Eeric Truumees, MD


Published 7/1/2015
Eeric Truumees, MD

Misaligned Incentives and Unexpected Outcomes

As orthopaedic surgeons, we’ve all been told that our reimbursements are on an inevitable trajectory from volume- to value-based care. Many of us feel threatened by this transition, but not because we are worried about the care we deliver. We worry because of all the crucial unknowns—most importantly, who determines what constitutes quality care?

As surgeons, we control only a subset of the hundreds of factors that affect our patients’ treatment outcome. Arguably, the area in which we have the greatest control in determining outcome is careful patient selection. Treating sicker, less motivated, or psychologically troubled patients will rarely yield stellar results, regardless of the outcome measures used. Of course, we should consider patient comorbidities and psychosocial factors when making treatment recommendations. However, a misalignment between physician incentives and patients’ needs may lead to serious access-to-care problems for some sicker individuals.

Does it work?
One problem lies in the mechanics of measuring quality of care. In a recent article in Modern Healthcare, Sabriya Rice reported that some recent projects “linking financial rewards to cost-effective management of patient care or reducing adverse outcomes have not produced the desired results.”

Ms. Rice interviewed Jessica Greene, PhD, MPH, associate dean for research at George Washington University and the author of two studies examining physician incentive programs. “The programs are often less effective than the designers hoped,” said Dr. Green. “There is still so much we don’t know about how to design effective pay-for-performance programs.”

Ms. Rice also quoted Cleveland-based gastroenterologist Michael Kirsch, MD (“The things that really matter in terms of medical quality are very difficult to measure”) and Steffie Woolhandler, MD, a professor at the City University of New York’s School of Public Health (“There is essentially no evidence that pay-for-performance works and certainly no evidence that it works as it is being applied to American health care right now.”). She noted that the excessive documentation required for these programs could interfere with clinicians’ focus on real care improvement.

Practicing orthopaedic surgeons are routinely confronted by supposed measures of quality of care, including ‘Best Doctor’ lists and Yelp reviews. But, as Ms. Rice notes, “The science of measuring quality performance in health care is still in its infancy. Current measures are limited, and critics say linking them to compensation might be premature.”

As we’ve seen in other areas of health insurance reform, premature change may have unintended consequences such as “over-focusing on one specific issue at the peril of other, more important ones,” according to Ms. Rice.

Not only are our measures of quality inadequate, no reasonable model of compensation yet exists that aligns the interests of key stakeholders and combines both quality of care and incentives for productivity. As I recently overheard at a meeting of the AAOS Board of Specialty Societies, “Even if you perform the most perfect total hip in the world, just doing one won’t keep you in practice.”

One common measure used to grade hospitals (and by extension, admitting physicians) is the 30-day readmission rate. When the U.S. Centers for Medicare & Medicaid Services (CMS) released its third year of 30-day readmission penalties last fall, quality researchers were concerned because only 769 of more than 3,370 U.S. hospitals succeeded in avoiding the fines. With such limited success after 3 years, can that program achieve its desired goal of broadly improving quality of care?

Surgeon volume
Even more contentious is the issue of surgeon volume. A number of studies have suggested that high-volume centers may be able to offer elective orthopaedic procedures at lower cost and with fewer complications. We heard from a number of our readers after AAOS Headline News Now linked to the “Taking the Volume Pledge” story reported by Cheryl Clark, for HealthLeaders Media on May 20, 2015.

Ms. Clark’s story involved an initiative by three major U.S. health systems: Dartmouth-Hitchcock Medical Center, The Johns Hopkins Hospital and Health System, and the University of Michigan Health System. This initiative sought to set minimum volume thresholds on 10 surgical procedures, including total hip and total knee arthroplasties. For individual orthopaedic surgeons, the recommended minimum volume threshold for these procedures was 25 annually; for hospitals, it was an annual minimum of 50.

