February 1999 Bulletin

Orthopaedic oncology needs new paths

Plan to cope with intellectual, economic malalignment

By Michael A. Simon, MD and Terrance D. Peabody, MD

Historically, orthopaedic oncology had been the first subspecialty in orthopaedic surgery to interact with other medical disciplines. Through the mid-1970s, there was a diagnostic triad of radiology, pathology and orthopaedic oncology. Later, a therapeutic triad was added to our multidisciplinary effort, which included radiation oncology, medical oncology and pediatric oncology.

The diagnostic multidisciplinary conference changed from a diagnostic to a therapeutic conference with complex treatment algorithms. When compared to other orthopaedic subspecialties, orthopaedic oncology is intellectually, clinically and functionally the most broadly based, multidisciplinary subspecialty of orthopaedics. The question is, has orthopaedic oncology, based on its multidisciplinary nature and apparent diminishing shared interests and relevance to orthopaedic surgery at large, become malaligned from the rest of the field?

Orthopaedic oncology is becoming estranged from the American Academy of Orthopaedic Surgeons. Orthopaedic oncology contributes a smaller and ever decreasing component of the Academy educational activities and a smaller percentage of time allotted to orthopaedic oncology in the scientific sessions. Outstanding leaders in orthopaedic oncology, such as Drs. Mankin, Enneking, Thompson and Mindell, whose prominence in the educational and leadership activities of the Academy, American Board of Orthopaedic Surgery (ABOS), American Orthopaedic Association (AOA) and Residency Review Committee (RRC) outweighed our small numbers, have not been replaced (Figures 1 and 2).

Figure 1:

Orthopaedic oncologists in leadership positions

OrganizationNumber of oncologists/
Number of positions
Names
Academy Executive
Committee
0/16
RRC2/9 Michael Simon, MD;
Mark Gebhardt, MD
ABOS3/19 Michael Simon, MD; Mark Gebhardt, MD; Harold Dick, MD
AOS1/10 Michael Simon, MD
Orthopaedic chairmen5/150 Gary Friedlaender, MD;
B. Hudson Berry, MD;
Michael Simon, MD; James Neff, MD; Dempsey Springfield, MD
AOA Executive
Committee
2/16Joseph Buckwalter, MD;
Dempsey Springfield, MD

Figure 2:

RRC requirements pertaining to orthopaedic oncology

The microscope has disappeared from the examination of the ABOS, and there is a smaller percentage of examination questions on the ABOS certifying examinations concerning oncology. More fundamental is the profound difference in the nature of the patient interaction and the techniques and goals of the management of their patients that is separating the field from the rest of orthopaedic surgery. Thus, it is our opinion that the intellectual relevance of orthopaedic oncology to orthopaedic surgery is diminishing.

In addition, it is the authors' perception that, in the 1990s, the economics of orthopaedic surgery and that of orthopaedic oncology have become disparate. This economic disconnection is of concern for the future. Whereas much of orthopaedic surgery moved to outpatient activity, orthopaedic oncology is still very much hospital-based and, therefore, practices are challenged by the economic and administration risks of the institution. In addition, there have been no significant changes in the Current Procedural Terminology (CPT) coding in the last 10 years. Few, if any, codes apply to the types of procedures that we perform.

In contrast, those orthopaedic surgeons performing spine surgery and sports medicine have had a significant impact in changing and obtaining new codes. When time, intensity of the patient interaction and perioperative morbidity are considered, financial remuneration appears disproportionately high for procedures performed by other orthopaedic subspecialties, compared to those of orthopaedic oncology. Members of the Musculoskeletal Tumor Society (MTS) have been ineffective in influencing policy makers with regard to the issue of reimbursement.

If one looks at the present Medicare fee schedule for selected CPT codes in the Chicago zip codes (Figure 3), one can see that reimbursement for a total hip and knee arthroplasty is almost twice that for a radical resection of a soft-tissue neoplasm of the thigh and 1 1/2 times as great as that for a radical resection of the distal femur. Surgeons performing arthroscopically assisted anterior cruciate ligament repair are reimbursed more than those doing oncologic procedures. Of equal concern, the reimbursement for hip disarticulation is more than that for either radical resections. Obviously, this reflects the influence of the number of arthroscopic and joint replacement surgeons within the Academy.

