Orthopaedic traumatology: the hospital side of the ledger, defining the financial relationship between physicians and hospitals

Impact of a Dedicated Orthopaedic Trauma Room on Elective Arthroplasty Case Volume

OBJECTIVE

To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on elective arthroplasty volume.

DESIGN

Retrospective cohort study.

SETTING

Level I academic trauma center.

INTERVENTION

A retrospective analysis was performed for two 3-year intervals before and after DOTR introduction on January 20, 2013, at a Level I trauma center. Surgeons were included if they performed elective primary total hip arthroplasty (THA), total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), or reverse total shoulder arthroplasty (RTSA) regularly from 2010 to 2015.

MAIN OUTCOME MEASURES

Change in elective arthroplasty volume after the implementation of a DOTR.

RESULTS

A total of 2339 cases were performed by surgeons A-E, with an average of 303.3 cases per year pre-DOTR and an average of 476.3 cases per year post-DOTR. On average, within our institution, there were 75.79 per 10,000 cases/year in Michigan pre-DOTR and 104.2 per 10,000 cases/year in Michigan post-DOTR. Surgeons A-E averaged 173.0 more cases per year and increased their average proportion of elective arthroplasty case volume in Michigan. There was a statistically significant market share increase of 9.8 per 10,000 cases/year in Michigan, at our hospital in the post-DOTR periods ( P = 0.039) (CI [0.5442, 19.21], SE = 4.523). This market share increase of 9.8 cases/10,000 cases was the yearly increase in market share that our average surgeons saw after the DOTR implementation, this took into account the observed annual increase in arthroplasty volume statewide during those years.

CONCLUSION

Implementation of a DOTR was associated with increases in the total number, annual mean, and annual proportion of elective arthroplasty cases performed in Michigan for both elective surgeons and the institution as a whole. These findings reveal a benefit of DOTR implementation to elective arthroplasty surgeons and health systems on a larger scale, in the form of increased arthroplasty case volume.

The Epidemiology of Platelet-Rich Plasma Injections From 2010 to 2020 in a Large US Commercial Insurance Claims Database: A Recent Update

INTRODUCTION

The popularity of platelet-rich plasma (PRP) injections for the treatment of orthopaedic conditions has grown markedly. We sought to better define the trends in the usage of orthopaedic PRP injections across an insured US population over the past decade.

METHODS

The PearlDiver M91Ortho commercial administrative claims database was queried for all patients receiving PRP injections for orthopaedic conditions from 2010 through the first quarter of 2020 (Q1.2020). Trends in PRP use, reimbursement charges, demographics, joints injected, and administering physicians were assessed over time and reported as year-over-year (YOY) changes.

RESULTS

Over the study period, 14,096 unique patients had 17,759 orthopaedic PRP injections. The number of PRP injections administered had a YOY increase of 7.1% (144 injections/year, 95% confidence interval [CI] = 89 to 199, Ptrend = 0.0009). A YOY increase of 895% was observed in total nonsurgical charges ($683,974/yr, 95% CI 441,504 to 926,444, Ptrend = 0.0009). The median age of PRP recipients increased (YOY change = +0.6 years, 95% CI 0.4 to 0.8, Ptrend = 0.0005). Injections to the elbow (YOY change = -0.8%, 95% CI -0.10% to [-0.06%], Ptrend = 0.005) and foot/ankle (YOY change = -1.0%, 95% CI -1.4% to [-0.06%], Ptrend = 0.002) decreased, whereas hip (YOY change = +0.4%, 95% CI 0.2% to 0.6%, Ptrend = 0.019), knee (YOY change = +0.9%, 95% CI 0.3% to 1.2%, Ptrend = 0.016), and spine (YOY change = +0.2%, 95% CI 0.0% to 0.4%, Ptrend = 0.033) injections increased. PRP injections given by sports medicine orthopaedic surgeons (YOY change = +0.8%, 95% CI 0.6% to 1.2%, Ptrend <0.0001) increased over time, whereas those by general orthopaedic surgeons decreased (YOY change = -0.9, 95% CI -1.2 to [-0.6%], Ptrend = 0.001).

CONCLUSION

PRP injections quadrupled in prevalence from 2010 to Q1.2020, with a projected increase in annual usage in this data set of 66% by 2030. As greater evidence-based indications for PRP use are identified, more specialists and insurance providers may consider expanding their involvement in this growing field.

LEVEL OF EVIDENCE

III, retrospective cohort study.

