- Email: [email protected]
Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons
Accepted Manuscript Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons Jay R. Lieberman, M.D., Gregory Polkowski, M.D., Craig Della Valle, M.D. PII:
S0883-5403(16)30120-6
DOI:
10.1016/j.arth.2016.04.021
Reference:
YARTH 55147
To appear in:
The Journal of Arthroplasty
Received Date: 15 April 2016 Accepted Date: 21 April 2016
Please cite this article as: Lieberman JR, Polkowski G, Della Valle C, Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons, The Journal of Arthroplasty (2016), doi: 10.1016/j.arth.2016.04.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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ACCEPTED MANUSCRIPT
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Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons
M AN U
Jay R. Lieberman, M.D.
Gregory Polkowski, M.D.
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Craig Della Valle, M.D.
ACCEPTED MANUSCRIPT
Abstract: A survey was conducted at the 2015 annual meeting of the American Association of
2
Hip and Knee Surgeons to determine current practice management patterns among its members.
3
The purpose of this article is to summarize the audience responses to a number of different
4
questions related to type of practice, use of physician extenders, potential sources of ancillary
5
income, consulting activity, involvement in bundled payment contracts and the use of the
6
electronic medical records.
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Over the past decade total joint arthroplasty surgeons have developed various practice
25
management strategies in response to the changes in health care laws, various government
26
regulations, an increasing overhead burden combined with declining reimbursements. In order to
27
gain more knowledge regarding the present practice patterns of total joint arthroplasty surgeons a
28
survey was conducted at the 2015 annual meeting of the American Association of Hip and Knee
29
Surgeons (AAHKS) to delineate specific practice management strategies among AAHKS
30
members. Our goal is to use this information not only to educate AAHKS members and the
31
orthopaedic community but also to compare the results of the survey with a previous survey
32
performed in 2011. In addition, the information obtained from this survey can be used to
33
compare the results of future surveys to better understand changes in total joint arthroplasty
34
practices over time.
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35
Materials and Methods
37
This survey was conducted by the session moderator (JRL) during the annual AAHKS meeting.
38
A series of practice management issues were reviewed with AAHKS members who were at the
39
meeting. A survey of practice patterns have been previously performed at the annual meeting in
40
2011 and a similar format was used for this survey. [1] The survey contained both yes and no
41
and multiple choice questions. A handheld audience response system (ARS) was used by
42
audience members. The ARS allows each audience participant to select one response to each
43
particular question. The audience was given 10 seconds to respond to each question. During the
44
survey the audience responses were collected in a central data bank and the results were
45
displayed for the audience to review immediately after the questions were answered. Since the
46
answers were provided in percentages they were rounded to the next highest integer and for
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some questions the total percentage exceeded 100%. Only AAHKS members were asked to
48
respond to the survey. Overall 939 AAHKS members were registered for the meeting. The
49
audience was queried with respect to demographic issues and a broad number of issues related to
50
their practice.
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51
Results
53
The mean number of responses to each question was 521. The Appendix lists each specific
54
question, the number and the percentage responses to each question and the number of
55
respondents for each question (available online at www.arthroplastyjournal.org).
56
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AAHKS Member Demographics
58
The majority of AAHKS members (83%) were between 30 and 60 years of age and 14% of
59
members were between 61 and 70 years of age. Years in practice varied greatly with 27% in
60
practice 0 to 5 years, 14% between 6 and 10 years, 22% between 11 and 20 years, 13% between
61
21 and 25 years, 13% between 25 and 30 years and 12% greater than 30 years.
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AAHKS Members Surgical Activity
64
When asked what percentage of their surgical practice was strictly related to total joint
65
replacement, 62% of members responded that greater than 80% of their practice was related to
66
total joint replacement. Twelve percent responded that between 71 to 80% of their practice
67
involved total joint replacement; 10% responded that 61 to 70% of their practice involved total
68
joint replacement and 10% responded that between 41 to 60% of their practice was related to
69
total joint replacement.
