Within the concept of a patient-centered medical home, key roles in care coordination are taken by “neighbors” such as orthopaedists and other specialists.


Published 10/1/2012
Mary Ann Porucznik

Will You Be In My Medical Neighborhood Home?

Options for orthopaedists in musculoskeletal care coordination

In July 2012, the American Association of Orthopaedic Surgeons (AAOS) Health Care Systems Committee (HCSC) sponsored a one-day symposium on the “Musculoskeletal Care Coordination: The Role of the Orthopaedist in the Medical Neighborhood.” Hosted by HCSC Chair Craig A. Butler, MD, MBA, and moderated by HCSC Member William Kumler III, MD, MBA, and Jeffrey M. Biehl, MBA, president of Access HealthColumbus, the symposium presented a variety of viewpoints—from payers and policymakers to hospital systems and physicians—on patient-centered care coordination through the medical home model.

The medical home is a delivery model that provides patient-centered, comprehensive, coordinated care. It enhances patient access to care and demonstrates a commitment to quality. Although primary care physicians are at the core of many medical home models, orthopaedists may serve as the primary source of care for patients with musculoskeletal health conditions.

Musculoskeletal health care accounts for a significant portion of healthcare costs. One in four individuals has a musculoskeletal condition that requires medical attention, and more than half of all chronic conditions in people older than age 50 are musculoskeletal disorders.

“The direct and indirect costs of musculoskeletal health care are $849 billion annually. That’s 7.7 percent of the U.S. gross domestic product. And that number is likely to increase with our aging—and increasingly obese—population,” said Joseph Stubbs, MD, MACP, a past president of the American College of Physicians (ACP), who outlined a vision of the medical home and care coordination.

Although the U.S. healthcare system has much to recommend it, many of the defects in the current system stem from its disorganization, which results in access problems, poorly coordinated care, and suboptimal outcomes. The patient-centered medical home, according to Dr. Stubbs, would help address the issues of fragmentation of care, gaps in care coordination, and wasted healthcare expenditures.

But just as family homes are part of a neighborhood, a patient-centered medical home—even if it is under a primary care physician—also needs neighbors, including orthopaedists. Other musculoskeletal neighbors might include rheumatologists, pain specialists, pharmacists, physical and/or occupational therapists, radiologists, and ancillary care providers. Each would have care coordination agreements that outline the provider’s responsibility with regard to the patient and to the medical home.

Specialists such as orthopaedists would play several roles in a medical home neighborhood, noted Dr. Stubbs. For example, they might provide diagnostic or therapeutic advice (cognitive consultation), perform a specific procedure (procedural consultation), share or assume primary management of a long-term or chronic condition, or serve as the patient’s primary care physician.

What does it look like?
Although the Agency for Healthcare Research and Quality (AHRQ) has a specific definition of care coordination, symposia participants spent time discussing and defining orthopaedic expectations for successful care coordination, including the following:

  • It is patient-centered/caring.
  • It is based on high-quality, evidenced-based outcomes.
  • It results in improvements in patient safety.
  • It employs shared decision making.
  • It delivers the right care at the right time and in the right place.
  • It is efficient and reduces waste.
  • It involves clear communication among providers and patients.

Such a model, they agreed, would deliver value to patients, businesses (employers and purchasers, insurance companies, and owners of healthcare delivery services), government, and healthcare providers (hospitals, specialists, primary care physicians, and other licensed professionals).

For example, patients would benefit from better access to healthcare providers, a feeling of security, lower costs, and shared decision making. Businesses would see a healthier work force, cost reductions, improved transparency on value, increases in productivity, and reductions in absenteeism. Government would benefit from better public health, lower costs, and better access with the same work force. Happier patients and doctors, improved patient safety, higher compensation for primary care services, and increased market share would accrue to healthcare providers.

How do we get there?
Moving from concept to action, however, is a challenge. Participants outlined several steps that the AAOS could take, beginning with the preparation of a primer to answer the question, “Who controls musculoskeletal health care?” Such a primer would frame the issue of a musculoskeletal medical home and present a blueprint for its construction.

Developing reporting measures that the orthopaedic community sees as meaningful would be another step. Participants also recommended that the AAOS work with specialty societies to develop standards and tools for care coordination of musculoskeletal conditions, including care pathways for common conditions. These pathways would outline treatment guidelines, imaging guidelines, and referral guidelines.

“No one is doing this on the specialist side,” said Dr. Stubbs. He pointed out, however, that both the American College of Physicians and the American Association of Family Physicians have sections of their websites dedicated to helping members build medical homes.

Although issues remain—including how current antitrust legislation would affect clinical integration models, all participants agreed that the move toward care coordination will continue. The impact that musculoskeletal conditions have on the health of the nation necessitates that orthopaedists participate in care coordination efforts.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org