Solutions must address complicated issues

The crisis in emergency care in the United States is especially significant for children with orthopaedic trauma, according to James H. Beaty, MD, who spoke at the 2009 POSNA Annual Meeting.

“For the practicing pediatric orthopaedic surgeon, trauma is a significant part of what we do—whether at a Level I trauma center in a children’s hospital or at an outpatient clinic,” Dr. Beaty said.

Several complex, challenging, and controversial issues are contributing to the crisis. The number of pediatric patients coming to emergency departments (EDs) continues to climb, while the number of orthopaedists willing to “take emergency call” has declined.

At the national level, increasing numbers of uninsured patients, combined with increased medical liability premiums, and decreased reimbursements, are among the factors that must be addressed.

Appropriate transfer of patients under the Emergency Medical Treatment and Active Labor Act (EMTALA) is also part of the trauma controversy.

Forging solutions on multiple fronts
Solutions to these complex issues can be found within the political, economic, and clinical arenas, according to Dr. Beaty.

“I encourage you to become engaged with those in your community who make decisions about pediatric trauma,” he urged. “That includes your fellow physicians, your hospitals, the payors, local and state governments, and interested members of the public.”

He added a word of caution. “When you speak to legislators, remember that they will respond to true patient care and access issues. Focus your presentation on quality of care—do not present this as a reimbursement issue.”

Dr. Beaty proposed regional coordination of ED access as a potential answer to this crisis. “Pediatric orthopaedic surgeons should build relationships with general and adult orthopaedic surgeons in their regions. This will help ensure a local solution to who is providing care in the community or in a Level I children’s hospital.”

Orthopaedic surgeons can also assist their hospitals in establishing criteria for “definitive care” for orthopaedic emergencies. These criteria can be used by the regional group of hospitals—facilitating the appropriate, timely transfer of orthopaedic emergencies to facilities that can provide that care.

Assisting hospitals with their transfer policies is one way that orthopaedic surgeons can support a case for reimbursement beyond just taking call. “You have to show that you have a positive impact in reducing costs in areas such as equipment costs and length of stay, while improving the quality of care,” he said.

Dr. Beaty presented the following models for on-call reimbursement that are currently being utilized in some centers in the United States:

• Stipend
• Activation fee payable only when the physician goes to the ED
• Subsidies for care of uninsured patients
• Reimbursement for excess call only

Based on a national survey of physicians conducted by the Medical Group Management Association in 2008, the median stipend for orthopaedic surgeons was $1,100 for taking call. The highest stipends were paid in the Eastern United States and the lowest in the West (Fig. 1).

Call to action
Dr. Beaty also believes numerous opportunities exist to address this crisis in other ways—from establishing dedicated fracture clinics to implementing “after hours clinics,” so that patients can come to their orthopaedist’s office after 5 p.m. instead of visiting an ED.

“It could not be a better time to be a pediatric orthopaedic surgeon with an interest in fracture management. New techniques and instrumentation are being introduced every year,” he said.

“I challenge you to embrace the challenges of these changes and find the opportunities to be part of the solution in your community and your region,” Dr. Beaty concluded.

Dr. Beaty reported the following disclosures for education at his institution: DePuy, A Johnson & Johnson Company, and Synthes.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org