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Published 10/1/2015
Hazel Oreluk, MA; John Cherf, MD, MPH, MBA

Practice Settings and Productivity

Where and how do orthopaedic surgeons practice?

Think of the last course you took at the AAOS. Were your lab partners private practitioners, members of a group practice, or hospital employees? Did you talk about the dominant payers in your geographic area? Did you discuss how many procedures you performed?

The AAOS member census, Orthopaedic Practice in the United States (OPUS) Survey, has answers to these and other questions that you can use to benchmark yourself and your practice. Data are gathered by the AAOS research & scientific affairs department every other year. The information ranges from basic demographics to specialty, practice setting, payer mix, and productivity data.

Full-time, part-time
According to the 2014 OPUS Report, more than half (57 percent) of all full-time surgeons (average age, 50.23 years) are specialists. Part-time orthopaedists tend to be older (average age, 69.14 years) and are mostly generalists (48.6 percent). Based on the 2014 census, full-time surgeons work an average of 56 hours per week and perform 31 procedures per month while part-time surgeons work an average of 23 hours per week and perform 5 procedures per month.

Since 2008, the number of hours worked by both full-time and part-time surgeons has remained fairly steady, although a slight downward trend can be noted (Fig. 1). During that same period, the number of procedures performed per month by full-time surgeons has remained stable. Among part-time surgeons, however, the number has dropped considerably (Fig. 2).

More than a third (37 percent) of all full-time orthopaedists are in private practice groups. Despite the interest in hospital employment, just 16 percent of full-time orthopaedists are employed by hospitals; another 13.5 percent receive a salary from an academic institution as part of an academic practice. The remainder of full-time orthopaedists are in solo (13 percent) or multispecialty group (9.7 percent) practices.

Part-time orthopaedists are mostly in solo private practice (30.2 percent), followed by private practice group (19.6 percent), other (15.6 percent), hospital employment (10.1 percent) and private practice multispecialty group (8 percent).

The opportunity for part-time practice is more prevalent in the private practice setting, particularly in a solo practice. Less part-time work is available in academic settings and in hospitals or medical centers. Overall, larger practice enterprises tend to support full-time practice more than part-time practice. It may be important in the future for all practice settings to accommodate part-time practitioners if current trends continue. As orthopaedists age, they may be more interested in part-time work; workforce shortages and constrained access to orthopaedic surgeons may also increase the need for part-time orthopaedists to remain active.

Payer distribution
The AAOS member survey also asked about the distribution of patients by payer source. Medicare (26 percent) and private insurance carriers (40.91 percent) account for about two-thirds of all orthopaedic patients.

Significant differences were found in payer distribution between full-time and part-time orthopaedists (Fig. 3). Whereas private insurance accounted for nearly half of all patients seen by full-time orthopaedists, only one-fourth of patients seen by part-time orthopaedists were covered by private carriers.

With implementation of the Affordable Care Act, specifically the Medicaid expansion option, the number of patients covered by Medicaid may increase significantly. This will be an area to watch in the next survey. Legislative attempts to address the plight of illegal immigrants by extending citizenship or easing naturalization processes may also result in a significant increase in Medicaid patients.

Work hours and procedures
The online version of this article shows the number of hours worked each week by orthopaedic surgeons in various practice settings. Whether paid by an academic institution or by an affiliated private practice, surgeons in the academic setting worked the most hours each week (63.7 and 62.3 hours per week, respectively). Military orthopaedic surgeons, locum tenens surgeons, and hospital-employed surgeons all worked more than 55 hours per week.

Surgeons in private practice settings worked slightly fewer hours per week. Those in a private practice group worked 55 hours per week, while those in a multispecialty group worked 54 hours per week and those in solo private practice worked 53.6 hours per week.

Academic surgeons receiving their salaries from private practice performed the greatest number of procedures per month (35). They were followed by orthopaedists in private practice single or multispecialty groups (34 and 32 procedures per month, respectively).

Comparing hours worked and surgical productivity across practice settings shows that the private practice setting seems to be one of the most efficient and productive. This volume-driven healthcare economy efficiency may require remodeling if the market continues to transition to a value-driven economy.

Practice setting
Members were asked to identify their practice setting. In 2014, the most popular practice setting was a group private practice (35 percent), followed by academic practice (16 percent), solo private practice (15 percent), hospital (15 percent) and multispecialty group private practice (10 percent). Locum Tenens, military, HMO, public institution, and other accounted for the remaining 9 percent. The results showed that orthopaedic surgeons were leaving solo and group private practice settings and moving to hospital centers and academic practice.

Overall, the traditional orthopaedic private practice setting has decreased from 65.2 percent in 2008 to 50 percent in 2014. At the same time, hospital employment has increased from 6.7 percent to 15 percent. It is unclear whether this trend of hospital employment will continue to increase. As employed orthopedic surgeons renegotiate their initial employment agreements, some attrition may occur. The salaried academic practice setting has also increased significantly—from 12 percent in 2008 to 16 percent in 2014.

Orthopaedic surgeons of all ages can be found in all practice settings (Fig. 4). Hospitals/medical centers equally employ orthopaedists from all age groups until age 70. Multispecialty orthopaedic groups tend to hire those aged between 30 and 69 years. Older orthopaedists can be found in solo practices, while most orthopaedists younger than age 50 work in private orthopaedic groups.

Payer sources
According to the 2014 OPUS Report, private insurance carriers and Medicare are the top two payer sources for orthopaedists in private practice, academic practice, and hospital/medical centers. Orthopaedists in military and public institution practice settings indicated that most of their income came from other sources.

Significant differences can be seen in the payer mix for different practice settings. The private practice setting tends to capture a higher percentage of patients insured by private insurance plans, Medicare, and workers’ compensation. Patients with Medicaid were more commonly treated in practice settings that provide a regular income source for the physician (academic salaried and hospital/medical center employed).

Hazel Oreluk, MA, is manager of healthcare statistics and surveys in the AAOS department of research and scientific affairs. John Cherf, MD, MPH, MBA, chairs the AAOS Practice Management Committee.

Editor’s Note: This is the last in a series of articles summarizing the results of the AAOS biennial census. The first article (“Orthopaedic Practice in the United States,” AAOS Now, August 2015) covered key findings; the second article (“Orthopaedic Workforce Trends,” AAOS Now, September 2015) covered changing patterns within the orthopaedic workforce.

2016 Will Be a Census Year
The next census data gathering year will be in 2016. Questionnaires will be sent to AAOS members via email, fax, or U.S. post office mail. As always, a 100 percent response rate is expected, so orthopaedic surgeons are encouraged to answer the survey as soon as they receive it during the first quarter of 2016.

Additional Information: