Workforce, Work, and Advocacy Issues in Pediatric Orthopaedics

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1 This is an enhance PF from The Journal of Bone an Joint Surgery The PF of the article you requeste follows this cover page. Workforce, Work, an Avocacy Issues in Peiatric Orthopaeics Steven L. Frick, B. Stephen Richars, Stuart L. Weinstein, James H. Beaty an J. Michael Wattenbarger J Bone Joint Surg Am. 2010;92:31. oi: /jbjs.j This information is current as of ecember 10, 2010 Reprints an Permissions Publisher Information Click here to orer reprints or request permission to use material from this article, or locate the article citation on jbjs.org an click on the [Reprints an Permissions] link. The Journal of Bone an Joint Surgery 20 Pickering Street, Neeham, MA

2 e31(1) COPYRIGHT Ó 2010 BY THE JOURNAL OF BONE AN JOINT SURGERY, INCORPORATE AOA Critical Issues Workforce, Work, an Avocacy Issues in Peiatric Orthopaeics* By Steven L. Frick, M, B. Stephen Richars, M, Stuart L. Weinstein, M, James H. Beaty, M, an J. Michael Wattenbarger, M The subspecialization of the orthopaeic surgery profession has le to a ivision of work; competition among orthopaeic subspecialties with regar to grauating resients seeking fellowships an patients seeking care for problems involving ifferent subspecialties; potential splintering of the profession regaring reimbursement an avocacy initiatives; anisagreement about the role, responsibilities, an work of a so-calle general orthopaeic surgeon. The issues of cost an access are now prominent in the ongoing health-care reform iscussions an pening legislation, an legislative ecisions may profounly impact patients an physicians. This symposium reviews how these issues are affecting peiatric orthopaeics. Peiatric Orthopaeic Workforce Issues In a survey at the 2007 Annual Meeting of the American Orthopaeic Association 1, 59% of the auience consiere peiatric orthopaeic surgery to be the most unersupplie subspecialty. Trauma was a istant secon at 17%, an oncology was thir at 8%. The reasons consiere for the perceive unersupply inclue the buren of taking peiatric trauma call, meicolegal liability risks that may exten for many years, the lower pay ifferential compare with other orthopaeic subspecialties, too much nonoperative time, anealing with parents. Toay, this perception remains. But is peiatric orthopaeics *This report is base on a symposium presente at the Annual Meeting of the American Orthopaeic Association on June 11, 2009, in Bonita Springs, Floria. unersupplie at the present time an, if so, why? Statistics from the Annual Meeting of the Peiatric Orthopaeic Society of North America (POSNA) in May 2009 showe continue growth, with 807 members in the Unite States, sixty-four members in Canaa, an seventy-six members from the remaining countries worlwie 2. Of the North American POSNA members, however, many have retire or will o so in the next several years. As almost 20% of the members have senior status, 80% of the 871 North American POSNA members can be consiere full-time peiatric orthopaeic surgeons. o these 648 U.S. an forty-nine Canaian full-time practicing peiatric orthopaeic surgeons represent a sufficient number to provie orthopaeic care for the peiatric population among the 305 million citizens in the Unite States an the thirty-three million citizens in Canaa? POSNA continues to stuy this issue an to work to attract resients to peiatric orthopaeics as a career choice. In 2006, the Association of American Meical Colleges (AAMC) recommene a 30% increase in meical school enrollment by 2015 to prevent an expecte physician shortage 3. Others believe the future orthopaeic workforce will be insufficient to care for the growing population 4,5. Each year, 650 to 670 resients enter into, an grauate from, allopathic orthopaeic resiency programs, an 3% to 4% of grauates pursue peiatric orthopaeic fellowships. Thus, twenty to twentyseven peiatric orthopaeic fellowship positions are usually fille each year. Recently, there has been increase interest, best illustrate by the 2009 peiatric orthopaeic fellowship inter- isclosure: The authors i not receive any outsie funing or grants in support of their research for or preparation of this work. Neither they nor a member of their immeiate families receive payments or other benefits or a commitment or agreement to provie such benefits from a commercial entity. J Bone Joint Surg Am. 2010;92:e31(1-6) oi: /jbjs.j.00333

3 Peiatric Urgent Orthopaeic an Trauma Care In the past, peiatric orthopaeic fellowships offere training focuse primarily on complex elective conitions such as spinal eformity, hip ysplasia, clubfoot, skeletal ysplasia, an limb eformity. Less emphasis was place on acute-care peiatric orthopaeics, such as trauma or infection, because these were regularly aresse by general orthopaeists in the community. Changes in practice an referral patterns, as well as societal esires for subspecialist care, have calle into question which patients nee to see a peiatric orthopaeic surgeon. In many areas now, community orthopaeists are less comfortable with the care of urgent peiatric orthopaeic problems an more reaily seek to refer the patients, resulting in increasing pressure on peiatric orthopaeic practices to o work that was once consiere to be in the realm of the general orthopaeist. Further, the emergence of peiatric trauma referral centers has