Annual Meeting symposium explores disparities in health care
During the symposium, "The Quality Conundrum: Recognizing and Reckoning with Disparities in Musculoskeletal Health and Health Care," held during the 2017 Annual Meeting in San Diego, presenters reviewed sources of gender, racial, ethnic, and socioeconomic disparities in musculoskeletal care. They also summarized the costs and frameworks required to achieve healthcare equity and provide maximum value for all patients.

"This truly is a conundrum—a complex problem with no clear solution," said Ramon L. Jimenez, MD, who moderated the symposium. "How are we going to deliver quality care to minority populations?"

Gender differences
"Women are not little men," said Mary I. O'Connor, MD, chair of the AAOS Diversity Advisory Board. "Instead, every cell has a sex and every person has a gender," she explained. She also noted that research related to the evaluation and treatment of musculoskeletal disorders has been, in general, not sensitive to sex, gender, racial, or ethnic influences. "But we are trying to change that moving forward. An awareness of gender, race, and ethnicity differences may even promote improved outcomes and satisfaction," she said.

For example, Dr. O'Connor noted that, compared to men, women are disproportionately impacted by osteoarthritis, are more physically disabled, and report greater disability at the time of total knee arthroplasty (TKA). The result is a "never catch up" situation: Although women improve just as much as men after knee replacement surgery, they don't achieve the same final outcomes and they experience more postoperative pain. Moreover, the degree of underutilization of total hip arthroplasty and TKA is three times greater in women than in men.

"There are a lot of women out there who would benefit from joint replacement surgery who aren't getting it," she said.

Dr. O'Connor explained that women also underutilize other surgical procedures. For example, women are 22 percent less likely to be placed on a kidney transplant list. This demonstrates, she said, "major societal issues with how we view patients through the gender lens."

Dr. O'Connor recommended that surgeons become aware of their personal bias, embrace the use of clinical guidelines and shared decision-making tools, and be tolerant of the narrative style—which women often use—of relaying information. "We all see things through our own lens. It's important to recognize that the way we see something is not necessarily the way someone else sees it," she said.

Physician diversity, risk modification, and reporting requirements
Bonnie Simpson Mason, MD, highlighted the impact of a diversified workforce on outcomes. She pointed out that as the healthcare system moves from volume to value, the emphasis on patient satisfaction will increase. She also noted that patients report more satisfaction when managed by a physician from their same culture and that students from diverse medical schools feel more confident managing patients with diverse backgrounds.

"I believe we all have an individual responsibility to help move our profession forward when it comes to diversification," said Dr. Simpson Mason. "At the end of the day, we have to come up with a solution, or several solutions, where everyone gets their needs met in this healthcare environment. Together we are making a difference."

Claudette M. Lajam, MD, focused on regionalized risk management and explained how value-based models, including Comprehensive Care for Joint Replacement (CJR), have affected healthcare delivery. Specifically, risk modification affects disparities because "diseases that impact outcomes and readmissions are not evenly distributed in society," she stated. In addition, because optimization may not be possible for some of these patients, "one out of four of these patients might never be able to undergo joint replacement, despite having severe arthritis."

"We can't ignore access to care and communities when we make policy and financial decisions about how we pay people for joint replacement," Dr. Lajam stressed. "We need a broader view of value that also includes our communities."

In addressing the effects of systems and reporting on disparity issues, Alexandra E. Page, MD, noted that today's healthcare environment can influence disparities both pro and con. In particular, she highlighted a National Quality Forum finding that, as health care moves from volume to value, "use of measures that result in incorrect conclusions about quality poses a substantial risk for penalizing healthcare organizations and providers who serve more disadvantaged populations."

Dr. Page also explained the different reporting requirements of the Merit-based Incentive Payment System (MIPS). She believes the "Improvement Activities" reporting category will help tackle disparity issues by encouraging use of evidence-based decision aids to support shared decision-making, engagement of community for health status improvement, practice improvements that engage community resources to support patient health goals, and more. She also highlighted a recent Assistant Secretary for Planning and Evaluation report that recommends adjusting for social risk factors directly in the quality measures or in the payment mechanism, which "gives us a path going forward."

Sonny Bal, MD, was an additional presenter during the symposium. He addressed the legal sources of disparities and solutions, and the evolution of health disparities law and policy.

Elizabeth Fassbender is manager, health policy and communication, in the AAOS office of government relations. She can be reached at fassbender@aaos.org