January 1996 Bulletin

Work group urges 'summit,' education

Report funds need for more team work, new image

An "environmental assessment" of the evolving health care delivery system by an Academy work group has recommended a five-part strategy to respond to evolving musculoskeletal care systems and strengthen the capabilities of orthopaedic surgeons to meet the challenges ahead.

Last August and September, the Work Group on the Role of Orthopaedic Surgeons in Future Delivery Systems, headed by Douglas W. Jackson, MD, contacted 28 managed care organizations, including 25 medical directors and 19 orthopaedic surgeons. The goal was to increase the Academy's understanding of the current and future role of orthopaedists as providers of musculoskeletal care in evolving integrated delivery systems.

Emphasizing that the report was not an endorsement of the growth of managed care, capitation, nor managed care organizations in the care manager model, Dr. Jackson presented 16 key findings of the work group to the Board of Directors on Dec. 8, 1995.

Clearly impressed by the scope of the report, the directors heard Dr. Jackson stress the need for more team work among musculoskeletal providers, a renewed focus on the changing market demands, the need to demonstrate abilities necessary for success in the managed care marketplace, and a new "customer service" oriented, team-player image.

"Managed care often looks at orthopaedic surgeons as pilots, but they want team players," Jackson said. (Richard Kyle, MD, later described orthopaedists as "fighter pilots.")

Dr. Jackson said orthopaedic surgeons traditionally want to be in surgery most of the time, while managed care wanted them to provide more ambulatory care. "We have to define what we want to be," Dr. Jackson said. "If we want to be more relevant to patient care in managed care settings, we may need to be in the clinic more often."

The findings of the work group suggested a need for orthopaedic surgeons to assume new leadership positions in multispecialty groups, be more effective in their role as educators, and a need for continued knowledge of how the market is behaving.

Bridge building, externally and internally, was a keystone of the work group's recommendations. Their report urged that the Academy sponsor and/or stimulate an external summit of musculoskeletal providers to address patient care to populations under managed care, to develop a shared forum, and to plan for future communication and interaction among musculoskeletal physicians and other providers.

The work group also urged that the Academy develop mutually beneficial education programming with primary care and other first contact providers at regional, local, and on-site locations.

At the same time, the Academy should continue to educate practicing orthopaedic surgeons about the growth of managed care, changes in the private health care sector, and their current and future impact on orthopaedic practice.

To prepare future generations of orthopaedic surgeons, the Academy should influence their graduate medical education in ways that will prepare them for the evolving delivery system and changing roles of orthopaedic surgeons.

And to stay current with the evolving environment, the work group recommended the Academy should track, analyze, and interpret the growth of managed care and the evolution of health care delivery networks, groups, and systems nationally and regionally. The Academy should critically address the impact of these changes on urban, suburban, rural, and academic orthopaedic practice and communicate this information quickly and effectively to Academy leadership and the fellowship.

The directors approved the report in principle and told Dr. Jackson to submit specific methods to implement its recommendations at the February Board of Directors meeting.

Dr. Jackson prepared the directors for a review of the key findings of the work group, by stressing it was a "snapshot" view of the marketplace, not the result of a scientific study. What the directors heard was sobering, but not pessimistic.

The work group found that some orthopaedists working in managed care are often content to give up minor foot procedures to podiatrists. Managed care organizations were moving to a comprehensive multidisciplinary back care approach for patients, only a small percentage of whom required surgery. They heard hand care was being done by orthopaedic surgeons, but fellowship-trained hand surgeons were not in demand in these evolving systems.

David Mauerhan, MD, pointed out that the findings were referable to areas where managed care is mature; that there are many opportunities for orthopaedists in other areas where managed care is not entrenched. Dr. Mauerhan and other directors praised the report for pointing out opportunities that could be exercised to influence the environment.

The key findings of the work group were:

Scope of musculoskeletal practice Current managed care organizations are interested in finding orthopaedic surgeons to provide nonoperative and outpatient ambulatory musculoskeletal care. The ratio of traditional, surgically-oriented orthopaedic surgeons to 100,000 lives will decrease, particularly in the urban and suburban areas in the moderately- to highly-penetrated managed care regions.

Foot care Orthopaedists working in managed care organizations are willing to have foot problems triaged to podiatrists. The podiatrists are perceived as offering greater "customer service," with lower utilization of resources in a capitated setting.