facilitate the ease for trauma referrals from outsie community hospitals, increasing the nee in referral centers for peiatric orthopaeists focusing more on acute-care trauma an infection 7,8. Kasser stuie supraconylar fractures in New Englan an foun that, in 1991, 63% of supraconylar humeral fractures were treate by general orthopaeists, while 37% were treate at centers with peiatric orthopaeic subspecialists available 8. In 2004, this change, with general orthopaeists caring for only 32% of peiatric supraconylar fractures. In California, Hennrikus et al. showe that, from 1996 to 2004, the number of trauma cases one by peiatric orthopaeists in a single hospital increase almost ninefol 9.Inthissame eight-year perio, with the number of clubfeet treate use as a marker of peiatric population growth an of complex elective peiatric orthopaeic referrals, no substantial changes in the number of patients treate was note 5. A recent stuy foun that fracture care may account for half of the workloa for an urban peiatric orthopaeic practice 7.Suchapracticemay benefit from an increase in physician exteners, primarily nurse practitioners or physician assistants 10. Trauma is the leaing cause of eath anisability in the peiatric population: more chilren between the ages of one an fourteen years ie of injury-relate causes than all other causes combine 11. Some stuies have ocumente that injure chilren have higher survival rates when treate at peiatric centers rather than at ault level-i trauma centers Peiatric trauma emergency epartments, however, face the same ifficulties as their ault counterparts: increases in patient volume, the number of unerinsure patients, an liability concerns, with ecrease numbers of orthopaeists on call an lower reimbursements for emergency epartment services. In the U.S., an estimate seventeen million chilren younger than fifteen years of age o not have access to a peiatric trauma center within one hour of travel time 11. In aition to the issues of access to care for chilren with life-threatening multisystem injuries, the lack of peiatric trauma centers can create access problems for patients to receive care for isolate fractures, as many communities withe31(2) view process, which resulte in forty-eight positions being fille for the fellowship year. To enhance opportunities for peiatric orthopaeic fellowship training, a new formal match process for fellowships began in September 2009 for the fellowship year. Possible explanations for the increase interest are (1) a greater unerstaning by resients of a peiatric orthopaeic surgeon s career, mae possible in part by scholarships to the annual International Peiatric Orthopaeic Symposium in Orlano, Floria (provie by POSNA, the Shriners Hospitals for Chilren, an grants from inustry); (2) mentoring in resiency programs substantially impacts career choices, an earlier exposure to peiatric orthopaeic rotations in some programs allows contact with influential faculty; (3) recent recognition of esirable subspecialization opportunities within peiatric orthopaeics, such as spinal eformity, sports meicine, an han surgery; an (4) the eman for peiatric subspecialists by practices, epartments, an hospitals has increase, resulting in attractive employment packages. To assess the balance between retiring an new peiatric orthopaeic surgeons, POSNA has assesse the expecte length of a professional career, population growth, an the evolving changes in the professional lifestyle of a peiatric orthopaeic practitioner. Consiering that an average peiatric orthopaeic career extens approximately thirty-four years (beginning at an average age of thirty-one at the conclusion of training an ening with retirement at the age of sixty-five), POSNA estimates that maintaining a steay state of the current supply of North American practitioners woul require twenty to twenty-two grauating fellows every year. Another consieration on the supply-sie projection is the evolving emphasis on lifestyle preferences by young physicians, which may ecrease the effective workforce, as work-sharing opportunities an jobs with fewer uty hours are sought. The eman for peiatric orthopaeic expertise is likely to increase, combining population growth with societal expectations for easily accessible subspecialty experts. Thus, POSNA estimates an aitional eight to ten peiatric orthopaeic fellowship grauates may be neee each year over the next twelve years to accommoate these growth projections an lifestyle changes in practice. The economic ownturn in 2008 to 2009 aversely affecte charitable peiatric orthopaeic institutions, especially the Shriners Hospitals for Chilren system. The Shriners system employs more peiatric orthopaeic surgeons than any other institution in North America, with over 370 orthopaeic surgeons on the Shriners meical staffs. In July 2009, at the annual national Shriners convention, the organization ecie on a new irection by agreeing to accept thir-party reimbursement as a metho of cost recovery. Current plans call for all twenty-two North American Shriners Hospitals to remain open, although some may become outpatient care centers 6, an some will begin billing professional fees. Reorganization of the meical staffs from Shriners Hospital employment status to university faculty in some locations will facilitate changes. This evolving situation may have substantial workforce effects an will be followe closely by POSNA.