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Substantial variability was noted between surgeons when queried about how many hip
71
and knee replacements they performed per year. Forty-five percent of audience participants
72
performed between 51 and 150 total hip arthroplasties (THA) per year; 17% performed between
73
151 and 200 THA per year, and 17% performed greater than 200 per year. Similar findings were
74
noted with respect to total knee arthroplasties (TKA) performed per year. Thirty-eight percent of
75
the members performed between 51 and 150 TKA per year, 20% performed between 151 and
76
200 per year and 21% performed greater than 200 TKA per year. Interestingly 12% of members
77
performed greater than 300 TKA per year and 8% of members performed greater than 300 THA
78
per year. Only 12% of AAHKS members reported performing total joint replacements at an
79
outpatient surgery center.
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The audience was polled with respect to the number of hip arthroscopies they perform per
81
year. Eighty-six percent of AAHKS members did not perform any hip arthroscopies. Only 3%
82
of members performed more than 50 hip arthroscopies per year. Osteotomies and other hip
83
preservation procedures are not being performed on a regular basis by AAHKS members with
84
87% of AAHKS members not performing these procedures. Ten percent of members performed
85
between 1 and 10 procedures and only 1% of members performed more than 50 hip preservation
86
procedures per year. Knee arthroscopies, however, were performed more frequently by AAHKS
87
members with 57% percent performing between 1 and 50 knee arthroscopies per year and 22%
88
performing more than 50 per year. Nineteen percent did not perform knee arthroscopy.
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Practice Status of AAHKS Members
91
Fifty-one percent of AAHKS members remain in private practice, 10% work for a multispecialty
92
group; 20% are hospital employees and 17% are on the full time faculty of an academic
ACCEPTED MANUSCRIPT Practice Management Strategies
5
institution. The source of compensation for AAHKS members was extremely variable. Fee for
94
service remains the most common form of compensation (48%) followed by salary with a
95
performance incentive (23%). Both relative valve unit (RVU) based compensation (19%) and a
96
fixed salary (9%) were less common. Only 1% of members did not accept any insurance.
97
Ninety percent of members responded that between 20% and 80% of their practice included
98
Medicare beneficiaries. Six percent of members responded that between 1% and 20% of their
99
practice included Medicare patients. Only 10% of survey participants responded that they
100
restricted the number of Medicare or HMO patients that were seen in their practice. Thirty-nine
101
percent of AAHKS members are participating in bundled payment contracts at this time.
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93
102
Physician Extenders
104
The survey also queried members with respect to the use of physician extenders. Thirty-one
105
percent of members employed a physician assistant and 5% employed only a nurse practitioner.
106
Twenty-one percent employed multiple physician assistants and/or nurse practitioners in their
107
practice and another 21% employed a physician assistant, nurse practitioner and an athletic
108
trainer or physical therapist in their office. Only 15% of respondents did not employ any type of
109
mid-level provider. Sixty-three percent of members polled had some type of mid-level provider
110
provided by the hospital to assist them in the operating room.
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103
112
Ancillary Income
113
The survey participants were polled with respect to potential sources of ancillary income. The
114
audience was asked to respond yes or no related to sources of ancillary income in the following
115
areas including: physical therapy (37%, yes), magnetic resonance imaging (31%, yes), physician
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ownership of a surgery center (35%, yes). When asked to determine what percentage of their
117
income was from these ancillary services 53% of survey participants responded that they
118
received no income from ancillary services; 26% responded that between 1% and 20% of their
119
income came from ancillary services, 14% had between 21% and 40% of income from ancillary
120
services and 7% had between 41% and greater than 80% of their income from ancillary services.
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AAHKS members were also queried with respect to other sources of income. Seventy
122
percent of AAHKS members did not generate any income from medical legal reviews or IME
123
activities. Twenty-seven percent had between 1% and 10% of income from medical legal
124
reviews or IME activities and 3% answered that between 11% and 40% of their income was
125
generated from medical legal reviews or IME related activities.
126
members received compensation from the hospital for a medical directorship or participating in
127
some other type of administrative activity for a hospital. When asked how much of the income
128
did members used to support research 54% responded that none of their income was used to
129
support research. Forty-four percent stated that between 1% and 10% of their income was used
130
to support research and 2% of the participants used more than 10% of their income to support
131
their research.
