February 2003 Bulletin

2002 Orthopaedic Physician Census completed

Shows growth in specialization, payment from managed care

The results from the Academy’s biennial member census are in, showing subtle shifts in orthopaedic practice since the last census was conducted in 2000. Changes also were seen in the orthopaedic workforce, in practice characteristics and in sources of reimbursement. The national trend toward an aging population is having an impact on orthopaedic practice as well.

The ninth biennial AAOS member census survey, the 2002 Orthopaedic Physician Census (OPUS 2002), was conducted from December 2001 through June 2002. A total of 12,534 members (out of 20,756 AAOS members) responded to the census. The OPUS 2002 collected information on demographics, practice and professional characteristics, practice payment sources and job satisfaction.

Methodology

Every two years since 1985, the AAOS has conducted a member census survey to update information in its member database. The census allows the AAOS to track changes in surgeon population characteristics, provides data to assist in program and service planning, provides practice demographics for the AAOS Washington, D.C. office and also identifies target candidates for special activities.

The 2002 Orthopaedic Physician Census was administered and processed by Survey and Ballot System, Inc. of Minneapolis, Minn. Data were provided to the AAOS department of information services for incorporation into the member database, and to the department of research and scientific affairs for analysis and reporting.

The OPUS 2002 report is based on data provided by 10,647 board-certified orthopaedic surgeons (drawn from the total 12,534 respondents) currently practicing full- or part-time clinical or non-surgical clinical orthopaedic medicine in the United States, its territories or military posts. This sample of active, practicing orthopaedic surgeons represents 85 percent of members responding in 2002, a ratio that has held steady in surveys since 1988. Other member categories include orthopaedic surgeons who are currently taking fellowships, who work full-time research or administration, and who are retired Fellows.

Demographics

Of the practicing board-certified surgeons who responded to the 2002 census survey, 77 percent were in full-time practice, 21 percent in part-time clinical practice and 2 percent in full-time non-clinical practice. Following are some key demographic findings from the census report.

Gender. In 2002, 3.2 percent of active, board-certified orthopaedic surgeons were women. This is a slight increase over the 2.7 percent reported in 2000. Prior to 2000, gender of respondents was not reported in the biennial OPUS.

Age. The average age of orthopaedic surgeons in 2002 was 50.9 years, with the age of actively practicing orthopaedic surgeons ranging from 31 to 80 years. The median (midpoint) age is 49 years.

The 2002 distribution reflects a smaller proportion of doctors under the age of 35 (0.5 percent) and a higher proportion in all categories age 65 and over than was found in any of the previous four censuses.

The proportion of orthopaedic surgeons age 70 or over who are continuing to practice at least part-time is increasing, and represented nearly 3 percent of the total orthopaedic population in 2002. There was a similar increase among orthopaedic surgeons between the ages of 65 and 70, with a modest increase in the age group 60-to-64.

Geographic age variations. The states with the oldest orthopaedic population are Massachusetts (53.3 years), West Virginia (52.9 years), Oregon (52.5 years) and New York (52.3 years). States with the youngest orthopaedic surgeon population are South Dakota (47.1 years), Wyoming (47.6 years), Puerto Rico (47.9 years) and Indiana (48.8 years).

Community size. More than one-half of orthopaedic surgeons (57 percent) practice in metropolitan areas of one million or more population. Less than 2 percent are found in communities with populations of 100,000 or fewer, with 13 percent in communities of 100,000 to 250,000 population. The balance (29 percent) practice in communities of 250,000 to 1 million in population.

Age by community size. Orthopaedic surgeons under age 40 are most likely to practice in a community with a population of 250,000 or fewer (16%). Doctors between the ages of 50 and 59 are most likely to be found in the very smallest communities (100,000 or less population). Among doctors over the age of 70 still practicing, 70 percent lived in a community of 1 million or more.

Orthopaedic surgeon density. Although a slight dip was seen between 2000 and 2002, the national density of orthopaedic surgeons has been climbing for the past decade. In 2002, the estimated national density of orthopaedic surgeons was 6.1 per 100,000 population. States/areas with the highest density of orthopaedic surgeons per 100,000 population are Montana (10.0), Wyoming (9.9), Alaska (9.6) and Washington, DC (9.6). States with the lowest density of orthopaedic surgeons per 100,000 population are Michigan (4.2), West Virginia (4.3), Mississippi (4.3), Texas (5.1), New Mexico (5.2) and Kansas (5.3).