4 Avocacy for Peiatric Orthopaeic Issues Of the 824,000 physicians currently in the Unite States, only 2.4% are practicing orthopaeic surgeons an only 3% of these orthopaeic surgeons are peiatric orthopaeic surgeons (0.07% of practicing U.S. physicians). In aition to the AOA an AAOS, POSNA an the Scoliosis Research Society (SRS) are the two primary professional organizations that peiatric orthopaeic surgeons rely on for eucation an avocacy. As POSNA an SRS are small in size, their avocacy resources are limite. In 1997, the Acaemy forme a 501(c)6 organization, the American Association of Orthopaeic Surgeons, to become more active in avocacy on behalf of all of the Boar of Specialty Societies that make avocacy a part of their mission, incluing POSNA an SRS. In 1999, the AAOS forme the AAOS Political Action Committee (PAC). The PAC is the vehicle that avances the legislative agena of the AAOS an the specialty societies. The AAOS PAC is the number-one fune meical specialty society PAC in America 24, an through connections to peiatric orthopaeic surgeons via membership or specialty societies, is the primary vehicle for political avocacy for peiatric orthopaeic issues. Some of the main avocacy issues for peiatric orthopaeic surgeons inclue reimbursement uner Meicai an other government programs; the Meical Liability Reform initiative an its effect on practice an recruiting; evice evelopment an approval; an general peiatric-specific health-care issues, such as obesity, wellness, isease an injury prevention, an school screening for scoliosis, to name a few. The Presient, the Unite States Congress, an the American public care about health-care issues for chilren, which was evience by the reauthorization of the Chilren s Health Insurance Program (CHIP) as the first accomplishment of the Obama aministration an the 111th Congress 25. In aition, the health-care reform legislation passe in 2010 will have as yet unetermine effects on health-care resources an access for chilren. Of the seventy-four million chilren currently in the U.S. 26, thirty-six million are on Meicai an CHIP, an eight million chilren are uninsure 27. Thus, 60% of the peie31(3) out a peiatric trauma center o not have peiatric orthopaeists. If general orthopaeic surgeons are unwilling to provie care for isolate musculoskeletal injuries in chilren, the patients an families have to travel long istances for peiatric fracture care, even for simple fractures. Orthopaeic trauma work often comes at inconvenient times an involves patients for whom the treatment is linke with poor reimbursement 7, Historically, taking emergency epartment call was a way to buil a practice base, an the financial loss incurre by caring for unerinsure or uninsure patients was offset by the number of insure (so-calle private) patients gaineuring call. Also, taking emergency call was part of professionalism in practice, a way of giving back for the privilege of practicing meicine. A 2008 survey of members of POSNA reveale that most responents (77%) continue to believe that taking trauma call is an integral part of being a peiatric orthopaeist, but a number of reasons for not wishing to take emergency epartment call were also cite: isruption of lifestyle, inaequate compensation, isruption of elective practice, high volume of unerinsure patients, increase liability risks, inaequate training to manage complex trauma, an the inpatient trauma practice versus outpatient practice setting 19.Thesurvey also note that many cite trauma coverage as the main reason for early retirement 19. This may be an inication that the increase trauma eman has le to lifestyle issues for many peiatric orthopaeic surgeons, not just as a career ecision factor for resients. isruption of the elective practice of an orthopaeist is a major factor in the reluctance to be on call for the peiatric emergency epartment. Many on-call surgical proceures are one the same night as the emergency epartment visit, while others occur the next ay or later in the same week, which can isrupt the elective surgery an clinic scheules. Not only o emergency epartment-generate surgical proceures conflict with normal surgery an clinic scheules, but these proceures often are inaequately compensate because of the large numbers of unerinsure or uninsure patients seen in the peiatric emergency epartments. A to these factors the increase liability risk inherent in the extene perio of the statute of limitations for chilren in many states, an it is clear why many orthopaeists may see peiatric emergency epartment call as a so-calle lose-lose situation. Of those responing to the POSNA survey, only 28% were receiving aitional compensation for taking emergency epartment call. Call compensation range from $100 to $2000 per night on call, with $1000 the most common rate 19. Whether this compensation is aequate or appropriate is ebatable. Other suggeste plans for call coverage reimbursement inclue a so-calle activation fee, which is pai to the physician each time he or she is calle to the emergency epartment; a subsiy for uninsure patients base on a set percentage of