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Thirty-seven percent of
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Royalties and Consulting Activities
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Only 15% of AAHKS members received royalties from an orthopaedic manufacturer.
135
Thirty-eight percent of AAHKS members received income for consulting with either orthopaedic
136
or pharmaceutical companies for participation on advisory boards, product evaluation or
137
educational activities. Overall 64% of AAHKS members did not earn any income from
138
consulting. Nine percent of members received between $1 and $5,000 for consulting activities,
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12% received between $5,001 and $20,000; 6% of members received between $20,001 and
140
$50,000 and 9% of members received greater than $50,001 per year for consulting activities.
141
Electronic Medical Record
143
A series of questions were asked related to the members use of an electronic medical record in
144
their practice. Only 34% of survey participants had their patients make appointments online.
145
Fifty-three percent of AAHKS members had a completely paperless office and 42% still had
146
charts with some paper. Five percent of members did not use an electronic medical record.
147
Fifty-two percent of members funded the EMR through practice revenue and 28% received some
148
hospital support to fund their electronic medical record. Ten percent of respondents used both
149
hospital and practice support to fund the electronic medical record. Forty-three percent of
150
AAHKS members were submitting data to the American Joint Replacement Registry or another
151
registry.
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Emergency Department Call
154
Sixty-seven percent of members were taking emergency room call with 45% not receiving any
155
kind of reimbursement for taking call. Eleven percent of members received between $1 and
156
$500 per day for taking call; 38% of members received between $501 and $2,000 per day for
157
taking call and 6% of members received over $2,000 per day for taking emergency room call.
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Practice Satisfaction
160
Only 64% of members stated that they were as happy being an orthopaedic surgeon in practice as
161
they were 10 years ago.
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Discussion
163
This practice management survey enabled us to obtain valuable information from members of
164
the American Association of Hip and Knee Surgeons regarding practice patterns and practice
165
management issues. There were a few surprising findings obtained from the survey especially
166
when compared to the results obtained from a survey performed in 2011. [1] The majority of
167
AAHKS members (51%) still remained in private practice. Although, this number was down
168
from the 60% mark reported in the 2011 survey it still seems higher than what one would expect
169
based on national trends. Surprisingly, fee for service still remained the most common form of
170
compensation (48%) followed by salary with a performance incentive (23%). Only 19% of
171
survey respondents had their compensation based on RVUs which seems to be more prevalent in
172
other medical specialties.
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AAHKS members were more likely to perform a knee arthroscopy than a hip arthroscopy.
Fifty-seven percent of AAHKS members performed between 1 and 50 knee
175
arthroscopies per year and 23% performed between 51 and 200 arthroscopies per year.
176
Surprisingly, 86% of AAHKS members did not perform hip arthroscopy. Only 5% performed
177
between 1 and 10 hip arthroscopies per year and only 6% performed between 11 and 50
178
arthroscopies per year. This suggests that hip arthroscopy is either being performed by sports
179
medicine physicians or general orthopaedic surgeons with some type of expertise in hip
180
arthroscopy. The hip arthroscopy data is quite similar to the survey in 2011 where approximately
181
90% of members performed 10 or less hip arthroscopies per year. In addition, 87% of AAHKS
182
members did not perform pelvic osteotomies or other open hip preservation procedures. Only
183
10% of respondents performed between 1 and 10 hip preservation procedures per year and only
184
3% performed between 11 and 50 hip preservation procedures per year. It is surprising that the
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9
number of hip arthroscopy and preservation procedures is so low. AAHKS members treat a
186
significant number of patients with hip pathology in their practices but it seems that these
187
procedures are being done by other orthopaedic surgeons in the community. This data also
188
suggests that perhaps total joint arthroplasty fellowships should begin focusing on teaching hip
189
arthroscopy and hip preservation to their fellows. There is a general concern in the orthopaedic
190
community regarding the inappropriate selection of patients for some of these procedures and
191
perhaps the indications for these procedures could be fine tuned if more clinicians with more
192
comprehensive expertise in the hip treated these patients.
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185
AAHKS members do earn ancillary income from a variety of sources including physical
194
therapy (37%), magnetic resonance imaging (31%) or ownership of a surgery center (35%).
