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AAOS Now

Published 7/1/2011
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A. Alex Jahangir, MD; Manish K. Sethi, MD; Elliott W. Cole, BS; William T. Obremskey, MD, MPH

The demand for orthopaedic care: What orthopaedic surgeons need to know

Health care is a major driver of the U.S. economy, accounting for nearly 20 percent of the national gross domestic product. Yet, 47 million Americans lack health insurance and do not participate in the healthcare system, in part due to the cost of care.

With its push toward universal healthcare coverage, the Patient Protection and Affordable Care Act (PPACA) will dramatically reshape the structure of the American healthcare landscape. As the healthcare system mobilizes to include millions of newly insured patients, healthcare providers must understand the various factors that influence demand for their services. Specifically, orthopaedic surgeons must develop an understanding of the many factors influencing the potential need for orthopaedic care in the United States. With a more nuanced understanding of future demand, orthopaedic departments can plan for future resource needs and allocation.

Economic factors
The unemployment rate has often been cited as a major indicator of the health of the national economy. Previous studies have demonstrated that the volume of blunt trauma, which accounts for most orthopaedic trauma, inversely correlates with the worsening economy and higher unemployment rate. In other words, as the unemployment rate increases, the amount of blunt trauma decreases.

To better understand this relationship, we examined the impact of the unemployment rate on the demand for orthopaedic trauma care at our institution between 2000 and 2010. We noted that, during the two periods of economic recession (March 2001–November 2001 and December 2007–July 2009, as defined by the National Bureau for Economic Research), there was an inverse trend between the unemployment rate and the incidence of orthopaedic trauma cases at our medical center. Although this relationship is valid for just our institution, we believe it demonstrates the importance of identifying variables that impact the demand for orthopaedic care at any institution.

Several reasons may account for this inverse trend. During times of recession, the unemployment rate in many sectors of the economy increases. Jobs within the manufacturing sector are usually among the first eliminated, because the demand for consumer goods declines. As infrastructure projects are delayed or abandoned, construction workers are also laid off. These types of jobs can be dangerous and carry a higher-than-normal risk of injury; with fewer people working in high-risk jobs, the incidence of injuries decreases.

Additionally, people are less likely to spend money on dangerous recreational activities, such as drinking and drug use, which may decrease the number of motor vehicle accidents. People may also be less likely to purchase all-terrain vehicles and motorcycles, which also have been known to contribute to the incidence of traumatic orthopaedic injuries.

A ripple effect
During an economic recession, therefore, hospitals may experience a decline in overall trauma volume. However, the condition of the economy may influence more than just the volume of orthopaedic trauma—we believe it affects the volume of orthopaedic care in all specialties. As more Americans decrease their household budgets and lose insurance coverage due to unemployment, they are less inclined to undergo elective procedures such as total joint arthroplasty, sports procedures, or elective spine procedures.

Decreased patient volumes coupled with an increased number of uninsured patients may result in lower overall reimbursements to hospitals. During times of economic hardship, hospital administrators may look to cut funding and resources for services that have experienced a decrease in patient volumes. If the volume of orthopaedic services is down, the orthopaedic department may be one of those affected.

Unfortunately, department cuts leave hospitals without the necessary nurses, beds, and equipment to handle the increase in volume that results when the economy recovers and people go back to work. Prior to making cuts, therefore, hospital administrators and other decision makers should anticipate how to quickly reallocate resources once economic conditions improve and the need for these services increases.

Given the enormous stress that uninsured patients place on the American healthcare structure and the fact that most of these individuals will be part of the healthcare system by 2014 as a result of the PPACA, we, as orthopaedic surgeons, must develop a more informed understanding of the various factors that influence the need for our services. We believe that the factors and variables that affect the demand for orthopaedic care should be identified and further studied on a national level. This will enable more informed planning and allocation of resources and will result in a higher level of quality care for orthopaedic patients.

Manish K. Sethi, MD, and A. Alex Jahangir, MD, are codirectors of the Vanderbilt Orthopaedic Institute Center for Health Policy; William T. Obremskey, MD, MPH, is associate professor of Orthopaedic Surgery and Rehabilitation at Vanderbilt University.

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