Meicai- Meicare reimbursement; or a subsiy for malpractice insurance. One potential solution to the reimbursement issue is to make hospitals aware of the value of call coverage an the possible financial benefits to the institution. Several stuies have ocumente financial an logistic benefits to hospitals that have committe to proviing orthopaeic trauma care 20-22, an these benefits also may accrue to hospitals with peiatric emergency epartments. In 2006, the Orthopaeic Trauma Association (OTA) an American Acaemy of Orthopaeic Surgeons (AAOS) release position statements on emergency call coverage by orthopaeic surgeons. Some recommene components were fune call pay, the provision of milevel proviers, an operating-room availability. Althausen et al. showe that, when these provisions have been met by the hospital, it is possible to have an economically viable orthopaeic trauma program at a level-ii regional hospital 23. Increasingly, hospitals will nee to provie the same support to the subspecialists proviing peiatric orthopaeic trauma care as is one in other areas, such as neurosurgery, ault trauma surgery (incluing orthopaeics), an han surgery, if they expect to attract an retain quality peiatric orthopaeists.

5 e31(4) atric orthopaeic population is either on a government program or uninsure. Reimbursement uner Meicai an CHIP is thus critical to peiatric orthopaeic surgeons 28. Meicai uses public ollars to buy services, often in the private health-care sector, an has a efine benefit package. The contribution to state bugets from Meicai alone is 44% of all feeral funs appropriate to states an is the single largest source of feeral funs to each state 29. Overall, the feeral government funs 57% of Meicai spening. As states must balance their bugets, Meicai presents a substantial challenge. The most common way that states eal with controlling costs uner Meicai is to cut physician reimbursement. Thus, the average reimbursement is only 69% (range, 29% to 108%) of Meicare rates. In theory, patients with Meicai coverage shoul have a very goo health-care package. In reality, the low reimbursement pai to physicians results in access problems for Meicai patients. In Michigan, for example, an article in The Wall Street Journal note that treatment uner traitional Blue Cross insurance plans for a broken arm reimburse the physician at $416.50, an physicians caring for patients uner Meicare receive $357.58, while the reimbursement for patients uner Meicai totale only $ Stuies by Skaggs et al. ocumente the lack of access experience by Meicai patients for peiatric orthopaeic care The main issue thus create for chilren covere by Meicai an CHIP is access to care, which le the AAOS to take an aggressive stance with a position statement on existing government programs specifically ealing with Meicai an CHIP 31. The AAOS has also avocate for Meicai reimbursements to physicians to be at least equal with Meicare rates. Meicare reimbursement itself is flawe. While the AAOS continues to avocate for a fix to Meicare s flawe formula for physician reimbursement, it is critical for future access to health care for chilren that, in any health-care paraigm that evolves, Meicai shoul have parity with Meicare. Physician concerns about meical liability issues continue, with the key concerns being the contributions to poor access to care an rising health-care costs an their effects on meical stuent an resient career choices. In a recent survey of resients finishing their training in Pennsylvania, 81% state that they viewe every patient as a potential malpractice lawsuit, 33% state that they were less cani with their patients than they once were, 67% state that they were less eager to practice meicine than they once were, an 28% regrette choosing meicine as a career 32. One of the reasons often cite by senior resients for not choosing a career in peiatric orthopaeic surgery is the long-term meical liability concerns 5. A recent article looke at the interstate variability of the statute of limitations for meical liability an note that, in most regions, peiatric practitioners face increase liability risk base on substantially longer statute-oflimitation perios for minor patients, which in some cases last until the patient is twenty-three years of age 33.Meical liability reform is thus a major avocacy issue for peiatric orthopaeics. Practice Management an Peiatric Orthopaeics The POSNA Workforce Committee note that POSNA is an aging organization an that until recently orthopaeic resients were less likely to go into peiatric orthopaeics 1,5. Although many reasons were given by resients for not choosing peiatric orthopaeics, two major reasons were concerns about compensation an lifestyle 5. These areas are critical to career an life satisfaction among practicing orthopaeists also, as compensation an call issues are frequently the most ivisive issues facing practice leaers in groups anepartments. Some attempts at benchmarking prouctivity have foun the work relative value units (wrvus) prouce by peiatric orthopaeic work to be less than those of ault orthopaeists. When