The distribution of certified, practicing orthopaedic surgeons across the United States, based on nine major census divisions, is similar to that found in 2000. Four regions, each of which includes a very populous state or states, dominate in total share of orthopaedic surgeons. The proportion of total practicing orthopaedic surgeons in each division is:

New England states

7.0%

East South Central States

5.4%

Mid-Atlantic states

14.5%

West South Central States

9.3%

East North Central states

14.3%

Mountain States

7.0%

West North Central states

7.0%

Pacific States

6.5%

Certifications. Among board-certified, practicing orthopaedic surgeons, 6 percent were certified prior to 1970, 24 percent in the 1970s, 26 percent in the 1980s, 36 percent in the 1990s, and 8 percent since 2000.

Nearly one-third (30 percent) report they have been recertified by the American Board of Orthopaedic Surgery. Only 6 percent of these recertifications occurred prior to 1990. The majority (68 percent) occurred in the 1990s; however, 24 percent occurred in 2000 or later.

Only one in 12 orthopaedic surgeons (8 percent) report they have a Certificate of Added Qualification (CAQ) in hand surgery.

Practice and professional characteristics

Among the 10,657 certified, practicing orthopaedic surgeons whose responses were included in the census analysis, three in four (77 percent) currently have a full-time clinical practice of orthopaedic surgery. The majority of the remaining surgeons (21 percent) have a part-time clinical practice. Only 2 percent reported they have a full-time non-surgical clinical practice in orthopaedic surgery.

Solo versus group practice. Overall, only one in four orthopaedic surgeons (24.7 percent) report they practice in a solo practice. The majority (62.7 percent) practice in an orthopaedic group, with a small proportion (12.6 percent) practicing in a multi-specialty group. This distribution has held fairly steady for the past decade.

Orthopaedic surgeons in solo practice are likely to be older than doctors in a group practice (mean age of 54.8 years versus 49.5 years), less likely to have a medical school or teaching hospital appointment than doctors in a group practice (36 percent versus 52 percent), and more likely to be general practitioners rather than specialists (43 percent versus 30 percent of all certified, practicing orthopaedic surgeons).

Size of group practice. The average orthopaedic group practice is six to seven doctors. Overall, one in four group practices (23 percent) had only two or three orthopaedic surgeons in the group, while only 10 percent of group practices reported 18 or more orthopaedic surgeons. Only 1 percent of the members reported a group practice with more than 50 orthopaedic surgeons in the group.

The largest orthopaedic group practice, with 300 orthopaedic surgeons, was reported as an HMO/prepaid plan practice multi-specialty group located in a community of 1 million or more population.

Multi-specialty practices are more likely to be larger than orthopaedic groups. A mean of 10.8 orthopaedic surgeons were reported in multi-specialty practice versus 8.6 in orthopaedic groups.

Specialization trend continues. Since 1990, the proportion of orthopaedic surgeons reporting as specialists has steadily increased, rising from 20.9 percent in 1990/91 to 34.7 percent in 2002/03. Most of this shift results from surgeons moving from general orthopaedic surgery to a specialty field. The increase is coming as more younger orthopaedic surgeons move into specialty areas in greater numbers than in the past. Specialists are also more likely than general orthopaedic practitioners to:

The knee remains top focus. The knee continues to be identified as a focus area by more orthopaedic surgeons than any other anatomical area:

Nearly equal is a focus in arthroscopy:

Top six specialty areas. The top areas of specialty focus are:

Practice setting. The majority of orthopaedic surgeons (80.5 percent) work in private practice. This trend is consistent with past member census reports. The next largest group, 10.5 percent, reported that they work in academic practice. Clinical hospitals and other group practices account for the third largest group at 4.3 percent. The three smallest practice settings were reported by 2 percent or less of respondents: pre-paid plan/HMO practice (2.2 percent), military practice (1.6 percent) and non-military/public entity practice (0.9 percent).

Academic practice. Nearly one in two (48 percent) orthopaedic surgeons report some teaching activity, but two out of three of these appointments are non-paying teaching positions. One in five orthopaedic surgeons (approximately 21 percent) with an academic appointment (approximately one in 10 overall) receives all of his or her salary from a medical school, teaching hospital and/or academic clinical practice. Eight percent received a portion of their income from an academic clinical practice.

