Interventions that prevent emergency department utilization should be key focus of quality improvement projects to limit health care resource utilization following bariatric surgery.     

Minimalistic approach to treating wrist torus fractures

Thirty-three patients with unilateral wrist torus fractures were reviewed retrospectively. Patients were all treated with a removable plaster-of-Paris volar forearm splint and a symptom-based splinting protocol. This protocol emphasized the parents and patients deciding when to wean from the splint as their symptoms improved. Patients were followed about 4 weeks after fracture, and initial and follow-up radiographs were compared for any changes in fracture angulation. All of the fractures healed without significant clinical change in angulation or complications. The authors propose the following treatment protocol: radiographic diagnosis and application of the removable splint in the emergency department, and one orthopaedic office/clinic visit to confirm the diagnosis and provide splinting instructions. The elimination of the additional orthopaedic visit for repeat radiographs and cast removal reduces the family's time lost from school and work and the physician's time and costs.     

Orthopaedic GP Fellowship: does it work?

BACKGROUND: General practitioners (GPs) see a significant number of musculoskeletal problems in their daily caseload. However, orthopaedic training often forms a relatively small part of their undergraduate and postgraduate training. METHODS: A training fellowship for GPs was set up in Warrington to improve management of patients with common orthopaedic complaints in the primary care setting, and to facilitate more appropriate referrals to orthopaedic surgeons. Following the fellowship, GP referral patterns were examined. RESULTS: It was found that the GP fellows were managing many conditions more appropriately, either conservatively, or with skills learnt during the fellowship. There was an increase in the number of referred cases being listed for surgery indicating a more appropriate referral pattern to hospital. CONCLUSIONS: The Orthopaedic GP Fellowship has improved patient management in primary care and helped GPS better identify those patients who need to be referred for a specialist orthopaedic opinion.     

Academic health systems management: the rationale behind capitated contracts

OBJECTIVE: To determine why hospitals enter into "capitated" contracts, which often generate accounting losses. The authors' hypothesis is that hospitals coordinate contracts to keep beds full and that in principal, capitated contracts reflect sound capacity management. SUMMARY BACKGROUND DATA: In high-overhead industries, different consumers pay different prices for similar services (e.g., full-fare vs. advanced-purchase plane tickets, full tuition vs. financial aid). Some consumers gain access by paying less than total cost. Hospitals, like other high-overhead business enterprises, must optimize the use of their capacity, amortizing overhead over as many patients as possible. This necessity for enhanced throughput forces hospitals and health systems to discount empty beds, sometimes to the point where they incur accounting losses serving some payors. METHODS: The authors analyzed the cost accounting system at their university teaching hospital to compare hospital and intensive care unit (ICU) lengths of stay (LOS), variable direct costs (VDC), overhead of capitated patients, and reimbursement versus other payors for all hospital discharges (n = 29,036) in fiscal year 1998. The data were analyzed by diagnosis-related groups (DRGs), length of stay (LOS), insurance carrier, proximity to hospital, and discharge disposition. Patients were then distinguished across payor categories based on their resource utilization, proximity to the hospital, DRG, LOS, and discharge status. RESULTS: The mean cost for capitated patients was $4,887, less than half of the mean cost of $10,394 for the entire hospitalized population. The mean capitated reimbursement was $928/day, exceeding the mean daily VDC of $616 but not the total cost of $1,445/day. Moreover, the mean total cost per patient day of treating a capitated patient was $400 less than the mean total cost per day for noncapitated patients. The hospital's capitated health maintenance organization (HMO) patients made up 16. 0% of the total admissions but only 9.4% of the total patient days. Both the mean LOS of 3.4 days and the mean ICU LOS of 0.3 days were significantly different from the overall values of 5.8 days and 1 day, respectively, for the noncapitated population. For patients classified with a DRG with complication who traveled from more than 60 miles away, the mean LOS was 10.7 days and the mean total cost was $21,658. This is in contrast to all patients who traveled greater than 60 miles, who had an LOS of 7.2 days and a mean total cost of $12,569. CONCLUSION: The capitated payor directed the bulk of its subscribers to one hospital (other payors transferred their sicker patients). This was reflected in the capitated group's lower costs and LOS. This stable stream of relatively low-acuity patients enhanced capacity utilization. For capitated patients, the hospital still benefits by recovering the incremental cost (VDC) of treating these patients, and only a portion of the assigned overhead. Thus, in the short run, capitated patients provide a positive economic benefit. Other payors' higher-acuity patients arrive more randomly, place greater strains on capacity, and generate higher overhead costs. This results in differential reimbursement to cover this incremental overhead. Having a portfolio of contracts allows the hospital to optimize capacity both in terms of patient flows and acuity. One risk of operating near capacity is that capitated patients could displace other higher-paying patients.     

