As the U.S. population ages and demand for joint replacements and spine procedures climbs, orthopedics has increasingly talked about shifting toward prevention — treating patients before they need surgery rather than after. Justin Iorio, MD, an orthopedic spine surgeon at Syracuse N.Y.-based St. Joseph’s Physicians Orthopedics, says that shift is real, but the reimbursement system underneath it hasn’t caught up.
“I think we need value-based care, and I think that would be our prevention shift,” Dr. Iorio said. “We are trying to prevent procedures — prevent hip replacements, knee replacements, spine surgeries — saving those for the people that need them. In order to have value-based care, you would need the insurance company to be in some kind of program where there’s a cost or a profit sharing, because we’re paid to do procedures, and therefore you’d have to be reimbursed to not do procedures. Otherwise, it certainly doesn’t work.”
The fee-for-service structure also intersects with a reimbursement problem. As reimbursement per procedure declines, surgeons make up the difference in volume.
“If you had reimbursements that correlated with inflation, I suspect you probably would be having less people doing surgery,” he said.
The consequence, he said, is that surgeons sometimes operate on patients who could have avoided surgery altogether with more time and non-surgical management.
“What happens is you’re probably going to operate on people that are less good surgical candidates,” Dr. Iorio said. “It doesn’t mean the surgeries are unreasonable, or they don’t need surgery. It means they’re not optimized, and that’s where the value-based care problem comes in.”
Under a different payment structure, he said, that conversation could look different, and prevention and preservation could be a part of the routine clinical practice in orthopedics.
“If you were compensated in a way that was more reasonable, then you probably could say, ‘Mr. Smith, let’s have you lose that 40 pounds, and we’ll keep seeing you,’ and you’ll get paid for that management of the non-care,” he said. “That would improve the patient’s potential outcome, or avoid surgery, because a lot of times, over time, people do better.”
Dr. Iorio said the clinical case for that type of approach is already well-documented — orthopedic research societies have long prioritized tracking patient outcomes. What’s missing, he said, is a payment structure willing to act on it.
“We know it, and we’re willing,” he said. “We just need a voice and a reasonable recipient.”
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