AAOS Now

Published 3/24/2021
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Tanmaya D. Sambare, BA; Nicholas J. Giori, MD, PHD, FAAOS; Karl M. Koenig, MD, MS, FAAOS

In the Wake of the COVID-19 Pandemic, What About Orthopaedic Care Equity?

In early 2020, most U.S. households did not know of the existence of coronaviruses. Since then, our lives and livelihoods have been upended. On top of the unimaginable human losses, COVID-19 has brought a healthcare financial crisis to our doorstep.

Early, conservative modeling suggested there will be roughly $163 billion in direct COVID-19–related healthcare expenses, which may underestimate true values, as cases have increased more than originally anticipated. Sequelae continue to impact COVID-19 survivors, and estimates of the total costs of long-term health impairments could surpass $2.5 trillion. Furthermore, the nation’s health insurance system—largely based on employer-sponsored insurance—has been reeling from high levels of unemployment, and the underinsured population is nearing levels seen before enactment of the Affordable Care Act. Those who maintain insurance through their employers are likely to see higher deductibles and out-ofpocket limits as payers look to recoup some of the unexpected COVID-19– related costs of care.

Additionally, health systems have incurred significant financial losses through the curtailment of elective procedures as part of the COVID-19 response. In short, the health-related financial burden of this pandemic is of great magnitude and affects patients, providers, payers, and policymakers alike.

Prior to March 2020, several decades of rising healthcare costs had prompted a variety of efforts to control costs and drive greater value in care delivery, particularly for elective orthopaedic procedures such as total joint arthroplasty (TJA). In fact, the issue was so impactful that policymakers, payers, and physicians were all in rare agreement that flattening the cost curve is a top priority. Large employers were acting to control the costs of care received by their employees through centers-of-excellence programs. The Centers for Medicare & Medicaid Services (CMS) expanded its Comprehensive Care for Joint Replacement (CJR) program in light of data showing its effectiveness in reducing the costs of arthroplasty episodes. Greater attention was given to postoperative length of stay, post-acute care, and implant costs, along with greater interest in moving surgeries to the ambulatory setting. Telemedicine technologies were piloted across the country in hopes of broadening the reach of care delivery with a lighter resource footprint.

With the “systemic shock” of COVID-19, we will likely see an acceleration of all of those changes. Centers-of-excellence models and episode- based reimbursement may become the norm for elective orthopaedic care. We have already seen rapid implementation of telemedicine into care delivery to maintain physical distancing, and virtual visits/remote monitoring will continue to be heavily utilized in the future. Although the energy of care delivery reform is certainly exciting, existing initiatives do not fully address access and equity in orthopaedic care, as mentioned in an AAOS Now position statement (“AAOS Position Statement Addresses Access to Care During COVID-19,” August 2020). There remain important considerations of equity that need to be addressed proactively prior to large-scale changes in the standard of orthopaedic care. This article highlights several points for consideration regarding where these changes may exacerbate existing disparities in orthopaedic care.

Orthopaedic care access for patients with greater resource needs

One source of conflict between financial incentives and orthopaedic care equity is episode-based payment. Although there is ample evidence highlighting the effectiveness of episode-based payments in reducing direct costs of care, there is a dearth of discussion on how greater accountability for episode costs may result in the perverse incentive of limiting care for patients with greater resource needs, more medical comorbidities, or poor social support.

Another consideration is the added incentive to perform primary TJA on younger patients who are earlier in the course of disease, a trend observed in early CJR data. This may limit complications and produce lower-cost episodes of care, but these patients may be ahead of traditional surgical indications, and the surgeries may occur at the expense of older, more complex patients. It is important that indications for surgery are not altered due to the financial impacts of the COVID-19 pandemic. One idea to be considered by CMS and the Center for Medicare and Medicaid Innovation is risk adjustment for patients requiring greater resources. This idea has been explored previously and includes modifications of diagnosis-related group payments to hospitals caring for a large proportion of lower-income populations. Such modifications can allow health systems to deploy resources for important care elements such as perioperative risk optimization or social support.

As we gain a greater understanding of risk optimization and the role that social determinants play in patient outcomes and resource utilization, risk adjustment for social needs and medical risk at the individual level should be seriously considered by policymakers in order to mitigate incentives that might otherwise perpetuate disparities in access to elective orthopaedic care.

Prudence in the Implementation of technology into the standard of care

Telemedicine—namely virtual visits and wearable devices—is now among the most common buzzwords in healthcare discussions. Virtual visits present an exciting opportunity to extend patient care and improve the efficiency of information exchange through mobile consultations or follow-up encounters, and wearable devices can help extend monitoring capabilities. When utilized in appropriate cases, these platforms can potentially save clinical resources by reducing the need for in-person visits. Although the excitement around such technologies is certainly justified, it is also important to recognize their limitations.

For instance, the impact of virtual visits on communication in the setting of language barriers is unknown, as most studies examining the effectiveness of video visits have excluded non-English speakers. Furthermore, studies examining the effectiveness of wearable devices have not examined how age or technological proficiency may impact outcomes. Academic investigations into the effectiveness of telemedicine and technological interventions in care delivery should evaluate the impact of language, age, culture, and socioeconomics on outcomes of interest.

Machine learning (ML) is another recent healthcare buzzword. Although there is great utility to using ML models for care delivery elements such as prognostication, warnings should be heeded, as improperly implemented algorithms have the potential to perpetuate existing biases and inequities. As the industry strives to extend the reach in delivering care, we should be excited by the technologies that enable our efforts. However, we must also exercise appropriate caution to ensure that any changes do not come at the expense of particular groups of patients.

Orthopaedic care access for the underinsured

With the financial losses and scheduling backlogs incurred by health systems following the suspension of elective procedures, they are likely to prioritize financial recovery in the immediate future. Consequently, there may be a greater focus on serving commercially insured patients who yield higher rates of reimbursement and a simultaneous disincentive in providing uncompensated care. Knowing that service workers—among many other sectors—are currently seeing record high levels of unemployment and that contracted employees often do not have healthcare benefits, the underinsured population will assuredly expand. Despite all our energy in improving orthopaedic care delivery, we may find elective procedures rendered inaccessible for a large portion of the population. As the new presidential administration considers healthcare reform, specialty care access for the underinsured must be considered.

Conclusion

The COVID-19 “shock” offers an opportunity for honest reflection on the state of the health system, one that has been steadily weighed down by costs of care and an antiquated reimbursement system. The pandemic has brought new energy to longstanding discussions about payment and delivery reform.

Elective orthopaedic care such as TJA—with its relatively low variation and high volume across geographies—serves as an excellent case study. However, the elective nature of orthopaedic procedures renders them more susceptible to contrary incentives that could perpetuate existing inequities in care. In 2001, the Institute of Medicine (IOM) presented its six domains of healthcare quality. The sixth domain is that of equity, which IOM defines as “care that does not vary in quality because of personal characteristics.” As we seek to recover and retool our capabilities of delivering orthopaedic care after the pandemic, it is imperative that we remain prudent and uphold equity for our patients.

Tanmaya D. Sambare, BA, is a medical student at Stanford School of Medicine.

Nicholas J. Giori, MD, PhD, FAAOS, is chief of orthopaedic surgery at the VA Palo Alto Health Care System and professor in the Department of Orthopaedic Surgery at Stanford University.

Karl M. Koenig, MD, MS, FAAOS, is the division chief of orthopaedic surgery and associate professor in the Department of Surgery and Perioperative Care at the University of Texas at Austin.

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