separate out by orthopaeic subspecialties, peiatric orthopaeists ha lower average annual wrvus than i foot, trauma, sports meicine, han, joint, shouler an elbow, an spine orthopaeic surgeons 34. The wrvus for frequently performe peiatric orthopaeic proceures accoring to Common Proceural Terminology (CPT) coes are often less than those for commonly performe proceures in aults. Thus, peiatric orthopaeists may see more patients on an outpatient basis 35, may have similar or greater numbers of call shifts, an may perform similar numbers of proceures as ault orthopaeic surgeons, yet the iscrepancy in wrvus per performe CPT coes can result in lesser annual wrvus. In the practice group of one of the authors (J.M.W.) with over fifty orthopaeists, the peiatric orthopaeists generate only 80% of the wrvus of the practice average in No physician in peiatric orthopaeics generate >85% of the average wrvus of the group. Other surveys have foun the wrvus for peiatric orthopaeists to be similar or slightly higher than general, foot, han, an trauma orthopaeic specialists but less than hip, spine, an sports meicine specialists. espite similar wrvus, peiatric orthopaeic physicians have a lower average compensation than other subspecialists 35. Because of a limite sample size of peiatric orthopaeic surgeons for these surveys, the information may not be accurately generalize. The methoology of some prouctivity an salary information can also vary between reports, as some use survey ata rather than so-calle harata pulle from practice or epartmental billing an accounting atabases 34. As note above, reimbursement for the meical care of chilren is frequently less than that for aults, particularly from government payers. Another factor for orthopaeic surgeons has been the shift in reimbursements from specialists to primary care proviers by Meicai 36.espitethis,salariesfor peiatric orthopaeists have been increasing. Between 2003 an 2006, the average salary for peiatric orthopaeists increase approximately 35% 35. What woul lea to such a large increase? Increasingly, physicians are relying on other forms of income for compensation outsie of irect patient care. These sources of income inclue pay for call coverage, service line agreements with hospitals, an income from practice ancillaries such as physical therapy, raiographic imaging stuies, urable meical equipment sales, an ambulatory surgery centers. For the peiatric orthopaeists employe by hospitals, it

6 e31(5) coul be that the market was reacting to a perceive shortage of peiatric orthopaeists, with a commensurate increase in salary for peiatric orthopaeists as eman rose for their services at hospitals. There may also have been an increase along with those in other orthopaeic subspecialties, as salaries in all areas of orthopaeics have increase in the past few years. Increasingly, mi-level proviers are playing an important role in peiatric orthopaeic practices. In many cases, they are able to see chilren with more simple orthopaeic problems, allowing more patients to be seen in a practice, while ecreasing the workloa of the peiatric orthopaeic surgeon. For many practices, mi-level proviers are able to generate income, another potential metho leaing to increase salaries for peiatric orthopaeists 10. Given the financial pressures of fee-for-service practice, with increasing costs anecreasing reimbursement for irect patient care, peiatric orthopaeists may not survive in the private practice moel. Compare with other orthopaeic surgeons, they see a much higher percentage of Meicai patients an generate fewer wrvus than their counterparts. If other group members o not share the call coverage responsibilities with their peiatric partners, the combination of lower salary an the averse impact of peiatric call coverage on lifestyle may lea peiatric orthopaeic surgeons to seek employment in other venues. Looking Forwar There has been a recent increase in the number of applicants for peiatric orthopaeic fellowships, which it is hope will provie an aequate workforce to eliver access to quality care for peiatric patients. Changing physician practice patterns an expectations from patients families an referring physicians has blurre the efining line between peiatric conitions care for by general orthopaeic surgeons an those neeing fellowship eucation an/or subspecialty expertise. Recent healthcare reform legislation is expecte to have substantial effects on peiatric orthopaeics, as many more chilren in the U.S. are expecte to have government-backe health care. These issues will be tracke carefully by leaership from the AOA, POSNA, an AAOS. Steven L. Frick, M epartment of Orthopaeic Surgery, Carolinas Meical Center, 1616 Scott Avenue, Charlotte, NC aress: steven.frick@carolinashealthcare.org B. Stephen Richars, M Texas Scottish Rite Hospital, 2222 Welborn Street, allas, TX aress: steve.richars@tsrh.org Stuart L. Weinstein, M epartment of Orthopaeic Surgery, University of Iowa, 200 Hawkins rive, Room JPP, Iowa City, IA aress: stuart-weinstein@uiowa.eu James H. 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