The United States spends more of its gross domestic product on health care than any other nation, but it ranks last among wealthy countries in healthcare quality. As “Baby Boomers” age, the demand for orthopaedic services will increase, but the current workforce strategy isn’t designed to deliver enough specialists to meet that demand. The result is a musculoskeletal time bomb, ready to explode.

Defusing that time bomb won’t be easy, agreed the panelists at the AAOS Annual Meeting symposium, “The International Musculoskeletal Time Bomb: Time for Action.” Mounting problems, including soaring costs and shrinking resources, will require major changes to correct and transform the “unsustainable” way that health care is currently being delivered.

Costs soaring, quality lagging
According to Stuart L. Weinstein, MD, of the University of Iowa, the situation in the United States is less than rosy. Medicare expenditures have soared, with the government laying out a total of $1.05 trillion on health-related programs. The average annual health insurance premium for family coverage rose from $5,791 in 1999 to $16,800 in 2014, while the average workers’ contribution to insurance premiums rose 212 percent. Concurrently, the burden to employers has become onerous. He noted that General Motors spends $5 billion on healthcare expenses and that these costs add $1,500 to $2,000 to the sticker price of every car it makes.

Demographic trends are not favorable, said Dr. Weinstein. The population is aging, and the number of Medicare beneficiaries is projected to grow from 47 million in 2010 to 80 million in 2030, while the number of workers per beneficiary shrinks from 3.4 to 2.3 during that period. These numbers place Medicare on a trajectory toward insolvency.

Tracking just what is being provided and received for these staggering sums is a difficult and often puzzling endeavor, Dr. Weinstein said. “The U.S. system lacks transparency,” he said. Costs for the same procedure or service vary widely by geographic location, often for no obvious reason, and Medicare pays vastly different fees for some procedures, depending on whether they are done in a freestanding clinic or a hospital. “Why are costs different for different locations?” Dr. Weinstein asked.

Similarly, prices for specific services generally are far higher in the United States than in other nations. A hip replacement may cost $62,000 in the United States, compared to just $9,000 in Belgium, and these discrepancies are driving a wave of international medical tourism.

Although the United States may claim the top spot for costs, it does not deliver the best care, according to many ranking systems. The Commonwealth Fund ranked health care in the United States last among wealthy countries, and the World Health Organization ranked it 37th among 191 countries overall. “Quality in the United States is poor and variable,” Dr. Weinstein said. “It is not the quality of care that a developed country should have.”

Quality in health care, he said, means “care that is based on the best scientific information and meets a patient’s needs, providing what you need, when you need it—not more, not less.” Yet a study found that just 54.9 percent of participants received recommended care. Unfortunately, quality often bears no correlation to cost; “More isn’t always better,” Dr. Weinstein said.

All of these shortcomings associated with the American system led to the push for reform that culminated in the passage of the Affordable Care Act (ACA) in 2010. “Did we need healthcare reform? Yes,” said Dr. Weinstein, who chaired the Orthopaedic Political Action Committee for 8 years. “This doesn’t mean you like the outcome of that reform.”

The implementation of healthcare reform is changing the way medicine is practiced and providers are compensated, as the federal government and insurers attempt to tie pay to quality and value. For example, the federal government has set goals that would increase the portion of Medicare disbursements through alternative models such as accountable care organizations (ACOs) and bundled payments. In 2016, the goal is 30 percent, increasing to 50 percent by 2018. Incentives and penalties related to quality and efficiency will also be implemented.

Dr. Weinstein noted that orthopaedic care will receive continued scrutiny, given the resources necessary to treat musculoskeletal disease. The number of hip and knee arthroplasty procedures will continue to increase, especially for knee arthroplasty. The demand for services may outpace the number of practicing surgeons, possibly to an overwhelming degree, which may lead to longer wait times for care.

The coming workforce squeeze
Scott D. Boden, MD, of Emory Orthopaedics & Spine Center, zeroed in on the workforce issues that will arise as the demand for orthopaedic services continues its ascent.

“The increase in population of people older than age 65—the aging Baby Boomers—is going to place a tsunami of demand on our healthcare system,” Dr. Boden said. “Musculoskeletal care will be affected in a major way.”

A key factor in meeting the demand is the system for training orthopaedic surgeons, specifically the number of residency slots. “In this country, graduate medical education (GME) funding has not really changed in the number of slots,” he said. “Although more people are graduating from medical schools, the number of residency training slots has not changed. If anything, funding for GME is likely to decrease. Currently, training of orthopaedic surgeons takes 5 to 6 years.”

Practice habits of new surgeons and the departure from the profession of experienced physicians will have an impact on the capacity of the system. “The Generation Z workforce is not working the crazy hours that many older physicians did and still do. It has different work-life balance expectations,” Dr. Boden said. “Many practicing surgeons are contemplating earlier retirements, partly due to accelerated changes and inconveniences in the healthcare system.

“The numbers don’t lie,” he continued. “While the general population increases by 35 percent, orthopaedic demand could potentially increase 50 percent by 2030. How will our current workforce strategy handle that increase in demand?”

To answer that question, he posed the following two questions:

• Can the country and the profession afford 5 to 6 years of limited GME dollars to train surgeons who operate only 50 percent or less of their time?
• Do surgeons who spend 80 percent of their work week in surgery gain proficiency and efficiency faster and produce a higher-quality surgical product?

“For many of us who went through traditional training and are now taking care of the full spectrum of musculoskeletal disorders, these are somewhat provocative and perhaps even distasteful questions,” Dr. Boden continued. “But looking at it from a healthcare and societal resource point of view, somebody is going to ask these questions. If orthopaedics, as a profession, doesn’t ask these questions, develop legitimate answers, and make changes, somebody else may—and in a way that is not as friendly.”

The challenge of meeting demand requires rethinking the approach to training. “My program trains five residents per year,” said Dr. Boden. “That represents about 25 person years of training, not counting fellowship. Most of these residents will spend half their time in surgery and half in the office. We produce 5 full-time-equivalent (FTE) orthopaedic surgeons, but basically 2.5 FTEs as surgeons and 2.5 FTEs as office physicians.”

But to meet demand in 2030, he said, “we need to produce 10 FTEs.” One approach would be to split the five trainees and provide 4 years of surgical training for two of them, and 2 years of nonsurgical training for the other three, with the assumption that the surgeons spend 80 percent of their time operating. “That adds up to 14 person-years of training, but still only 5 FTEs,” he said.

Next, he proposed adding an additional track that would train five nonoperating musculoskeletal physicians every 2 years. These physicians would spend 100 percent of their time in the office. “We would continue to train five surgeons for 4 years, and they would spend 80 percent of their time in the operating room. That results in about 30 person-years of training, slightly more than today, but generates 10 FTEs, and the math potentially works.”

Along with this expansion of care provided by nonoperating orthopaedic physicians, the role of nonphysicians providing nonsurgical care may expand as well, Dr. Boden said.

Also participating in the symposium were Tim Briggs, FRCS, of the United Kingdom; Jan De Vos, MD, of South Africa; and Stephen Graves, MD, and Peter F. Choong, FRACS, of Australia. The presentation by David S. Jevsevar, MD, MBA, on barriers to change will be covered in next month’s issue of AAOS Now.

Details of the authors’ disclosure as submitted to the Orthopaedic Disclosure Program may be accessed electronically at www.aaos.org/disclosure

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org