A review of hand surgery provision in England

This study reviews hand surgical activity and the resources available for provision of hand surgery in England in 2001. Operation rates for three common procedures, viz. carpal tunnel release, Dupuytren's surgery and ganglion surgery, were considered. The local population and the number of hand surgeons in each NHS Hospital Trust were compared. We identified 275 consultant surgeons with an interest in hand surgery working in the NHS in England. Approximately two-thirds were orthopaedic surgeons, almost one-third were plastic surgeons and a small number were accident and emergency surgeons. Half of all hand surgeons worked in large units, with three or more hand surgeons, but almost 20% of hand surgery was delivered in hospitals in which there was no surgeon with a declared interest in hand surgery. Surgery rates for Dupuytren's contracture varied from 0.04 to 0.36 cases per 1,000 population per annum and for carpal tunnel syndrome varied from 0.25 to 1.31 cases per 1,000 per annum. We found a correlation between rates of surgery and the number of hand surgeons, locally. A recent audit (Burke, Dias, Heras-Pelou, Bradley, & Wildin, 2004. Providing care for hand disorders, a reappraisal of need. Journal of Hand Surgery, 29B: 575-579.) has suggested that one hand surgeon is required to meet the needs of a population of 125,000, with a national requirement for 393 hand surgeons. We conclude that there are insufficient hand surgeons in England and believe that the wide local variations in hand surgery rates are indicative of a significant unmet demand for hand surgery in the English population.     

Total Joint Arthroplasty Utilization After Orthopaedic Surgery Referral: Identifying Disparities Along the Care Pathway

BackgroundAlthough racial and ethnic disparities in total joint arthroplasty (TJA) have been thoroughly described, only a few studies have sought to determine exactly where along the care pathway these disparities are perpetuated. The purpose of this study was to investigate disparities in TJA utilization occurring after patients who had diagnosed hip or knee osteoarthritis were referred to a group of orthopaedic providers within an integrated academic institution.MethodsA retrospective, multi-institutional study evaluating patients with diagnosed hip or knee osteoarthritis was conducted between 2015 and 2019. Information pertaining to patient demographics, timing of clinic visits, and subsequent surgical intervention was collected. Utilization rates and time to surgery from the initial clinic visit were calculated by race, and logistic regressions were performed to control for various demographic as well as health related variables.ResultsWhite patients diagnosed with knee osteoarthritis were significantly more likely to receive total knee arthroplasty (TKA) than Black and Hispanic patients, even after adjusting for various demographic variables (Black patients: odds ratio [OR] = 0.63, 95% CI = 0.55-0.72, P = .002; Hispanic patients: OR = 0.69, 95% CI = 0.57-0.83, P = .039). Similar disparities were found among patients diagnosed with hip osteoarthritis who underwent total hip arthroplasty (THA; Black patients: OR = 0.73, 95% CI = 0.60-0.89, P = <.001; Hispanic patients: OR = 0.72, 95% CI = 0.53-0.98, P <.001). There were no differences in time to surgery between races (P > .05 for all).ConclusionIn this study, racial and ethnic disparities in TJA utilization were found to exist even after referral to an orthopaedic surgeon, highlighting a critical point along the care pathway during which inequalities in TJA care can emerge. Similar time to surgery between White, Black, and Hispanic patients suggest that these disparities in TJA utilization may largely be perpetuated before surgical planning while patients are deciding whether to undergo surgery. Further studies are needed to better elucidate which patient and provider-specific factors may be preventing these patients from pursuing surgery during this part of the care pathway.Level of EvidenceLevel IV.