Clinical Review

Orthopedics in US Health Care

Am J Orthop. 2015 December;44(12):538-541

Yu S

References

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2. US Bone and Joint Initiative. Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal, and Economic Cost. 2nd ed. Rosemont, IL: US Bone and Joint Initiative; 2011. http://www.boneandjointburden.org. Accessed October 26, 2015.

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In the United States, the landscape of health care is changing. Health care reform and fluctuating political and economic climates have affected and will continue to affect the practice of orthopedic surgery. Demand for musculoskeletal care and the costs of providing this care are exceeding available resources—which has led to an evolution in how we practice as individuals and in the institutions where we provide care. Patient safety, quality, and value have become the outcomes of importance. Orthopedic surgeons, as experts in musculoskeletal care, must be a part of these changes. In this review, we offer perspective on the changing face of orthopedic surgery in the modern US health care system.

1. Meeting the demand

Musculoskeletal conditions represent one of the most common and costly health issues in the United States, affecting individuals medically and economically and compromising their quality of life.^1,2 In 2008, more than 110 million US adults (1 in 2) reported having a musculoskeletal condition for more than 3 months, and almost 7% reported that a chronic musculoskeletal condition made routine activities of daily living significantly difficult.¹ Overall, in the United States, some of the most common chronic conditions are musculoskeletal in origin. These conditions include osteoarthritis and back pain.

Osteoarthritis is the leading cause of chronic pain and disability. Physician-diagnosed arthritis is expected to affect 25% of US adults by 2030,³ and in more than one-third of these patients arthritis limits work or other activity.⁴ Back pain is another of the most common debilitating conditions in the United States.^3,5 St Sauver and colleagues⁶ found that back pain is the third most common condition (23.9%) that prompts patients to seek health care—following skin-related problems (42.7%) and osteoarthritis/joint pain (33.6%).

As life expectancy increases, so do expectations of enjoying higher levels of activity into the later years. Patients expect to be as active in their geriatric years as they were in middle age, and many are able to do so. Amid the growing obesity epidemic and increased incidence of chronic comorbidities, however, the aging population not only is at substantial risk for developing a chronic musculoskeletal disorder but may face new challenges in accessing care.

Although orthopedic surgeons specialize in treating musculoskeletal conditions, up to 90% of common nonsurgical musculoskeletal complaints are thought to be manageable in the primary care setting.⁷ With a disproportionate increase in musculoskeletal demand against a relatively constant number of orthopedic providers,⁸ it is becoming increasingly important for nonorthopedists to adequately manage musculoskeletal conditions. Physiatrists, rheumatologists, internists, family practitioners, and the expanding field of sports medicine specialists provide primary care of musculoskeletal conditions. To meet the growing demand and to ensure that patients receive quality, sustainable, effective, and efficient care, orthopedic surgeons should be actively involved in training these providers. As high as the cost of managing musculoskeletal conditions can be, it is far less than the cost resulting from inadequate or improper management. There is already justification for formal development of a specialization in nonoperative management of musculoskeletal care. Establishing this specialization requires a multidisciplinary approach, with orthopedic surgery taking a lead role.

2. The cost equation

As the prevalence of orthopedic conditions increases, so does the cost of delivering musculoskeletal care. The economic implications of meeting this growing demand are an important area of concern for our health care system. Steadily increasing hospital expenses for personnel and services, rising costs of pharmaceuticals and laboratory tests, constant evolution of costly technology, and insurance/reimbursement rates that do not keep pace with rising costs all contribute to the rapid escalation of the “cost of care.”

Health care expenditures accounted for 17.2% of the US gross domestic product (GDP) in 2012 and are expected to represent 19.3% by 2023.⁹ For musculoskeletal disease, direct costs alone are expected to approach $510 billion, equaling 5% of GDP and representing almost 30% of all health care expenditures. In Medicare patients, osteoarthritis is the most expensive condition to treat overall, and 3 other musculoskeletal problems rank highly as well: femoral neck fractures (3rd), back pain (10th), and fractures of all types (16th).¹⁰ Clearly, musculoskeletal care is one of the most prevalent and expensive health conditions in the United States.

Part of the direct costs of care that consistently increase each year are the steadily increasing costs of technology, which is often considered synonymous with orthopedic care. Promotion of new and more costly implants is common in the absence of evidence supporting their use. However, use of new implants and technology is being scrutinized in an effort to strike the proper cost–benefit balance.