The economics of patients undergoing periacetabular osteotomy for hip dysplasia: the financial relationship between physicians and hospitals

Periacetabular osteotomy (PAO) is the gold standard for treating hip dysplasia in patients with preserved articular cartilage. The aim of this study is to evaluate the financial relationship between facility and professional revenue for patients undergoing PAO for hip dysplasia and acetabular version abnormalities. All patients who underwent PAO for hip dysplasia by a single surgeon at a tertiary academic medical center between December 2016 and November 2020 were identified. Financial records for facility and professional services were reviewed and analyzed. The orthopedic charge multiplier, the dollars of facility charge created by a single dollar of orthopedic professional charge, and orthopedic net revenue multiplier, the dollars collected by the hospital for facility services generated for each dollar collected by the orthopedic surgeon, were calculated. A total of 36 patients were included in the study. The mean total charge for all patients was $144 939.35 ± $23 726.48 (range $109 002.71 to $227 290.20), and the average total revenue for all patients was $44 218.79 ± $12 352.97 (range $29 397.39 to $90,830.62). The mean orthopedic charge multiplier was 2.47 ± 1.32 (range 0.78-6.53), and the net revenue collection multiplier was 8.62 ± 10.69 (range, 1.20-57.80). The majority of charges and revenue related to care of patients undergoing PAO return to the hospital. The significant mean orthopedic charge multiplier for this procedure increases the value of the service and the surgeon to hospital profitability. This information can help shape the relationship between the hospital and the surgeon and create a firm platform to advocate for program advancement.

Increased Reimbursement for Surgical Fixation of Hip Fractures: The Difference Between the Hospital and the Surgeon

OBJECTIVES

To evaluate trends and variations in hospital charges and payments relative to surgeon charges and payments for surgical treatment of hip fractures in the US Medicare population.

METHODS

Hospital and surgeon charges and payments after treatment of hip fractures by closed reduction and percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or intramedullary nail (IMN), along with corresponding patient demographics, 90-day and 1-year mortality, Charlson Comorbidity Index (CCI), and length of stay (LOS) from 2005 to 2014 were captured from the 5% Medicare Standard Analytic Files. The ratio of hospital to surgeon charges (CM: Charge Multiplier) and the ratio of hospital to surgeon payments (PM: Payment Multiplier) were calculated for each year and region of the United States and trended over time. Correlations between the CM and PM and LOS were evaluated using a Pearson correlation coefficient (r).

RESULTS

Three thousand twenty-eight patients who underwent CRPP and 25,341 patients who underwent ORIF/IMN were included. The CM for CRPP increased from 10.1 to 15.6, P < 0.0001. The CM for ORIF/IMN increased from 11.9 to 17.2, P < 0.0001. The PM for CRPP increased from 15.1 to 19.2, P < 0.0001. The PM for ORIF/IMN increased from 11.5 to 17.4, P < 0.0001.

CONCLUSIONS

Hospital charges and payments have continually increased relative to surgeon charges and payments for treatment of hip fractures despite decreasing LOS.

Factors associating with surgical site infection following operative management of malleolar fractures at an urban level 1 trauma center

OBJECTIVES

To identify comorbidities and injury characteristics associated with surgical site infection (SSI) following internal fixation of malleolar fractures in an urban level 1 trauma setting.

DESIGN

Retrospective.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Seven-hundred seventy-six consecutive patients with operatively managed malleolar fractures from 2006 to 2016.

INTERVENTION

Open reduction internal fixation.

MAIN OUTCOME MEASUREMENTS

Superficial SSI (erythema and drainage treated with oral antibiotics and wound care) or deep SSI (treated with surgical debridement and antibiotics).

RESULTS

Fifty-six (7.2%) patients developed SSI, with 17 (30%) of these being deep infections. An a-priori power analysis of n = 325 (α=0.05, β=0.2) was tabulated for differences in univariate analysis. Univariate analysis identified categorical associations (P < .05) between SSI and diabetes mellitus, drug abuse, open fracture, and renal disease but not tobacco abuse, body mass index, or neuropathy. Multivariate logistic regression identified categorical associations between diabetes (OR = 2.2, 95% CI: 1.1-4.3), drug abuse (OR = 3.9, 95% CI: 1.2-12.7), open fracture (OR = 4.1, 95% CI: 1.3-12.8), and renal disease (OR = 2.7, 95% CI: 1.4-5.0) and any (superficial or deep) SSI. A separate multivariate logistic regression analysis found categorical associations between deep SSI requiring reoperation and diabetes (OR = 4.4, 95% CI: 1.6-12.2) and open fracture (OR = 4.1, 95% CI: 1.3-12.8). Furthermore, American society of anesthesiologists classification (ASA) Class 4 patients were (OR = 9.2, 95% CI: 2.0-41.79) more likely to experience an SSI than ASA Class 1 patients.