Hand care The vast majority of managed care patients with hand complaints are being cared for by orthopaedic surgeons, but fellowship-trained hand surgeons are not in demand. A ratio of one hand surgeon per 100,000 enrollees has been quoted, which explains why difficult and complex hand injuries are often outsourced. General orthopaedists are currently performing carpal tunnel and other common hand procedures. The trend indicates that MCOs are meeting their patients needs with "generalists with an interest in hand problems."

Back Care Back care will be provided, increasingly, by "back care teams," including family practitioners, osteopaths, chiropractors, physiatrists, physical therapists, orthopaedic surgeons, neurologists, and neurosurgeons. The orthopaedic surgeon may or may not choose or be chosen to head up this team.

Carve outs As managed care organizations grow in size, consolidate, and find ways to provide medical services more cost-effectively "in-house" than under contractual relationships with outside providers, the use of widespread carve outs will diminish.

Physician assistants and nurse practitioners The use of physician assistants and nurse practitioners is likely to increase because they are perceived in other areas of managed care as providing more education to patients, able to increase patient satisfaction, and helpful in controlling utilization.

Communications with primary care providers/referral patterns Open and easy communication that fosters the timely, appropriate exchange of patients and patient information between primary care providers and orthopaedists will be essential for the success of orthopaedists in managed care organizations regardless of system or payment method.

Guidelines and algorithms Managed care organizations, as they evolve and mature, will seek guidelines and tools to measure and improve quality, control costs, and manage utilization of resources. They are unlikely to embrace guidelines and algorithms developed by individual specialty societies and providers whose incentives and treatment philosophies differ from theirs.

Capitation Capitation will play an increasing role and it will fundamentally change orthopaedic practice. Utilization review for over-utilization will change to quality assurance (commission versus omission).

Provider-owned and -driven organizations Multispecialty networks (group practice models) seem well positioned to take on large capitated contracts. They may be better positioned than single specialty groups in the changing marketplace. Orthopaedic surgeons will be able to participate and be stakeholders in the physician group (the "medical components") of future delivery systems.

Selection and retention Managed care organizations will select "team players" among the orthopaedic work force, known and liked by their primary care providers, with the needed clinical talent, desirable geographic coverage, in good standing, board certified, agreeable to payment methods, who "buy into the system," and who will help the organization to achieve its targets in quality management, resource utilization, and patient satisfaction.

Satisfaction of orthopaedists Some orthopaedic surgeons, practicing in large medical group models, say they are satisfied with their professional lives within managed care. Their reasons include less administrative hassle, more reasonable hours, the volume and quality of orthopaedic work they are doing, and good communication among administrators and other providers in the system.

Dissatisfaction of orthopaedists On the other hand, many orthopaedic surgeons, with any number of discounted fee-for-service contracts, are dissatisfied with a general loss of autonomy, lack of control over patient care decision, reduced incomes, and increased administrative hassle.

Open versus closed panel The number and size of open panels will diminish as managed care organizations become more selective. Networks of providers will consolidate as managed care market penetration increases, and more physicians will be at risk for care to populations.

Point-of-service Point-of-service appears at this time to be desirable to patients, and MCOs use them to attract enrollees. They will not fulfill some orthopaedists' hopes for increased or sustained access to specialist care outside of the MCO. MCOs will, increasingly, see use of this option as a failure of their systems and will take greater steps to keep patients in the network.

Education Managed care organizations will expand their in-house medical education programs. They will need a combination of science-based and practice management offerings, tailored to the needs of their providers and goals of their respective systems. There will be more limitations on education dollars for orthopaedists.

In other findings, the work group said orthopaedic surgeons moving from traditional fee-for-service to full or part-time practice under contract or salary to managed care organizations are likely to experience: lower net incomes; decreased "job" security; a different practice focus-more nonsurgical musculoskeletal care or increasingly technical work; more team work, less independence; and new working relationships with other musculoskeletal providers.

Focusing on the Academy, the work group said it will need to face the challenges of a more diverse membership. The Academy will need to monitor committees and councils to ensure that they are composed in ways that are sensitive to these changes and address these diverse issues. The Academy will need to focus on a membership at various points along the "change curve," and in different reimbursement and practice situations.

The work group said the Academy will need to determine its role and educational mission with and for nonorthopaedic surgeon musculoskeletal providers. The Academy will need to meet the advocacy needs of a membership with diverse, and at times, conflicting interests.

Members of the work group are Dr. Jackson; James Breivis, MD; D. Kay Clawson, MD; Paul Collins, MD; Richard F. Kyle, MD; David R. Mauerhan, MD; Gilbert Shapiro, MD; Jeffery B. Husband, MD; Terry L. Whipple, MD; and Walter B. Greene, MD.


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