195
There has been some change in the ancillary income data since the last survey that was published
196
in 2011. In 2011 70% of AAHKS members received no income from ancillary services and now
197
53% do not receive any ancillary income. In 2011 only 9% of AAHKS members received
198
between 21% to 60% of their income from ancillary services, and in the present survey this
199
percentage increased to 19% receiving 21 to 60% of their income from ancillary services. This
200
change may have occurred for two major reasons. First, by providing ancillary services in the
201
office AAHKS members may be able to serve their patients better and it is also possible because
202
of declining reimbursements that AAHKS members are more aggressively seeking ancillary
203
sources of income. However, the majority of AAHKS members still receive no income from
204
ancillary services.
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205
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Over the past decade there has been an increased focus on conflict of interests related to
206
the relationships between orthopaedic surgeons and device manufacturers and pharmaceutical
207
companies. However, 62% of AAHKS members did not have any relationships with any type of
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208
orthopaedic or pharmaceutical companies and only 15% of AAHKS members received royalties
209
from an orthopaedic manufacturer. These numbers have not changed since 2011. [1] The use of the electronic medical record has significantly increased among AAHKS
211
members. In this year’s survey 53% of AAHKS members had a completely paperless office and
212
42% had EMR but still had charts with some paper. Only 5% of members had no electronic
213
medical record. In contrast, in the 2011 survey only 30% of respondents had a completely
214
paperless office and 48% had an EMR but still used some charts with paper. At that time 21%
215
of survey participants did not use an electronic medical record at all.
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The majority of AAHKS members (67%) still take emergency room call. Fifty-five
217
percent of respondents receive some type of reimbursement for taking emergency room call.
218
The most frequent amount of reimbursement for call was between $500 and $2,000 dollars
219
(38%) per day. There was no difference in the percentage of members that are receiving
220
reimbursement for taking call since the 2011 survey. [1]
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Three areas of activity will need to be carefully evaluated in future surveys. Only 39% of
222
members are participating in bundled payment programs at this time. Forty-three percent of
223
members are submitting data to the American Joint Replacement Registry or some other registry.
224
The participation in bundled payment contracts and the AJRR should increase rapidly over the
225
next few years. Finally, only 12% of members are doing total joint replacements in a free
226
standing outpatient surgery centers at this time.
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Unfortunately, the orthopaedic surgeon satisfaction numbers have not improved over
228
time. In 2011 only 66% of members responded yes when asked were they still as happy being an
229
orthopaedic surgeon as they were 5 to 10 years ago and 64 percent of members responded yes to
230
this question this year.
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The major strengths of this study are that the responses were anonymous, a large sample
232
size was surveyed and all the data was collected at one time. However, here are also some
233
limitations associated with this type of survey including: the questions have not been validated
234
for interresponder reliability; the answers to some of the questions may not have been completely
235
accurate even though the survey was anonymous; and some of the answers may have been
236
inaccurate because the respondents did not truly understand the questions that were being asked
237
or their responses were affected by their own recall bias. Finally, although the moderator
238
requested that only AAHKS members respond to the survey other surgeons and guests may have
239
answered questions which could affect the accuracy of the results.
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In summary, the data presented are quite interesting and there are a number of findings
241
that were surprising. It is our plan to repeat this poll in two years. There are five potential areas
242
for a significant change in practice patterns over the next two years among AAHKS members
243
including: private practice activity, fee for service compensation, participation in bundled
244
payment programs, participation in a total joint replacement registry and performing total joint
245
replacements in an outpatient surgery center. Hopefully the data that has been collected this year
246
is of value to all members of AAHKS, other members of the orthopaedic community and
247
individuals interested in health care. [1]
249 250 251 252 253
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1. Lieberman JR, Freiberg, AA, Lavernia CJ. Practice management strategies among members of the American Association of Hip and Knee Surgeons. J Arthroplasty. 2012 Sep;27(8 Suppl):17-9.e1-6.doi: 10.1016/j.arth.2012.02.030. Epub 2012 Apr 12.