CONCLUSIONS

Factors associated with SSI following malleolar fracture surgery in a single urban level 1 trauma center included diabetes, drug abuse, renal disease, and open fracture. The presence of diabetes or open type fractures were associated with deep SSI requiring reoperation.

LEVEL OF EVIDENCE

Level 3 prognostic: retrospective cohort study.

Variations in Revenue Generation for the Care of Orthopaedic Trauma Patients

BACKGROUND

In the background of increasing competition between trauma centers, this study investigated the relative reimbursement of trauma care provided in an urban trauma setting, comparing patients previously unknown (new) to the system, representing potential sources of new revenue, and those who were known (established), having received medical care previously in the same system.

METHODS

A retrospective review of 440 patients with high-energy fractures at a single level 1 trauma center was conducted. Payment to charge (P/C) ratios for professional and facilities services within 6 months of injury were calculated.

RESULTS

Mean professional charges per patient were $35,522 and $30,639 (P = 0.11), between new and established patients, respectively, whereas mean professional payments were statistically different, $7,894 and $4,365 (P < 0.001). Mean differences in P/C for facilities payments for new and established patients were not statistically significant, but professional P/C was higher in new patients (P < 0.001), consistent with better insured patients.

DISCUSSION

Insurance companies reimburse for professional or facilities services with statistically different P/C ratios. Treating new patients at our institution likely benefits our institution by offering exposure to a more favorable payer mix and more complex patients.

LEVEL OF EVIDENCE

Retrospective level III.

A Practical Guide for the Current Use of Biologic Therapies in Sports Medicine

Over the past decade, there has been an increased interest in the use of biologic therapies in sports medicine. Although these technologies are in relatively early stages of development, there have been substantial increases in marketing, patient demand, and clinical utilization of biologics, including platelet-rich plasma, bone marrow aspirate concentrate, and other cell-derived therapies. Direct-to-consumer marketing of biologics has also proliferated but is largely unregulated, and clinicians must accurately convey the safety and efficacy profiles of these therapies to patients. Because most insurance companies consider biologic treatments to be experimental or investigational for orthopaedic applications given the lack of high-quality evidence to support their efficacy, patients receiving these treatments often make substantial out-of-pocket payments. With a range of treatment costs among centers offering biologics, there is a need for appropriate and sustainable pricing and reimbursement models. Clinicians utilizing biologics must also have a thorough understanding of the recently clarified Food and Drug Administration guidelines that regulate the clinical use of cell and tissue products. There is a lack of consensus on the optimal preparation, source, delivery method, and dosing of biologic therapies, which has been exacerbated by a lack of sufficient experimental detail in most published studies. Future research must better identify the biologic target of treatment, adhere to better standards of reporting, and better integrate researchers, industry, and regulatory bodies to optimize applications.

Assessing the Economic Efficiency of Physician On-call Payments

On-call services provided by physicians are critical to the function of a robust healthcare delivery system, but such services are not generally accounted for by standard physician productivity metrics, such as the work relative value unit (wRVU). There is significant diversity on how physicians are compensated, if at all, for these on-call services. Simultaneously, there exists a considerable shortage, particularly in the surgical subspecialties, for on-call coverage – most commonly in rural and underserved communities. While we agree that “call” services should undergo standardized valuation, we suggest that the wRVU is an ill-posed metric for this purpose as its primary role is to value discrete physician services provided to patients. In contradistinction, “call” is a physician service to a hospital – the disproportionate beneficiary of the service. We maintain that systemic and regulatory factors undervalue physician on-call compensation relative to the hospital’s value chain and lead to call shortages that impact patient care and foster inequity. Finally, we urge subspecialty professional organizations to develop guidelines for call valuation.

The Role of Business Education in the Orthopedic Curriculum

The field of orthopedics is becoming increasingly complex as the demands for success are not merely clinical competence and good interpersonal skills. To achieve practice stability strategic planning, contract negotiation, health care law, practice management, health care economics, and personal finance are all needed skills. Unfortunately, most of these areas of professional growth require some basic background in business principles. This is an area that most recent residency graduates feel is neglected as a core educational competency. In these changing times, it is imperative that orthopedic residents and fellows obtain some formal business education.

Utilization of Platelet-Rich Plasma for Musculoskeletal Injuries: An Analysis of Current Treatment Trends in the United States

Background:

Platelet-rich plasma (PRP) has emerged as a popular biologic treatment for musculoskeletal injuries and conditions. Despite numerous investigations on the efficacy of PRP therapy, current utilization of this treatment within the United States is not widely known.

Purpose:

To investigate the national utilization of PRP, including the incidence and conditions for which it is used in the clinical setting, and to determine the current charges associated with this treatment.

Study Design:

Descriptive epidemiology study.

Methods:

Using a national database (PearlDiver) of private insurance billing records, we conducted a comprehensive search using Current Procedural Terminology (CPT) codes to identify patients who received PRP injections over a 2-year period (2010-2011). Associated International Classification of Diseases, 9th Revision (ICD-9) codes were identified to determine the specific conditions the injection was used to treat. The aggregate patient data were analyzed by yearly quarter, practice setting, geographic region, and demographics. PRP therapy charges were calculated and reported as per-patient average charges (PPACs).

Results:

A total of 2571 patients who received PRP injections were identified; 51% were male and 75% were older than 35 years. The overall incidence ranged from 5.9 to 7.9 per 1000 patients over the study period. PRP was most commonly administered in hospitals (39%) and ambulatory surgical centers (37%) compared with in private offices (26%). The most common conditions treated were knee meniscus/plica disorders, followed by unspecified shoulder conditions, rotator cuff injuries, epicondylitis, and plantar fasciitis. Further evaluation revealed that 25% of all patients received injections for cartilage-related conditions, 25% meniscus, 25% unspecified, 12% tendon, 8% glenoid labrum, and 5% ligament. The PPAC for PRP treatment was US$1755 per injection.

Conclusion:

Despite a lack of consensus regarding PRP indications and efficacy, we observed widespread application of this treatment for a myriad of musculoskeletal injuries. Most treated patients were older than 35 years, and the most commonly treated conditions included cartilage and meniscus disorders. Given the current controversy surrounding this treatment, further studies are necessary to guide clinicians on the value of this therapy for each clinical diagnosis.

Impact of Hospital-Employed Physician Assistants on a Level II Community-Based Orthopaedic Trauma System

OBJECTIVES

The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital.

DESIGN

Retrospective case series.

SETTING

Level II trauma center.

PATIENTS/PARTICIPANTS

One thousand one hundred four trauma patients with orthopaedic injuries.

INTERVENTION

PA involvement.

MAIN OUTCOME MEASUREMENTS

Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients.

RESULTS

At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27).

CONCLUSIONS

Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue

OBJECTIVES

We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay.

DESIGN

Prospective consecutive series.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0.

INTERVENTION

Femur, pelvis, or spine fractures treated surgically.

MAIN OUTCOME MEASUREMENTS

Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded.

RESULTS

Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days).

CONCLUSIONS

Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Isolated sacral injuries: Postoperative length of stay, complications, and readmission

AIM: To investigate inpatient length of stay (LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.

METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach (open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists’ score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher’s exact and non-parametric t-tests (Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches.

RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31 (30.4%) who underwent open reduction and internal fixation (ORIF) vs 63 (67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients (P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups (19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups (9.5% percutaneous vs 6.5% ORIF).

CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.

Does Fracture Care Make Money for the Hospital? An Analysis of Hospital Revenues and Costs for Treatment of Common Fractures

OBJECTIVES

To determine the relative profitability for a hospital of treatment of common fractures within a state-regulated reimbursement system.

DESIGN

Retrospective cohort.

SETTING

Regional trauma referral center with state-regulated hospital reimbursement system.

METHODS

We reviewed hospital medical and financial records of 1228 patients admitted from 2008 through 2012 with a principle diagnosis of acute traumatic fracture requiring surgical treatment. Patients whose principle diagnosis fit into 1 of 6 common anatomic categories were included. Sixty-five pelvic, 275 acetabular, 277 hip, 255 femoral shaft, 148 tibial shaft, and 208 ankle fractures were identified. Patients with a different principle diagnosis were excluded. Net revenue, total cost of inpatient care, and direct margin for each patient's acute inpatient hospital course were recorded.

MAIN OUTCOME MEASUREMENT

Direct margins, costs.

RESULTS

Per patient, the overall mean net revenue was $39,813, overall mean cost of inpatient care was $21,231, and overall mean direct margin (profitability) was $18,582. Mean direct variable expense was $14,898 per patient, and mean direct fixed expense was $6333 per patient. Factors most influencing cost included length of stay, supplies, and operating room use. Of 1228 patients, 46 (3.7%) had a negative direct margin (net loss to hospital). The most profitable diagnosis was pelvic fracture (mean direct margin, $21,767).

