As healthcare reform takes shape and healthcare consumers become more cost conscious, evidence-based, cost-effective approaches to what orthopaedic surgeons do can make a big difference in both patient access to care and physician compensation.

Looking at just one set of numbers—the projected increase in total knee arthroplasty (TKA) surgeries, for example—might well raise eyebrows among insurers, employers, and legislators for several reasons. In 1990, approximately 129,000 TKA procedures were performed in the United States. Twenty years later, in 2010, that figure had grown to more than 600,000 TKA procedures. And projections over the next 20 years indicate that as many as 3 million TKA procedures could be performed in 2030.

With healthcare inflation rising faster than inflation in the general economy and studies indicating that an aging population alone isn’t sufficient to account for the increase in surgeries, many on the payer side might wonder if all those surgeries are needed—and whether the surgeries might actually contribute to any future cost savings. But no one had done the research or developed a model that would answer those questions.

That was the challenge facing the AAOS Value Project Team, chaired by John R. Tongue, MD, past president. “We weren’t trying to define the burden of disease,” said Dr. Tongue, “but rather to change the dialogue to consider the ‘value’ that orthopaedic surgery brings to society.”

Dr. Tongue and several members of the team—including Steven D.K. Ross, MD; Peter J. Mandell, MD; Michael F. Schafer, MD; and Mininder S. Kocher, MD, MPH—presented the results of that effort during the 2013 AAOS Annual Meeting symposium, “The Social and Economic Value of Orthopaedic Surgery.” “Thanks to this research,” said Dr. Tongue, “we can now articulate and quantify the benefits of orthopaedic treatments that can get people back to work and keep them living independently.”

Measuring value
The project team began with the question: What is the social and economic value of musculoskeletal care in the United States? Because no prospective, randomized, controlled study could answer this question, the project team collaborated with a group of healthcare economists to develop a workable, reproducible methodology. To connect functional changes with both quality and economic parameters, they turned the question around and asked the following:

• In the absence of musculoskeletal care, what would be the burden of musculoskeletal disease?
• What would each dollar of musculoskeletal care buy in terms of reduced burden?

The team defined value measures as medical services used (ie, complications and resulting services), nonmedical needs (nursing home and assisted living costs), and productivity (work days). They used Medicare reimbursement rates to estimate the cost of care for most of the conditions in the study, and they assumed that surgical treatment was appropriate for patients who received it.

Burden of disease
When it comes to the burden of disease, few disorders in medicine can match the impact of musculoskeletal conditions. As the result of bone and joint pain, 10 percent of Americans missed work during the past year (a total of 440 million missed work days) and 33 percent visited a doctor. Disabilities due to musculoskeletal conditions account for more than a quarter of all new disability claims.

But although they may be prevalent, musculoskeletal conditions are often non–life-threatening. As a result, they may be overlooked—especially when it comes to research dollars and spending priorities—and their care may be seen as “discretionary” or “elective.” Convincing legislators and payers of the value of musculoskeletal care has often been an uphill battle.

Patients—who are also constituents, policyholders, and voters—can most effectively make the case for access to and research for musculoskeletal care, so starting with their stories is key. As patients speak up, they build awareness and help to reframe how key audiences such as employers and legislators perceive the value of orthopaedics. (See “Because of My Orthopaedic Care, I Can…,” at the end of the article.)

The kind of message that will help reshape health policy on musculoskeletal care was delivered by 2013 AAOS Annual Meeting keynote speaker and former White House Chief of Staff Erskine B. Bowles. “I can stand here today because my orthopaedic surgeon reconstructed both of these shoulders and both of these knees,” he announced.

Condition-specific costs
So, what would be the impact on society if access to TKA is progressively restricted? Consider the following:

• Lost or limited productivity due to missed work days and shortened work hours by individuals who find it too painful to stand, walk, or climb due to their knee pain
• Reduced earnings for individuals who might have to find jobs that require less load on their knees
• Disability payments to those who can no longer work at all due to their knee pain
• Nonsurgical treatment costs for therapies and equipment
• Home help or nursing care

Although some of these costs might also be incurred by individuals who do have TKAs, total costs would generally be lower because payments would be made over a shorter time.

Orthopaedic surgeries such as TKAs enable individuals to keep working result in increased productivity, increased earnings potential, and decreased disability payments—all factors that can offset the cost of surgery.

According to Lane Koenig, PhD, a principal with the firm KNG Health Consulting LLC who worked with the AAOS Project Team on the study, “Total knee replacement increases direct medical costs by $20,704. The indirect cost savings to society—85 percent of which come from the increased earnings of those patients who are still working—is more than $40,000, nearly double the costs of surgery.”