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References
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12
S0883-5403(16)30120-6
DOI:
10.1016/j.arth.2016.04.021
Reference:
YARTH 55147
To appear in:
The Journal of Arthroplasty
Received Date: 15 April 2016 Accepted Date: 21 April 2016
Please cite this article as: Lieberman JR, Polkowski G, Della Valle C, Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons, The Journal of Arthroplasty (2016), doi: 10.1016/j.arth.2016.04.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RI PT
ACCEPTED MANUSCRIPT
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Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons
M AN U
Jay R. Lieberman, M.D.
Gregory Polkowski, M.D.
AC C
EP
TE D
Craig Della Valle, M.D.
ACCEPTED MANUSCRIPT
Abstract: A survey was conducted at the 2015 annual meeting of the American Association of
2
Hip and Knee Surgeons to determine current practice management patterns among its members.
3
The purpose of this article is to summarize the audience responses to a number of different
4
questions related to type of practice, use of physician extenders, potential sources of ancillary
5
income, consulting activity, involvement in bundled payment contracts and the use of the
6
electronic medical records.
RI PT
1
SC
7 8
M AN U
9 10 11 12
16 17 18 19 20 21 22 23
EP
15
AC C
14
TE D
13
ACCEPTED MANUSCRIPT Practice Management Strategies
2
Over the past decade total joint arthroplasty surgeons have developed various practice
25
management strategies in response to the changes in health care laws, various government
26
regulations, an increasing overhead burden combined with declining reimbursements. In order to
27
gain more knowledge regarding the present practice patterns of total joint arthroplasty surgeons a
28
survey was conducted at the 2015 annual meeting of the American Association of Hip and Knee
29
Surgeons (AAHKS) to delineate specific practice management strategies among AAHKS
30
members. Our goal is to use this information not only to educate AAHKS members and the
31
orthopaedic community but also to compare the results of the survey with a previous survey
32
performed in 2011. In addition, the information obtained from this survey can be used to
33
compare the results of future surveys to better understand changes in total joint arthroplasty
34
practices over time.
M AN U
SC
RI PT
24
35
Materials and Methods
37
This survey was conducted by the session moderator (JRL) during the annual AAHKS meeting.
38
A series of practice management issues were reviewed with AAHKS members who were at the
39
meeting. A survey of practice patterns have been previously performed at the annual meeting in
40
2011 and a similar format was used for this survey. [1] The survey contained both yes and no
41
and multiple choice questions. A handheld audience response system (ARS) was used by
42
audience members. The ARS allows each audience participant to select one response to each
43
particular question. The audience was given 10 seconds to respond to each question. During the
44
survey the audience responses were collected in a central data bank and the results were
45
displayed for the audience to review immediately after the questions were answered. Since the
46
answers were provided in percentages they were rounded to the next highest integer and for
AC C
EP
TE D
36
ACCEPTED MANUSCRIPT Practice Management Strategies
3
some questions the total percentage exceeded 100%. Only AAHKS members were asked to
48
respond to the survey. Overall 939 AAHKS members were registered for the meeting. The
49
audience was queried with respect to demographic issues and a broad number of issues related to
50
their practice.
RI PT
47
51
Results
53
The mean number of responses to each question was 521. The Appendix lists each specific
54
question, the number and the percentage responses to each question and the number of
55
respondents for each question (available online at www.arthroplastyjournal.org).
56
M AN U
SC
52
AAHKS Member Demographics
58
The majority of AAHKS members (83%) were between 30 and 60 years of age and 14% of
59
members were between 61 and 70 years of age. Years in practice varied greatly with 27% in
60
practice 0 to 5 years, 14% between 6 and 10 years, 22% between 11 and 20 years, 13% between
61
21 and 25 years, 13% between 25 and 30 years and 12% greater than 30 years.
TE D
57
EP
62
AAHKS Members Surgical Activity
64
When asked what percentage of their surgical practice was strictly related to total joint
65
replacement, 62% of members responded that greater than 80% of their practice was related to
66
total joint replacement. Twelve percent responded that between 71 to 80% of their practice
67
involved total joint replacement; 10% responded that 61 to 70% of their practice involved total
68
joint replacement and 10% responded that between 41 to 60% of their practice was related to
69
total joint replacement.
AC C
63
ACCEPTED MANUSCRIPT Practice Management Strategies
4
Substantial variability was noted between surgeons when queried about how many hip
71
and knee replacements they performed per year. Forty-five percent of audience participants
72
performed between 51 and 150 total hip arthroplasties (THA) per year; 17% performed between
73
151 and 200 THA per year, and 17% performed greater than 200 per year. Similar findings were
74
noted with respect to total knee arthroplasties (TKA) performed per year. Thirty-eight percent of
75
the members performed between 51 and 150 TKA per year, 20% performed between 151 and
76
200 per year and 21% performed greater than 200 TKA per year. Interestingly 12% of members
77
performed greater than 300 TKA per year and 8% of members performed greater than 300 THA
78
per year. Only 12% of AAHKS members reported performing total joint replacements at an
79
outpatient surgery center.
M AN U
SC
RI PT
70
The audience was polled with respect to the number of hip arthroscopies they perform per
81
year. Eighty-six percent of AAHKS members did not perform any hip arthroscopies. Only 3%
82
of members performed more than 50 hip arthroscopies per year. Osteotomies and other hip
83
preservation procedures are not being performed on a regular basis by AAHKS members with
84
87% of AAHKS members not performing these procedures. Ten percent of members performed
85
between 1 and 10 procedures and only 1% of members performed more than 50 hip preservation
86
procedures per year. Knee arthroscopies, however, were performed more frequently by AAHKS
87
members with 57% percent performing between 1 and 50 knee arthroscopies per year and 22%
88
performing more than 50 per year. Nineteen percent did not perform knee arthroscopy.
EP
AC C
89
TE D
80
90
Practice Status of AAHKS Members
91
Fifty-one percent of AAHKS members remain in private practice, 10% work for a multispecialty
92
group; 20% are hospital employees and 17% are on the full time faculty of an academic
ACCEPTED MANUSCRIPT Practice Management Strategies
5
institution. The source of compensation for AAHKS members was extremely variable. Fee for
94
service remains the most common form of compensation (48%) followed by salary with a
95
performance incentive (23%). Both relative valve unit (RVU) based compensation (19%) and a
96
fixed salary (9%) were less common. Only 1% of members did not accept any insurance.
97
Ninety percent of members responded that between 20% and 80% of their practice included
98
Medicare beneficiaries. Six percent of members responded that between 1% and 20% of their
99
practice included Medicare patients. Only 10% of survey participants responded that they
100
restricted the number of Medicare or HMO patients that were seen in their practice. Thirty-nine
101
percent of AAHKS members are participating in bundled payment contracts at this time.
M AN U
SC
RI PT
93
102
Physician Extenders
104
The survey also queried members with respect to the use of physician extenders. Thirty-one
105
percent of members employed a physician assistant and 5% employed only a nurse practitioner.
106
Twenty-one percent employed multiple physician assistants and/or nurse practitioners in their
107
practice and another 21% employed a physician assistant, nurse practitioner and an athletic
108
trainer or physical therapist in their office. Only 15% of respondents did not employ any type of
109
mid-level provider. Sixty-three percent of members polled had some type of mid-level provider
110
provided by the hospital to assist them in the operating room.
EP
AC C
111
TE D
103
112
Ancillary Income
113
The survey participants were polled with respect to potential sources of ancillary income. The
114
audience was asked to respond yes or no related to sources of ancillary income in the following
115
areas including: physical therapy (37%, yes), magnetic resonance imaging (31%, yes), physician
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ownership of a surgery center (35%, yes). When asked to determine what percentage of their
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income was from these ancillary services 53% of survey participants responded that they
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received no income from ancillary services; 26% responded that between 1% and 20% of their
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income came from ancillary services, 14% had between 21% and 40% of income from ancillary
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services and 7% had between 41% and greater than 80% of their income from ancillary services.
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AAHKS members were also queried with respect to other sources of income. Seventy
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percent of AAHKS members did not generate any income from medical legal reviews or IME
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activities. Twenty-seven percent had between 1% and 10% of income from medical legal
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reviews or IME activities and 3% answered that between 11% and 40% of their income was
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generated from medical legal reviews or IME related activities.