Typical hours of practice per week. Orthopaedic surgeons report spending a mean of 59 hours per week on their practice or related activities. They typically practice 46 weeks per year, take four weeks of vacation, and spend two additional weeks outside their office/practice on practice-related activities. The younger the doctor, the higher the number of hours per week likely to be reported on practice activities. Overall, orthopaedic surgeons spend 82 percent of working hours on patient care activities, with the remaining 18 percent spent on other services such as interpreting x-rays, teaching, research and administrative activities.

Non-medical advanced degrees. Approximately one in 25 board-certifired, actively practicing orthopaedic surgeons holds a non-medical advanced degree in addition to their medical deggree. The most commonly held degreee is an MBA, but PhDs in either a general field or a biologicalscience are nearly as common. A very small proportion of orthopaedic surgeons (0.2 percent) hold multiple advanced degrees.

Practice payment sources

Over the past 14 years, private pay income dropped from 39 percent to 15 percent of a surgeon’s total practice income. At the same time, the proportion of practice payment that comes from managed care sources (HMO/capitation, HMO/PPO/IPA) has continued to climb. Since 1988, the proportion of practice revenue coming from managed care has risen from 11.6 percent to 31.7 percent, an increase of 172 percent.

Medicare and Medicaid have risen slightly as sources of overall practice reimbursement, from 26.4 percent to 28.1. "Other" sources of practice payment, with worker’s compensation compromising the greatest share.

About one in five orthopaedic surgeons report that at least 25 percent of their practice revenue comes from a private payor source. On the other hand, 68 percent report at least 25 percent of their practice income comes from a managed care payor source. Nearly 9 percent of orthopaedic surgeons report none of their practice income comes from Medicare/Medicaid, with another 8 percent reporting that Medicare/ Medicaid makes up 10 percent or less of their practice revenue.

Surgeon income. There were 4,448 board-certified respondents in full-time clinical or part-time practice in the United States who reported their income. This group represented 42% of all board-certified respondents in full-time clinical or non-surgical or part-time practice in the United States. Orthopaedic surgeons’ income, in general, is related to age, years in practice and degree of specialization. The highest reported median annual income ($380,000) occurred in the 40-to-49 year age bracket. Data indicated that income peaks in this age bracket and then decreases with increasing age of the orthopaedist.

The 2001 median gross income for all orthopaedic surgeons surveyed was $330,000. Full-time clinical practitioners reported a median gross income of $350,000.

Orthopaedic surgeons with 11 to 20 years of practice reported the highest median income, $370,000.

Orthopaedic surgeons with a specialty interest reported a median income of $350,000. Specialists reported the highest median income ($390,000) and general orthopaedic surgeons reported a median income of $310,000. In general, income increased as the number of hours worked per week increased.

Female orthopaedic surgeons reported a significantly lower median income ($235,000) than did males ($350,000).

Overall, median income did not seem to vary drastically by practice focus. However, those indicating a focus in spine–either adult or pediatric–reported the highest median income, $390,000.

Job satisfaction

Respondents were asked to indicate their level of agreement with eight statements relating to satisfaction with their practices and their lives as orthopaedic surgeons.

Overall, orthopaedic surgeons are willing to give whatever time is necessary to provide patient care. However, many are planning on cutting back on medical activities to spend more time with family who have supported their careers. In fact, they are willing to give up income to have more time for family. Despite some reservations, respondents said that if they were beginning their careers again, they would still choose medicine as their life’s work and orthopaedic surgery as their field of medicine.

Retirement expectations. Orthopaedic surgeons expect to partially retire from surgical practice at 60.5 years (overall mean age), and to fully retire at age 62 on average. Approximately one-fourth (28 percent) of orthopaedic surgeons expect to partially retire from their from surgical practices at age 60, with another 20 percent expecting to partially retire from their practices at age 65. By the age of 65, 90 percent of current, certified practicing orthopaedic surgeons expect to be at least partially retired from surgical practice. Currently, 7.8 percent of AAOS members are partially retired.

In addition to the OPUS 2002, four additional reports were developed from the 2002 census data. They are:

The complete OPUS 2002 and other census reports can be viewed in detail on the AAOS Web site, at www.aaos.org. Click on ‘Library and Archives’ and scroll down to ‘Orthopaedic Practice in the U.S.’ You also can contact the Research Department hotline at (847) 384-4312 or submit a request via e-mail at researchinfo@aaos.org.


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