CONCLUSIONS

The state-regulated reimbursement system allows analysis of hospital profitability in the context of a normalized revenue stream that should approximate the overall fiscal realities of other states. Providing orthopaedic trauma care can be economically feasible and profitable for a hospital.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Look before you leap

The decision to leave a job can be very stressful. Multiple variables must be considered before turning in your notice. The goal of this paper is to help you decide if changing jobs is a smart decision, and, if it is, when to do it.

Improving business IQ in medicine through mentorship and education

Business intelligence in the field of medicine, particularly with physicians, has been an abstract concept at best with no objective metric. Furthermore, in many arenas, it was taboo for medical students, residents, and physicians to discuss the business and finances of their work for fear that it would interfere with their sacred duties as health care providers. There has been a substantial shift in this philosophy over the last few decades with the growth and evolution of the health care industry in the United States. In 2012, health care expenditures accounted for 17.2% of the United States Gross Domestic Product, averaging $8915 per person. The passage of the Affordable Care Act in March of 2010 sent a clear message to all that change is coming, and it is more important now than ever to have physician leaders whose skills and knowledge in business, management, and health care law rival their acumen within their medical practice. Students, residents, and fellows all express a desire to gain more business knowledge throughout their education and training, but many do not know where to begin or have access to programs that can further their knowledge. Whether you are an employed or private practice physician, academic or community based, improving your business intelligence will help you get a seat at the table where decisions are made and give you the skills to influence those decisions.

Hospital fundamentals

Under the current system, orthopaedic trauma surgeons must work in some form of hospital setting as our primary service involves treatment of the trauma patient. We must not forget that just as a trauma center cannot exist without our services, we cannot function without their support. As a result, a clear understanding of the balance between physicians and hospitals is paramount. Historical perspective enables physicians and hospital personnel alike to understand the evolution of hospital-physician relationship. This process should be understood upon completion of this chapter. The relationship between physicians and hospitals is becoming increasingly complex and multiple forms of integration exist such as joint ventures, gain sharing, and co-management agreements. For the surgeon to negotiate well, an understanding of hospital governance and the role of the orthopaedic traumatologist is vital to success. An understanding of the value provided by the traumatologist includes all aspects of care including efficiency, availability, cost effectiveness, and research activities. To create effective and sustainable healthcare institutions, physicians and hospitals must be aligned over a sustained period of time. Unfortunately, external forces have eroded the historical basis for the working relationship between physicians and hospitals. Increased competition and reimbursement cuts, coupled with the increasing demands for quality, efficiency, and coordination and the payment changes outlined in healthcare reform, have left many organizations wondering how to best rebuild the relationship. The principal goal for the physician when partnering with a hospital or healthcare entity is to establish a sustainable model of service line management that protects or advances the physician's ability to make impactful improvements in quality of patient care, decreases in healthcare costs, and improvements in process efficiency through evidence-based practices and protocols.

Trauma program development

The development of a strong trauma program is clearly one of the most important facets of successful business development. Several recent publications have demonstrated that well run trauma services can generate significant profits for both the hospital and the surgeons involved. There are many aspects to this task that require constant attention and insight. Top notch patient care, efficiency, and cost-effective resource utilization are all important components that must be addressed while providing adequate physician compensation within the bounds of hospital financial constraints and the encompassing legal issues. Each situation is different but many of the components are universal. This chapter addresses all aspects of trauma program development to provide the graduating fellow with the tools to create a new trauma program or improve an existing program in order to provide the best patient care while optimizing financial reward and improving care efficiency.

Unravelling the debate over orthopaedic trauma transfers: The sender's perspective

INTRODUCTION

The increasing frequency of orthopaedic trauma patient transfers is an issue at the centre of the current orthopaedic "call crisis" that has the potential to inundate resources at tertiary care centres. Appropriateness of transfer has been investigated only from the perspective of receiving surgeons. This study investigates the suitability and reasons for orthopaedic trauma patient transfer from the viewpoint of transferring surgeons.

METHODS

A questionnaire was e-mailed to a random sampling of 500 active members of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association. Surgeons were split into three groups: senders of trauma patients (senders); orthopaedic traumatologists who receive transfers (traumatologist receivers); and other trauma transfer receivers that are not traumatologists (non-traumatologist receivers). The perceived complexity and appropriateness for transfer of eight virtual case scenarios were determined, along with the specific reasons mitigating transfer.