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members received compensation from the hospital for a medical directorship or participating in
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some other type of administrative activity for a hospital. When asked how much of the income
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did members used to support research 54% responded that none of their income was used to
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support research. Forty-four percent stated that between 1% and 10% of their income was used
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to support research and 2% of the participants used more than 10% of their income to support
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their research.
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Royalties and Consulting Activities
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Only 15% of AAHKS members received royalties from an orthopaedic manufacturer.
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Thirty-eight percent of AAHKS members received income for consulting with either orthopaedic
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or pharmaceutical companies for participation on advisory boards, product evaluation or
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educational activities. Overall 64% of AAHKS members did not earn any income from
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consulting. Nine percent of members received between $1 and $5,000 for consulting activities,
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12% received between $5,001 and $20,000; 6% of members received between $20,001 and
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$50,000 and 9% of members received greater than $50,001 per year for consulting activities.
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Electronic Medical Record
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A series of questions were asked related to the members use of an electronic medical record in
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their practice. Only 34% of survey participants had their patients make appointments online.
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Fifty-three percent of AAHKS members had a completely paperless office and 42% still had
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charts with some paper. Five percent of members did not use an electronic medical record.
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Fifty-two percent of members funded the EMR through practice revenue and 28% received some
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hospital support to fund their electronic medical record. Ten percent of respondents used both
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hospital and practice support to fund the electronic medical record. Forty-three percent of
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AAHKS members were submitting data to the American Joint Replacement Registry or another
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registry.
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Emergency Department Call
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Sixty-seven percent of members were taking emergency room call with 45% not receiving any
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kind of reimbursement for taking call. Eleven percent of members received between $1 and
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$500 per day for taking call; 38% of members received between $501 and $2,000 per day for
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taking call and 6% of members received over $2,000 per day for taking emergency room call.
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Practice Satisfaction
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Only 64% of members stated that they were as happy being an orthopaedic surgeon in practice as
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they were 10 years ago.
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Discussion
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This practice management survey enabled us to obtain valuable information from members of
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the American Association of Hip and Knee Surgeons regarding practice patterns and practice
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management issues. There were a few surprising findings obtained from the survey especially
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when compared to the results obtained from a survey performed in 2011. [1] The majority of
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AAHKS members (51%) still remained in private practice. Although, this number was down
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from the 60% mark reported in the 2011 survey it still seems higher than what one would expect
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based on national trends. Surprisingly, fee for service still remained the most common form of
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compensation (48%) followed by salary with a performance incentive (23%). Only 19% of
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survey respondents had their compensation based on RVUs which seems to be more prevalent in
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other medical specialties.
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AAHKS members were more likely to perform a knee arthroscopy than a hip arthroscopy.
Fifty-seven percent of AAHKS members performed between 1 and 50 knee
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arthroscopies per year and 23% performed between 51 and 200 arthroscopies per year.
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Surprisingly, 86% of AAHKS members did not perform hip arthroscopy. Only 5% performed
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between 1 and 10 hip arthroscopies per year and only 6% performed between 11 and 50
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arthroscopies per year. This suggests that hip arthroscopy is either being performed by sports
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medicine physicians or general orthopaedic surgeons with some type of expertise in hip
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arthroscopy. The hip arthroscopy data is quite similar to the survey in 2011 where approximately
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90% of members performed 10 or less hip arthroscopies per year. In addition, 87% of AAHKS
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members did not perform pelvic osteotomies or other open hip preservation procedures. Only
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10% of respondents performed between 1 and 10 hip preservation procedures per year and only
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3% performed between 11 and 50 hip preservation procedures per year. It is surprising that the
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number of hip arthroscopy and preservation procedures is so low. AAHKS members treat a
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significant number of patients with hip pathology in their practices but it seems that these
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procedures are being done by other orthopaedic surgeons in the community. This data also
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suggests that perhaps total joint arthroplasty fellowships should begin focusing on teaching hip
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arthroscopy and hip preservation to their fellows. There is a general concern in the orthopaedic
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community regarding the inappropriate selection of patients for some of these procedures and
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perhaps the indications for these procedures could be fine tuned if more clinicians with more
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comprehensive expertise in the hip treated these patients.
