Thomas P. Schmalzried, MD
Richard C. Johnston, MD, MS
Thomas P. Schmalzried, MD, is associate medical director of the Joint Replacement Institute at Orthopaedic Hospital, Los Angeles, and Chief of Joint Replacement at the Harbor-UCLA Medical Center. Dr. Schmalzried is President of California Orthopaedics and Sports Medicine Associates (COSMA), an all-orthopaedic IPA and musculoskeletal disease management company.
Richard C. Johnston, MD, MS, who has ceased performing hip and knee surgery after 30 years, has a masters degree from Dartmouth in Outcomes, Continuous Quality Improvement and Health Policy and heads his own consulting firm.
Orthopaedic surgery is under continuing attack by the federal government, and private insurance companies have followed this lead to reduce the reimbursement for our services. With a failing Medicare financing system and an aging population, part of the plan for balancing the Medicare budget includes further reductions in the reimbursement for surgical procedures commonly performed on Medicare patients. The disproportionate level of reductions indicate a lack of appreciation for the value of our services to patients and to society. For decades we have been assessing and comparing the results of various treatment methods within the musculoskeletal disease segment. It is now incumbent upon us to demonstrate the value of orthopaedic surgery, to the public and to payers, as compared to the value of other services outside the musculoskeletal disease segment.
Value is the ratio of quality to cost. Trying to combat falling reimbursement with arguments based on value is challenging because both true costs and quality are difficult to measure. Quality is generally considered to be the degree of positivity of an outcome and/or level of satisfaction. Choosing the right measurement of outcome (quality) is important. There is no one best instrument, as the responsiveness (ability to detect changes) of an instrument is disease-dependent. For example, in evaluating the outcomes of total knee replacement, the responsiveness of the SF-36 is not as great as the WOMAC or Knee Society scale. It is critical, however, that we include generic instruments like the SF-36 with our disease-specific instruments so that comparisons can be made with the outcomes of treatments for nonorthopaedic diseases. To demonstrate the true value of orthopaedic surgery we need to compare outcomes across disciplines.
It is ironic but fortuitous for orthopaedic surgery that total hip and total knee replacement have been targeted for further reduction in reimbursement. It is ironic because these interventions have been closely followed since their introduction and the outcomes of these procedures are among the most well-documented. It also is fortuitous because, based on a number of outcome measures, there is a consistent and marked improvement not only in physical function but also in social interaction and overall health, following total hip and knee replacement. Based on outcomes data, there is no rational basis for reducing reimbursement for joint replacement. On the contrary, the data indicates that joint replacement is one of the best values in the medical marketplace.
Because it is publicly-funded, there have been a number of studies within the Canadian health care system to evaluate and compare the cost-effectiveness of various medical interventions. By combining cost data with outcome data, it is possible to calculate the cost per quality adjusted life years (QALY) for any medical intervention. Using this type of methodology, total hip and total knee replacement rank among the most efficacious - if not the most efficacious - interventions and have cost-to-utility ratios similar to the treatment of moderate hypertension, which are dramatically lower than coronary artery bypass for angina, hemodialysis, liver transplantation and the management of HIV. The calculations do not consider the medical costs that would have occurred if the patient had not had total hip or total knee surgery. If this were taken into account, the cost-effectiveness of these procedures would be even greater.
It is rare that decision-makers consider the net reduction in the cost of a disease after treatment but rather concentrate on the cost of the treatment. A more thorough assessment includes consideration of the nonmedical economic impact of the intervention. By allowing the majority of patients to maintain an independent lifestyle, and many to return to gainful employment, orthopaedic procedures result in a net cost savings to our society at large. With the support of health economists, we can demonstrate the cost-effectiveness of orthopaedic surgery from a societal perspective.
There is a common image of orthopaedic surgery as "high-tech" treatment of non-life-threatening disease. However, the impact of musculoskeletal disease on general health cannot be underestimated. Based on SF-36 data, diseases such as rotator cuff tear and adhesive capsulitis have a more severe impact upon a patient's perception of general health than hypertension, acute myocardial infarction, diabetes, congestive heart failure and clinical depression. Further, recent communication from the Medical Outcomes Trust indicates that, based on comparison of SF-36 scores, five of the top 10 most efficacious medical interventions are orthopaedic surgical procedures.
In order to demonstrate the value of orthopaedic surgery, it is important that we all collect outcomes data. If the collection of this data is properly integrated with patient care, it can save time and money rather than increase cost and labor, as is commonly perceived. Patient administration is the only uniform method of data collection. The Academy's MODEMS program contains the essential elements, including a general health measure (SF-12 or 36); an anatomic or disease-specific measure; socioeconomic and co-morbidity data for stratification; and a measure of satisfaction. The key to widespread compliance is the development and implementation of low-cost systems that capture these data during routine office practice.
Outcomes data are central to demonstrating our value to payers and to the public, who are all potential patients. From this perspective, the public can be a powerful ally in support of musculoskeletal care. Outcomes data is a means to protect, and in some instances restore, value in the provision of the service for which we have been uniquely trained, musculoskeletal disease management and orthopaedic surgery.