RESULTS

51 Senders, 90 traumatologist receivers, and 98 non-traumatologist receivers completed 239 surveys. There was agreement between groups for case complexity and appropriateness for transfer in five of eight case scenarios (p<0.05). Fracture complexity was cited as the primary reason for transfer by 28% of senders. However, just as common was a lack of resources at the sending hospital; OR equipment (18%), critical care services (18%), and inability to handle the immediacy of the case (7%) were also cited. Likelihood of uninsured status was the least common reason for transfer (1%).

CONCLUSIONS

In most cases, both senders and receivers of orthopaedic trauma have similar viewpoints regarding fracture complexity and appropriateness of transfer. Sending surgeons cite case complexity and a lack of hospital resources as the primary reasons for patient transfer. Mandating increased call for orthopaedic surgeons at non-trauma centres without a concomitant increase in hospital resources is unlikely to substantially reduce unnecessary patient transfers to higher level facilities.

Why veteran orthopaedic trauma surgeons are being fired and what we can do about it?

The financial realities of providing trauma care to injured patients can make it difficult to produce an accurate assessment of the cumulative value orthopaedic trauma surgeons provide to healthcare and university institutions. As with many political battles in the field of medicine, physicians who have been diligently focused on providing patient care were completely unaware of the impending upheaval around them. Whether orthopaedic trauma surgeons are employed or in some type of partnership with hospitals, too often surgeons find the relationship one-sided. In order to effectively negotiate with hospitals, surgeons must demonstrate the comprehensive value they provide to their respective healthcare institutions and universities. Orthopaedic trauma surgeons make direct and indirect financial contributions to the hospital in addition to educational and community services. The sum total of these valued contributions helps fund non-revenue generating programs, provides marketing opportunities, and improves the regional and national reputation of the healthcare institution. This paper provides a comprehensive review of the value contributed to healthcare institutions by orthopaedic trauma surgeons and will serve as a blueprint for all surgeons to accurately account for and demonstrate their value to hospitals while providing efficient and compassionate care to our patients.

Understanding how orthopaedic surgery practices generate value for healthcare systems

BACKGROUND

Orthopaedic surgery practices can provide substantial value to healthcare systems. Increasingly, healthcare administrators are speaking of the need for alignment between physicians and healthcare systems. However, physicians often do not understand what healthcare administrators value and therefore have difficulty articulating the value they create in discussions with their hospital or healthcare organization. Many health systems and hospitals use service lines as an organizational structure to track the relevant data and manage the resources associated with a particular type of care, such as musculoskeletal care. Understanding service lines and their management can be useful for orthopaedic surgeons interested in interacting with their hospital systems.

QUESTIONS/PURPOSES

We provide an overview of two basic types of value orthopaedic surgeons create for healthcare systems: financial or volume-driven benefits and nonfinancial quality or value-driven patient care benefits.

METHODS

We performed a search of PubMed from 1965 to 2012 using the term "service line." Of the 351 citations identified, 18 citations specifically involved the use of service lines to improve patient care in both nursing and medical journals.

RESULTS

A service line is a structure used in healthcare organizations to enable management of a subset of activities or resources in a focused area of patient care delivery. There is not a consistent definition of what resources are managed within a service line from hospital to hospital. Physicians can positively impact patient care through engaging in service line management.

CONCLUSIONS

There is increasing pressure for healthcare systems and hospitals to partner with orthopaedic surgeons. The peer-reviewed literature demonstrates there are limited resources for physicians to understand the value they create when attempting to negotiate with their hospital or healthcare organization. To effectively negotiate for resources to provide the best care for patients, orthopaedic surgeons need to claim and demonstrate the value they create in healthcare organizations.

Factors affecting revenue from the management of pelvis and acetabulum fractures

OBJECTIVES

The purpose was to define charges and reimbursement in the management of pelvis and acetabulum fractures and to identify opportunities for revenue enhancement.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred sixty-five patients with 210 pelvic ring injuries and 285 acetabulum fractures.

INTERVENTION

All fractures were treated surgically.

MAIN OUTCOME MEASUREMENTS

Professional and facility charges and collections were determined for each patient. Costs of care and profitability were calculated for patients with isolated pelvis or acetabulum fractures.

