Published 11/1/2017
John Cherf, MD, MPH, MBA; Angela Buckley, MPA

What OPUS Reveals About Practice Settings and Productivity

Editor's note: This article is the final installment of a three-part series that summarizes the results of the biennial orthopaedic census. Previous articles include "Orthopaedic Practice in the United States" (AAOS Now, July 2017) and "Census Examines Orthopaedic Workforce Trends" (AAOS Now, August 2017).

Census data include payer mix and work hours
Since 1985, 16 surveys on Orthopaedic Practice in the United States (OPUS) have been conducted. Also known as the Census Survey, OPUS gathers demographics and practice data of U.S.-based orthopaedic surgeons who are members of the AAOS.

In 2016, survey responses were received from about one in four AAOS members (26 percent). The data are analyzed by the AAOS research, quality, & scientific affairs department. The information collected helps ensure that AAOS members are accurately represented, that Academy programs and products evolve to reflect changes in membership, and that the AAOS continues to address the professional needs and interests of its members.

Previous articles about the 2016 census summarized the results and examined workforce trend data. This article discusses practice setting, productivity, payer mix, payer distribution, work hours, and procedures performed per month.

Full-time versus part-time
According to the 2016 OPUS Report, full-time surgeons are on average 49 years old; the average age for part-time surgeons is 67 years. Full-time surgeons work an average of 56 hours per week and perform 32 procedures per month, while part-time surgeons work an average of 26 hours per week and perform 7 procedures per month. Part-time orthopaedic surgical productivity rose slightly from the 2014 report, but has significantly decreased over the past 8 years (see Figures 1, 2, 3, 4).

Full-time and part-time surgeons define themselves differently. More than 60 percent of full-time surgeons define themselves as specialists, compared to only 26 percent of part-time surgeons. Many part-time surgeons (approximately 40 percent) define themselves as general orthopaedic surgeons.

Most full-time providers work in traditional practice settings such as group private practices. More than a third are in a private practice group, with another 20 percent split nearly evenly between private practice solo and private practice multispecialty group. Approximately 17 percent are hospital-based, while just over 15 percent have an academic practice with a salary from an academic institution.

In contrast, two in five part-time orthopaedists are in either a private practice solo (21 percent) or a private practice group (21 percent). Slightly more than 15 percent of part-time orthopaedists are employed by a hospital, while another 14 percent work in another type of setting. Less than 10 percent of part-time orthopaedists have an academic practice with a salary from an academic institution. Practice settings that seem to be more conducive to part-time providers include solo practice, public institution, and locum tenens (see Fig. 5).

Practice setting
Members were asked to identify their practice setting. In 2016, more than a third of respondents (35 percent) were in a private practice group setting. The second-largest group was academic practices and included both those who received a salary from the academic institution and those who received a salary from a private practice. Other popular practice settings included hospitals (17 percent), private practice solo (11 percent), and private practice multispecialty (9 percent). Locum tenens, military, HMO, public institution, and "other" each accounted for just 2 percent or less of practice settings (see Figures 6, 7, 8).

Payer distribution by work status
Orthopaedic surgeons were asked to approximate the distribution of their patients by payer source. Although private insurance carriers were the largest payer source in the 2014 census, they accounted for just 15 percent of patients overall in 2016. "Other," which accounted for just 5 percent of patients in 2014, jumped to the lead, accounting for more than 60 percent of patients in 2016. This change in payer mix may be secondary to impact of the Affordable Care Act. Significant differences were found between full-time and part-time orthopaedists in patient distribution by private insurance, worker's compensation, and self-pay (see Fig. 9).

Payer sources by practice settings
According to the 2016 OPUS Report, orthopaedists in all practice settings had "other" sources as one of the top two payer sources. "Other" payer sources identified include the Veterans Administration, Military/Tricare, and "unsure/don't know."

Private insurance carriers were in the top two sources for orthopaedists in private practice (those in a multispecialty group, prepaid plan HMO, or military practice setting). Worker's compensation was a top-two source for solo private practices, orthopaedic group private practices, and public institution settings.

Medicaid was a top-two source for orthopaedists in academic practice and public institution settings, and Medicare was a top-two source in the academic practice (salary from private practice) setting only. Significant differences exist in all payer mixes between practice settings (see Fig. 10).

Work hours, procedures per month by practice setting
Surgeons in academic settings work the most hours per week. Surgeons who receive a salary from the institution work slightly more hours than those who receive a salary from a private practice. Military surgeons, hospital-employed surgeons, private practice group surgeons, and those in private practice multispecialty groups work similar hours. Solo practitioners work slightly fewer hours per week.

Surgeons in private practice groups perform an average of 35 procedures per month—higher than any other category. Academics who receive salaries from a private practice perform an average of 34 procedures per month, and surgeons in private practice multispecialty groups average 33 procedures per month (see Figures 11, 12).

The 2018 census
The next census data gathering year will be in 2018. Questionnaires will be sent to AAOS members via email, fax, or U.S. mail. As always, a 100 percent response rate is hoped for, so orthopaedic surgeons are encouraged to answer the survey as soon as they receive it during the first quarter of 2018.

The full 2016 Orthopaedic Practice in the United States report is available to AAOS members at www.aaos.org/2016censusreport. AAOS log-in and password are required to view the report. It is also available for purchase at the same web link.

John Cherf, MD, MPH, MBA, is the current practice and payment section leader of the Health Care Systems Committee, a member of the Council on Education, and a member of the AAOS Now editorial board. Angela Buckley, MPA, is a research analyst in healthcare statistics and surveys, in the AAOS department of research, quality, and scientific affairs.