Published 8/1/2014
Andrew J. Pugely, MD; Jared L. Harwood, MD; Richard C. Mather III, MD

The Value of Orthopaedic Surgery: A Paradigm Shift

More than 300 orthopaedic surgeons gathered in Washington, D.C., to attend the American Association of Orthopaedic Surgeons (AAOS) National Orthopaedic Leadership Conference (NOLC) this past May. In addition to lobbying Congress, attendees participated in symposia focused on health policy and advocacy-related issues, one of which celebrated the ongoing success the AAOS has had in defining “Value in Orthopaedics.”

The value initiative started under Past President John R. Tongue, MD, and has resulted in several successful ideas to quantify the full value that orthopaedic surgeons provide to society. During the past year, several peer-reviewed publications have published studies demonstrating the remarkable economic benefits of common orthopaedic procedures, including total knee arthroplasty (TKA), anterior cruciate ligament (ACL) reconstruction, rotator cuff repair, lumbar diskectomy, and hip fracture care.

Musculoskeletal (MSK) health care has long been undervalued due to the failure of many healthcare stakeholders to consider the complete economic impact of such care. A number of negative media stories focused on the cost of orthopaedic surgery prompted the need to change the narrative. As healthcare costs increase, the growing volume of routine elective surgical procedures, such as total joint arthroplasty, becomes an easy target.

Inpatient hospitalization costs of arthritis, back pain, and fracture care commonly rank among the top 20 most costly diagnoses to treat within the Medicare system. These higher direct costs blinded policymakers to the tremendous societal benefits and indirect cost savings provided by orthopaedic surgical procedures.

Dr. Tongue spearheaded the movement to scientifically explore the overall value of MSK care. Specifically, the AAOS Board of Directors authorized and commissioned a health economic research team to shed light on the cost effectiveness and cost savings of orthopaedic surgical care, develop the tools to perform this economic research, and utilize these research findings to serve the interest of the AAOS and its membership.

These efforts have helped to shift the cost paradigm of MSK care from a societal expense to an investment in societal productivity. Through the tireless efforts of many, the project has been overwhelmingly successful.

What’s it worth?
During “The Social and Economic Value of Orthopaedic Surgery” symposium at the 2014 NOLC, Dr. Tongue and Steven D.K. Ross, MD; Michael F. Schafer, MD; Richard C. Mather III, MD; and Thomas C. Barber, MD, provided updates on these efforts.

Dr. Tongue summarized the impetus and strategic plan behind the AAOS initiative. He noted the high burden of MSK disease; direct costs are approximately $510 billion or nearly 5 percent of the nation’s gross domestic product. Although the indirect economic impact from lost productivity caused by untreated MSK disease is certainly higher, this has not yet been quantified.

The concept of indirect cost analysis is not new and has been used previously to justify public safety programs, such as during a campaign to minimize vehicular deaths in the state of Oregon. Reframing the cost discussion around the issue of MSK care among the public has been the project’s underlying goal.

Dr. Mather simplified the complex economic methodology used to calculate indirect costs. He reviewed the specific projects and addressed assumptions in the Markov decision model that was used. According to the scientific work of the research team, the indirect cost savings gained from restoring function and returning patients to work dwarf direct medical costs.

To date, four projects have been published in peer-reviewed journals, and several more are in production. The AAOS-sponsored website www.ANationInMotion.org/value provides an overview of each project and an open-source link to the publication. Articles published to date include the following:

  • “The Direct and Indirect Costs to Society of Treatment for End-Stage Knee Arthritis,” The Journal of Bone and Joint Surgery (JBJS), August 2013. This article estimated that TKA generates lifetime savings to the U.S. economy of $12 billion.
  • “Societal and Economic Impact of Anterior Cruciate Ligament Tears,” JBJS, October 2013. Analysis found estimated annual savings from ACL reconstruction of $10 billion.
  • “The Societal and Economic Value of Rotator Cuff Repair,” JBJS, November 2013. Estimated annual savings to the U.S. economy were calculated at $3.44 billion.
  • “How Does Accounting for Worker Productivity Affect the Measured Cost-Effectiveness of Lumbar Discectomy?” Clinical Orthopaedics and Related Research, December 2013.

Spreading the word
Armed with this new cost savings data, the AAOS has taken an active role in communicating the value of orthopaedic surgery to the public and policymakers. Dr. Schafer described the reach of the A Nation in Motion campaign, which is aimed at raising awareness and shifting the focus on the economic paradigm of MSK care.

Through various media sources—including websites, videos, magazines, and Facebook—the AAOS has gotten the message out. An awareness ad in Politico, depicting an anatomic human emphasizing the role orthopaedic surgeons have in restoring function (Fig. 1), was recently awarded a prestigious advertising award.

The symposium concluded with Dr. Barber’s overview of the strategic advocacy plan. He believes the value message has begun to resonate well on Capitol Hill. Ultimately, the AAOS wants to restore orthopaedics as a “top-brand” in medicine. Under his guidance, the AAOS advocacy team will continue to target Congress, the Centers for Medicare & Medicaid Services, and other critical federal regulatory and budgetary offices.

The work of the AAOS value team is not over. A fifth manuscript on the economic impact of hip fracture treatment is currently being prepared. The value team is also writing a manuscript targeted toward the policy community. KNG Health Consulting and Dr. Mather are working with a team from the American Association of Hip and Knee Surgeons to apply this framework to total hip arthroplasty.

Fueled by the impressive cost savings observed from ACL reconstruction, interest in examining other high direct cost treatments in young patients (such as hip arthroscopy for femoroacetabular impingement and cartilage restoration therapy) is high. Lastly, the importance of advocacy around this work cannot be understated. Musculoskeletal providers and their patients must take responsibility for telling the value story.

Andrew J. Pugely, MD; Jared L. Harwood, MD; and Richard C. Mather III, MD, are Washington Health Policy Fellows.

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