RESULTS

: Definitive fixation was ≤ 24 hours of injury in 35% and >72 hours in 24%. Mean hospital length of stay (LOS) was 9.2 days, with mean 3.1 days in the intensive care unit (ICU). Mean facility charges were $51,069 with collections of $22,702 (44%). Mean orthopaedic professional charges were $20,184 with collections of $4629 (23%). Combined pelvis and acetabulum fractures had the highest facility collection rates (49%) with lower professional collections (21%) versus isolated fractures (25%, P = 0.03). The payer mix had significantly more commercial (27%), managed care (27%), and Bureau of Worker's Compensation (10%) versus the entire hospital, despite progressively more patients with Medicaid or no insurance during the study. Uninsured patients were significantly younger with lower injury severity score. Fractures managed definitively ≤ 24 hours had shorter LOS, shorter ICU stay, and fewer complications, with mean net facility revenue over costs of $2376. Longer LOS due to complications increased initial hospital costs by a mean of $14,829.

CONCLUSIONS

Patients with multiple injuries generated higher facility charges and collection rates. Professional collection rates were lower in patients with more than 1 surgical procedure in the same setting. Trauma patients were more likely to have commercial, managed care, and Bureau of Worker's Compensation insurance versus the entire hospital. Fractures managed definitively within 24 hours were associated with shorter LOS, shorter ICU stay, and fewer complications, resulting in lower treatment expenses. Fracture care was profitable to the hospital when definitively completed within 72 hours. Prolonged LOS and complications were associated with larger costs of care.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of hospital-employed physician assistants on a level II community-based orthopaedic trauma system

OBJECTIVES

The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospital-based PAs on orthopaedic trauma care at a level II community hospital.

DESIGN

Retrospective case series.

SETTING

Level II trauma center.

PATIENTS/PARTICIPANTS

One thousand one hundred four trauma patients with orthopaedic injuries.

INTERVENTION

PA involvement.

MAIN OUTCOME MEASUREMENTS

Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients.

RESULTS

At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P > 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27).

CONCLUSIONS

Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well.

Building a successful trauma practice in a community setting

The development of a busy community-based trauma practice is a multifaceted endeavor that requires good clinical judgment, business acumen, interpersonal skills, and negotiation tactics. Private practice is a world in which perfect outcomes are expected and efficiency is paramount. Successful operative outcomes are dependent on solid clinical training, good preoperative planning, and communication with mentors when necessary. Private practitioners must display confidence, polite behavior, and promptness. Maintaining availability for consultation from emergency room physicians, private practice physicians, and local orthopaedic surgeons is a powerful marketing tool. Orthopaedic trauma surgery has been shown to be a profitable field for hospitals and private practitioners. However, physician success depends on a sound understanding of hospital finance, marketing skills, and knowledge of billing and coding. As the financial pressures of medical care increase, hospital negotiation will be paramount, and private practitioners must combine clinical and business skills to provide good patient care while maintaining independence and financial security.

Finding your first job in a community hospital

Community hospitals offer excellent opportunities for graduating orthopaedic trauma fellows. To successfully compete for these jobs, applicants today must be better prepared than their predecessors. Organizing your practice aspirations and researching job opportunities before the interview are necessary for an effective job search. Often, a collaborative effort with hospital administrators is required to establish a viable practice that fulfills the unique needs of the hospital and surrounding community while concurrently satisfying your practice goals. Issues to consider in defining your desired practice, guidelines on how to prepare for an interview with a community hospital, and suggestions on how to justify the expense of establishing your practice are presented.

Full-Time Orthopedic Traumatologists Enhance Rural Trauma Center Pelvic Fracture Outcomes and Financials

We hypothesized that full-time orthopedic traumatologists would increase interfacility transfer patients with pelvic ring injuries at a trauma center seeking American College of Surgeons Level I verification. A trauma registry query identified 790 patients with pelvic ring injuries admitted to a trauma service over 10 years. The study groups included 173 patients 3 years before and 405 patients 3 years after recruitment of two full-time orthopedic traumatologists. Interfacility transfers of patients with pelvic ring injuries requiring operative procedures were increased over 230 per cent ( P < 0.01) with full-time orthopedic traumatologists. Financial analysis showed enhanced hospital margin per patient and decreased direct costs ( P < 0.01). Complications, mortality rates, and length of stay were decreased ( P < 0.01). Full-time orthopedic traumatologists enhance pelvic ring injury patient interfacility transfers, operative procedures, outcomes, and financials at a Level I trauma center in a rural setting.

Hand surgery volume and the US economy: is there a statistical correlation?

BACKGROUND

To the best of our knowledge, there have been no previous studies evaluating the correlation of the US economy and hand surgery volume. Therefore, in light of the current recession, our objective was to study our institution's hand surgery volume over the last 17 years in relation to the nation's economy.

