Q: What are the most significant challenges for orthopedic practices in the future?
Dr. Eric Monesmith: The biggest challenge will be healthcare reform. The whole issue of healthcare reform, I don’t think, is going to be good for doctors unless [legislators] kill the whole thing and start over. It’s going to be bad for doctors in terms of reimbursement and increased regulations that drive up the cost of practicing, much like the new HIPAA regulations have. The cost of doing business is going to rise, and no additional funds have been provided to cover this.
You also have the push for mandatory electronic medical records coming down the pipeline. The 2009 stimulus plan provides money for groups to purchase and implement EMR systems, but this one time capital injection is all you receive. Unfortunately, in 2014, practices will start being penalized for not utilizing EMRs in a “meaningful use” situation, which will be defined by the federal government. Once you get your EMR going, the costs are from then on borne by the doctor and the practice, and the ongoing costs for EMRs are quite substantial, including recurring licensing fees, hardware and software upgrades, repair and maintenance. There is no reimbursement for these costs. OrthoIndy implemented a comprehensive EMR system five years ago. Ideally, a next-generation EMR will help practices to schedule more effectively and shrink their workforce, but so far it has not made us more efficient or lowered our costs.
Q: What are the biggest opportunities for orthopedic practices in the next few years?
EM: Opportunities are going to vary by region, because different regions and states are going to have slightly different opportunities based on their political climate. Different states have different regulations regarding investment in ASCs and hospitals, which can provide surgeons a portion of the facility fee side of the reimbursement equation.
The bigger picture for orthopedics in general and for joint replacement in particular is that there is a projected growth in demand over the next several years because of the aging population. Several projections done by various orthopedic groups and specialty academies have looked at demographic data and surgical rates and have found that the demand for orthopedic surgeries, especially joint replacement, is going to be greater than supply of physicians to perform the surgeries for next 20 years. If these projections are accurate and there is a dramatic surge in demand, then this could create a backlog of patients waiting for surgery. A backlog could give surgeons the opportunity to go outside traditional insurance reimbursement programs and instead perform procedures as a private fee for service that is separate from these insurance programs.
Q: Recent reports have suggested that cartilage preservation techniques may reduce the demand for joint replacement in the future. Do you think this will at all reduce the demand surge for joint replacement predicted in the next 20 years?
EM: We are starting to see the advent of earlier intervention strategies; however, I don’t think it will drastically impact demand. Cartilage restoration procedures have been around for 10 or 11 years now, and the idea was that if we treat early cartilage lesions or damage, we might delay the onset of arthritis. Unfortunately, this hasn’t really panned out. There are several ongoing studies on cartilage implants and other technologies to prevent arthritis, but the technology we have today is surprisingly crude in terms of trying to grow new cartilage. [Cartilage preservation] has not made any impact yet on the number of total joints and it doesn’t look like it will based on the projections.
One of the reasons for this, I think, is that we as a scientific community don’t understand arthritis very well. We certainly know the correlative factors for it, such as obesity, trauma, high impact exercise, age and genetics, but we really don’t know the biochemical processes that lead to it. Some people just get it and some people don’t, and we don’t know why that is. There’s no pill or injection to prevent or cure it, or even slow its progression. We have treatments for the symptoms of arthritis, but nothing that keeps it from happening.
Q: There have also been recent moves to perform joint replacement, especially knee replacements, in the outpatient setting. Do you think this will continue to expand in the coming years?
EM: Most of the outpatient knee replacements taking place occur at 23-hour stay facilities. Total knee replacement can be performed safely in and ASC with the right patient. We may start to see more of this, but I don’t think it’s a trend, at least not here [in Indianapolis]. Despite the advances in anesthesia techniques that make this possible, I don’t see this as a big opportunity for knee surgeons. I don’t think there is a big enough difference to patients between the 23-hour stay and the 48 hours most patients are currently in the hospital for knee replacement surgeries.(which is routine now, even for elderly patients). There’s not really been pressure from patients for these to occur at the ASC.
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