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AAHKS members do earn ancillary income from a variety of sources including physical
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therapy (37%), magnetic resonance imaging (31%) or ownership of a surgery center (35%).
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There has been some change in the ancillary income data since the last survey that was published
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in 2011. In 2011 70% of AAHKS members received no income from ancillary services and now
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53% do not receive any ancillary income. In 2011 only 9% of AAHKS members received
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between 21% to 60% of their income from ancillary services, and in the present survey this
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percentage increased to 19% receiving 21 to 60% of their income from ancillary services. This
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change may have occurred for two major reasons. First, by providing ancillary services in the
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office AAHKS members may be able to serve their patients better and it is also possible because
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of declining reimbursements that AAHKS members are more aggressively seeking ancillary
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sources of income. However, the majority of AAHKS members still receive no income from
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ancillary services.
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Over the past decade there has been an increased focus on conflict of interests related to
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the relationships between orthopaedic surgeons and device manufacturers and pharmaceutical
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companies. However, 62% of AAHKS members did not have any relationships with any type of
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orthopaedic or pharmaceutical companies and only 15% of AAHKS members received royalties
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from an orthopaedic manufacturer. These numbers have not changed since 2011. [1] The use of the electronic medical record has significantly increased among AAHKS
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members. In this year’s survey 53% of AAHKS members had a completely paperless office and
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42% had EMR but still had charts with some paper. Only 5% of members had no electronic
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medical record. In contrast, in the 2011 survey only 30% of respondents had a completely
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paperless office and 48% had an EMR but still used some charts with paper. At that time 21%
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of survey participants did not use an electronic medical record at all.
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The majority of AAHKS members (67%) still take emergency room call. Fifty-five
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percent of respondents receive some type of reimbursement for taking emergency room call.
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The most frequent amount of reimbursement for call was between $500 and $2,000 dollars
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(38%) per day. There was no difference in the percentage of members that are receiving
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reimbursement for taking call since the 2011 survey. [1]
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Three areas of activity will need to be carefully evaluated in future surveys. Only 39% of
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members are participating in bundled payment programs at this time. Forty-three percent of
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members are submitting data to the American Joint Replacement Registry or some other registry.
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The participation in bundled payment contracts and the AJRR should increase rapidly over the
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next few years. Finally, only 12% of members are doing total joint replacements in a free
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standing outpatient surgery centers at this time.
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Unfortunately, the orthopaedic surgeon satisfaction numbers have not improved over
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time. In 2011 only 66% of members responded yes when asked were they still as happy being an
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orthopaedic surgeon as they were 5 to 10 years ago and 64 percent of members responded yes to
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this question this year.
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The major strengths of this study are that the responses were anonymous, a large sample
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size was surveyed and all the data was collected at one time. However, here are also some
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limitations associated with this type of survey including: the questions have not been validated
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for interresponder reliability; the answers to some of the questions may not have been completely
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accurate even though the survey was anonymous; and some of the answers may have been
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inaccurate because the respondents did not truly understand the questions that were being asked
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or their responses were affected by their own recall bias. Finally, although the moderator
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requested that only AAHKS members respond to the survey other surgeons and guests may have
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answered questions which could affect the accuracy of the results.
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In summary, the data presented are quite interesting and there are a number of findings
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that were surprising. It is our plan to repeat this poll in two years. There are five potential areas
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for a significant change in practice patterns over the next two years among AAHKS members
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including: private practice activity, fee for service compensation, participation in bundled
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payment programs, participation in a total joint replacement registry and performing total joint
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replacements in an outpatient surgery center. Hopefully the data that has been collected this year
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is of value to all members of AAHKS, other members of the orthopaedic community and
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individuals interested in health care. [1]
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1. Lieberman JR, Freiberg, AA, Lavernia CJ. Practice management strategies among members of the American Association of Hip and Knee Surgeons. J Arthroplasty. 2012 Sep;27(8 Suppl):17-9.e1-6.doi: 10.1016/j.arth.2012.02.030. Epub 2012 Apr 12.
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References
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