The study found that the 600,000 TKAs performed in 2009 generated $12 billion in society savings. In addition, surgical treatment provides patients with an additional 2.4 quality-adjusted life years.

Beware what you ask for
Policymakers need to know that current efforts to hold down healthcare costs by delaying or reducing access to surgical treatment of specific musculoskeletal conditions will often result in even higher costs to society. Appropriate treatment is associated with net economic benefits to society and has the potential to significantly reduce indirect costs.

“For everyone’s sake, the definition of value must not be dictated by the sticker price of the orthopaedic procedure or treatment,” said Dr. Tongue. “We also need to consider patients’ ability to remain independent and productively employed, as well as the reduction or elimination of payments for disability or long-term care.

“Patients experience the value of health care based on how they feel and what they are able to do. We will always have more research to do, but we have found a way to come much closer to measuring the economic value of that experience to all of us,” he concluded.

For more information on the value of orthopaedic care, visit http://anationinmotion.org/value/orthopaedic-care/

A link to the methodology paper, “Modeling the Indirect Economic Implications of Musculoskeletal Disorders and Treatment,” can be found here.

Disclosure information: Dr. Tongue—no conflicts. Dr. Koenig—BTG International; Johnson & Johnson. Dr. Ross—Lange Medical Books/ McGraw-Hill; Foot and Ankle International. Dr. Mandell—AAOS Now; Western Orthopaedic Association. Dr. Schafer—DePuy, A Johnson & Johnson Company; Medtronic; AAOS Now; Journal of Bone and Joint Surgery–American; Spine; Dr. Kocher—Best Doctors; Biomet; Gerson Lehrman Group; OrthoPediatrics; Smith & Nephew Endoscopy; Fixes 4 Kids; Pivot Medical; Saunders/Mosby-Elsevier; ACL Study Group; American Orthopaedic Society for Sports Medicine; Harvard Medical School; Harvard School of Public Health; Pediatric Orthopaedic Society of North America; PRISM; Steadman Philippon Research Institute.

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

AAOS Value Project Team
Mininder S. Kocher, MD, MPH
Peter J. Mandell, MD
Fred C. Redfern, MD
William J. Robb III, MD
Steven D.K. Ross, MD
Michael F. Schafer, MD
John R. Tongue, MD
Kristy L. Weber, MD
Anna Tosteson, ScD, Advisor

Because of my orthopaedic care, I can…
The AAOS campaign, A Nation in Motion® (www.anationinmotion.org) is designed to collect stories that make the case for the value of orthopaedic surgery. In patient story after patient story, the message is clear: My orthopaedic surgery enabled me to continue working; to live a full, active life; to be a contributing member of society, rather than a consumer of societal resources.

“I am now 7 weeks post surgery and I am back to work. I am doing 6-hour days for 2 weeks and then back to my 8-hour day shifts. I have no pain with returning to work and I am capable of doing all the things I did before my hip went bad,” writes one patient.

“I had a total left knee replacement on July 6, 2011, and 20 days later, I was back at the high school overseeing textbook distribution to 2,200 students. I did physical therapy for 3 months and never missed a day of school,” says another.

“Since my two operations to replace my right and left hips within 1 year, I have lost 50 pounds by dieting and walking 5 to 6 miles per day. My issues with borderline diabetes, high blood pressure, and elevated cholesterol have been reduced significantly to well-accepted levels without medication,” writes a third.

These real-life stories show how appropriate orthopaedic care can provide net economic benefits to society by enabling patients to return to work and improve their lifestyles. If your patients have similar tales to tell, send them to anationinmotion.org

Patients aren’t the only ones with stories, and the site enables AAOS members to share their enthusiasm, their caring, and their commitment to their patients. “Helping people get back in motion and active, whether it be returning to work or the tee box, is very rewarding,” writes R. Blake Curd, MD.

“Many patients come to me in their most desperate and agonizing times,” says Neel Anand, MD. “It is an absolute joy to see them after surgery; smiling, laughing, and living the pain-free and deformity-free lives they thought were never possible again.”

Tell your story at www.anationinmotion.org

Did you Know

• 29 percent of all workplace injuries and illnesses that required time away from work are due to musculoskeletal conditions
• Musculoskeletal conditions are the leading medical cause of disability claims, accounting for 27.5 percent of new claims in 2010
• Bone and joint pain causes more than half of all chronic conditions in people older than age 50
• One in three Americans saw a doctor in the past year due to musculoskeletal complaints