“What we’re trying to do is minimize the number of patients who wind up getting their care by so-called ‘hobbyists,’ surgeons and hospitals that seldom do these procedures, certainly not enough to attain a high level of honed proficiency,” John Birkmeyer, MD, outcomes researcher, and executive vice president for enterprise support services at Dartmouth-Hitchcock, was quoted as saying.

AAOS fellows understandably took exception to the term “hobbyist.” (It should be noted that AAOS Headline News Now offers content we think will be of interest to or is important for orthopaedic surgeons. Very often, the news may not be good. Certainly, the AAOS does not necessarily endorse the ideas or programs being reported.)

The concept of high-volume, magnet medical care is already familiar to European surgeons and patients. But the U.S. models for reimbursement, training, and practice development are very different than the European “professor-driven” systems. As much as they might want one, most surgeons do not start out in a “high-volume” practice. In spine care, it’s easy to view the recent fellowship graduate with a high-volume elective practice with a jaundiced eye. Clearly, the best way to increase volume is by relaxing indications. Marginally indicated surgery is technically much easier and less likely to require readmission, for example. With current measures, such a surgeon might come out smelling like a rose.

In American health care, geographic and funding issues are more problematic than in Europe. Elsewhere in this issue, the ethics of domestic medical tourism and the implications on the local surgeon are discussed (“Ethical Issues in Domestic Medical Tourism”). But, these problems are far from being solved. Funding factors—especially for patients covered by Medicaid, and, perhaps, insurance programs available through the Affordable Care Act exchanges—will affect where surgery can be performed.

Certainly, the hospital in which a surgery is performed matters. Which capital purchases might serve to improve outcomes? I do not perform total hip or knee surgery, but I recognize that, as with the spine, use of surgical robots is increasing and increasingly being debated. Is this an added cost with little benefit? Or, if a robotically aligned total joint performs better, will surgeons without access to this technology be unduly penalized for their outcomes? Are our current 2-year patient-reported outcomes data adequate to identify what may be a clinically important long-term benefit? I don’t know, and I doubt CMS does either.

An evolving issue
In a recent issue of the Journal of the American Medical Association, Victor R. Fuchs, PhD, and Mark R. Cullen, MD, provide an excellent, concise synopsis of the evolution of the role of U.S. physicians from the Flexner Report in 1910 to the present. They focus on the current transition of our care model from an individual physician in private practice in a fee-for-service system to a “team care” approach in which, increasingly, employed physicians offer care based on capitated or bundled payment models. They note that the “requisite knowledge for effective practice is also changing.” Physicians no longer have the luxury of exploring “every intervention that might help a patient regardless of cost.” In most cases, given increasing copays, I suspect the patient doesn’t want us to take this approach, either.

The concepts of population health and health economics are not a major part of the current medical school curriculum, which has not significantly changed since 1930. Here in Austin, Texas, the Dell Medical School at the University of Texas is proposing a new curriculum that will better prepare new physicians to take leadership roles in the evolution of health care.

We do not yet know how this new model of physician reimbursement will work. How completely will it change health care? How long will these changes take? Accepting the premise that our current system is unsustainable, we know these changes will eventually occur in some form.

To protect our patients and our profession, our job is to ensure access to high-quality musculoskeletal care. To do this, we will need to actively participate in the change process. We will have to have conversations and arguments with multiple other stakeholders over a long time and in several venues. AAOS Now will continue to update readers on those changes most important to orthopaedic surgeons, but we would continue to ask you for your insights, experiences, and suggestions as new models are proposed and changes occur.

Eeric Truumees, MD, is the editor-in-chief of AAOS NOW. He can be reached at

Additional Information:
Rice S: Physician quality pay not paying off,
Modern Healthcare, May 30, 2015.
Clark C: Limits urged on surgeries by low-volume providers,
HealthLeaders Media, May 20, 2015.
Fuchs VR, Cullen MR:
The transformation of US physicians. JAMA 2015;313(18):1821-1822. doi:10.1001/jama.2015.2915.