Figure 3:

Medicare physician fee schedule for selected CPT codes in Chicago

CPTProcedure Fee
29874Arthroscopy, knee,surgical; for removal of loose body or foreign body (e.g., osteochondritis dissecans fragmentation, chondral fragmentation) $638.19
29877Arthroscopy, knee, surgical; debridement/ shaving of articular cartilage (chondroplasty) $678.05
29881Arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving) $710.69
29876 Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (e.g., medial or lateral) $730.32
27592Amputation, thigh, through femur, any level; open, circular (guillotine) $759.91
27590Amputation, thigh, through femur, any level $879.91
27329Radical resection of tumor (e.g., malignant neoplasm), soft tissue of thigh or knee area $1,074.67
27365Radical resection to tumor, bone, femur or knee $1,245.18
29888 Arthroscopically-aided anterior cruciate ligament repair/augmentation or reconstruction $1,268.22
27295Disarticulation of hip $1,469.23
27130Arthroplasty, acetabular and proximal femur prosthetic replacement (total hip replacement), with or without autograft or allograft $1,834.35
27447Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing ("total knee replacement") $1,961.92

If the present fee schedule becomes adopted by all payers, orthopaedic oncology will be so unfeasible economically that clinicians will leave the field. Indeed, it is likely that they are doing so already. The time and effort involved in performing an oncologic procedure, together with preoperative and postoperative counseling, in addition to the stress involved in the practice of the specialty, will force orthopaedic surgeons away from oncology and into outpatient arthroscopy, total joint replacement or spine surgery.

Illustrating the economic impact of professional fees, many of our own prominent orthopaedic oncologists have looked to other methods of economic support besides professional fees. Many of them have become subsidized by hospitals or cancer centers, or they receive other institutional support. An orthopaedic oncologist in a purely professional-fee private-practice group or a professional-fee-based academic department can no longer support his/her own salary by being engaged only in orthopaedic oncology. This results in pressure on the individual to engage other clinical activities outside of oncology. The "end game," we fear, is that we will be "put out of business."

Having led a search for a surgical oncologist at the University of Chicago, we became familiar with a similar situation for breast surgeons. Breast surgery is poorly reimbursed, similar to the numbers we quoted above. Only institutions such as hospitals and cancer centers realize the value of breast surgeons. The value of surgical oncologists, who attract patients to these institutions, is immense because of the amount of income generated by imaging, pediatric and medical oncology, and radiation oncology. These sources of income are distributed to other medical and surgical specialties and to the institution. In our attempt to recruit another prominent orthopaedic oncologist, we learned the same lesson. We were not successful in recruiting that physician because a hospital realized the economic value of the individual to an enterprise and thus outbid us. Department chairpersons more than realize these economic realities.

To try to cope at least partially with this intellectual and economic malalignment, we make the following recommendations. If the leadership and rank and file of the MTS do not want to allow other specialists to join our organization, then we suggest, at least, that we have combined meetings with the Connective Tissue Oncology Society (CTOS). The MTS has remained almost exclusively an orthopaedic surgery organization. However, international organizations such as the European Musculoskeletal Tumor Society, and now, in North America, the CTOS, are truly multidisciplinary, including radiation therapists, medical and pediatric oncologists, basic scientists, pathologists and radiologists. Thus, unless we participate in these organizations, we will continue to be isolated intellectually from the very physicians with whom we interact with on a day-to-day basis. Furthermore, we suggest that orthopaedic oncologists join the CTOS so that we can have an impact on the direction of the organization.

Second, we suggest that our members join other multidisciplinary oncology organizations such as the American Society of Clinical Oncology (ASCO) and the Society of Surgical Oncologists (SSO). We should not look upon general surgeons as our competitors, but rather as our allies. We should join forces with other surgical oncologists in trying to educate policy makers about the relative value of the complex kinds of surgical procedures that we perform.

Third, we should develop interest and expertise in skeletal metastases and melanoma of the limbs. The number of bone and soft-tissue sarcomas is relatively small, and they are not perceived as a major public health hazard. Bone metastases, on the other hand, are a significant health issue and involve many other medical specialists. Therefore, we should actively enlarge our scope of oncology practice.

Fourth, although we have all been trained in and are initially intellectually-related as orthopaedic surgeons, our day-to-day practice of medicine forces us to have clinical relationships with other physician oncology specialists. If the organization that we belong to is entirely professional-fee-based, we need to look elsewhere for economic support. Chairpersons have to find support from hospitals, cancer centers, health systems or other institutional models for their clinical activities. The MTS should provide an economic road map for negotiating with such entities to demonstrate our value to, a health care delivery enterprise.

Fifth, orthopaedic oncologists need to have leadership positions in national orthopaedic surgery organizations. The MTS needs to have leaders in the Academy, otherwise we will never have an impact on CPT codes.

Sixth, individuals should consider becoming members of a cancer hospital or functional cancercenter, where their expertise is appreciated. Lastly, we should become chairmen or leaders of administrative entities, where we can protect our position and justify our existence.

It is our opinion that if we fail to be intellectual and economical partners with other oncology specialists while also becoming leaders in orthopaedic surgery organizations, our specialty will become isolated and irrelevant, and possibly will disappear.

Michael A. Simon, MD, is professor and chairman, section of orthopaedic surgery and rehabilitation medicine, University of Chicago; and Terrance D. Peabody, MD, is assistant professor, section of orthopaedic surgery and rehabilitation medicine, University of Chicago.


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