METHODS

A retrospective analysis of our institution's hand surgery volume, as represented by our most common procedure (ie, carpal tunnel release), was performed between January 1992 and October 2008. Liposuction and breast augmentation volumes were chosen to serve as cosmetic plastic surgery comparison groups. Pearson correlation statistics were used to estimate the relationship between the surgical volume and the US economy, as represented by the 3 market indices (Dow Jones, NASDAQ, and S&P500).

RESULTS

A combined total of 7884 hand surgery carpal tunnel release (open or endoscopic) patients were identified. There were 1927 (24%) and 5957 (76%) patients within the departments of plastic and orthopedic surgery, respectively. In the plastic surgery department, there was a strong negative (ie, inverse relationship) correlation between hand surgery volume and the economy (P < 0.001). In converse, the orthopedic department's hand surgery volume demonstrated a positive (ie, parallel) correlation (P < 0.001). The volumes of liposuction and breast augmentation also showed a positive correlation (P < 0.001).

CONCLUSION

To our knowledge, we have demonstrated for the first time an inverse (ie, negative) correlation between hand surgery volumes performed by plastic surgeons in relation to the US economy, as represented by the 3 major market indices. In contrast, orthopedic hand surgery volume and cosmetic surgery show a parallel (ie, positive) correlation. This data suggests that plastic surgeons are increasing their cosmetic surgery-to-reconstructive/hand surgery ratio during strong economic times and vice versa during times of economic slowdown.

Financial impact of a dedicated orthopaedic traumatologist on a private group practice

OBJECTIVE

The purpose of the study was to demonstrate the financial impact of the addition of a dedicated orthopaedic traumatologist to a private group practice at a Level II community-based trauma system.

DESIGN

Retrospective review of financial records.

SETTING

Level II trauma center and large group practice.

METHODS

Office billing and financial data were evaluated for the 12 months before the addition of a dedicated, hospital-based, orthopaedic traumatologist and for a 2-year period after the hiring. Outcomes such as payor mix, collection rates, time to breakeven, days off, call days, evenings worked, durable medical equipment, and x-ray and casting reimbursement were analyzed.

RESULTS

The addition of a dedicated traumatologist was financially beneficial for the partnership. Existing practices increased 23% in charges and 32% in collections despite partners taking more vacation days and 14% less call. This was partially the result of increased nontrauma referrals, full clinic templates, and uninterrupted elective operating room schedules. Over a 2-year period, elective arthroplasty cases increased 13.1%, elective arthroscopy cases increased 35.4%, and total patient office visits increased 18.8%. The payor mix for trauma patients was poorer than the group average; however, this was offset by decreased overhead requirements. Collections rate for the trauma partner in evaluation and management, surgery, casting, durable medical equipment, and radiology improved dramatically after the first year to become just slightly less than other clinic-specialized practices. The cost of bringing on a new trauma partner is substantial but regained after 6 months.

CONCLUSIONS

A dedicated orthopaedic traumatologist can be extremely beneficial to a group practice and to the traumatologist given the appropriate case volume, payor mix, and a relative value unit-based payment system.

The organizational and financial viability of an orthopedic trauma service

BACKGROUND

This study was designed to explore the effect of establishing an Orthopedic Trauma Service (OTS) on departmental revenue within an academic orthopedic department. The effect of the OTS on physician and resident perceptions of job satisfaction, education, and quality of patient care were also evaluated.

METHODS

A proforma financial analysis was undertaken using an optimization model to predict the potential financial performance of an OTS before its implementation. Financial data were then collected prospectively for the first year of the OTS and compared with the preceding year's financial data. All residents and faculty in the department completed visual analog scale surveys after the formation of the service.

RESULTS

While maintaining a fixed amount of work production (work relative value units [WRVUs]) per year, our model predicted an $111,000 increase in departmental charges as a result of a shift in the elective case mix. After implementation of the OTS, elective charges/WRVU increased by 7.4% while trauma charges/WRVU increased by 2.6%. This, combined with a minor increase in departmental work volume (115,661 WRVUs pre-OTS vs. 117,577 WRVUs post-OTS) and an improvement in collections/charge (47-48%), yielded a departmental collection increase of 11% ($1.1 million). Resident and faculty job satisfaction improved, as did the perception of the quality of trauma care that was being provided.

CONCLUSIONS

The organization and implementation of an OTS within an academic orthopedic department can lead to an improved professional experience for residents and faculty, the perception of improved patient care for the trauma patient, and an increase in departmental revenue.