20 Things to Know About Orthopedics

The following are 20 things to know about the business and distribution of orthopedics, satisfaction and compensation of orthopedic surgeons and future of the specialty.

1. Average compensation: In 2013, the average compensation for an orthopedist was $413,000. This is $62,000 more than the second highest compensated specialty, cardiology. Orthopedic surgeons in private groups reported earning on average $51,000 more than orthopedic surgeons employed by hospitals, at $439,000 versus $388,000 respectively, according to Medscape's 2014 Physician Compensation Report.

2. Growth in compensation: Orthopedic surgeons saw a 1.9 percent increase over last year's income on average. The highest average compensating region for orthopedic surgeons is the Northwest, with average compensation at $468,000 annually, according to Medscape's 2014 Physician Compensation Report.

3. Exchanges and compensation: Orthopedists expect their income to be affected as a direct result of the insurance exchanges. While one-third expect no change in income, 64 percent say their income will decrease, according to the Medscape report.

4. ACO participation: 18 percent of orthopedic surgeons are currently participating in accountable care organizations, and another 10 percent plan to join an ACO in 2014, according to Medscape's 2014 Physician Compensation Report.

5. Surgeon density by the numbers: According to the American Academy of Orthopaedic Surgeons 2012 Orthopaedic Surgeon Census, there were 27,773 orthopedic surgeons in the United States that year. The national average density of orthopedic surgeons is 8.72 per 100,000 population, with the highest densities in Wyoming, the District of Columbia, Montana, New Hampshire and Vermont (between 13 and 15 per 100,000 population). The lowest densities of orthopedic surgeons were in Mississippi, West Virginia, Texas, Arkansas and Nevada, at between 6.5 and 7 per 100,000 population.

6. Specialties: The most common primary orthopedic specialties as reported by AAOS, where surgeons may have more than one specialty, include arthroscopy (38 percent), adult knee (37 percent), sports medicine (36 percent), adult hip (28 percent) and total joint (17 percent).

7. Employment breakdown: According to AAOS, 44 percent of orthopedic surgeons are partners in an orthopaedic group, while 18 percent working as solo practitioners and 9 percent work in multispecialty groups. Only 9 percent worked in academic practice or hospital/medical center, respectively. The remaining orthopedic surgeons work in academic private practice (3 percent), military practice (2 percent), on a pre-paid plan or HMO (2 percent), "other" (2 percent), in a public institution (1 percent) or locum tenens (1 percent)

8. Top orthopedic hospitals: The top 10 hospitals for orthopedic surgery in the United States according to the U.S. News & World Report's best hospitals rankings include: Hospital for Special Surgery (New York City), Mayo Clinic (Rochester, Minn.), Cleveland Clinic, Massachusetts General Hospital (Boston), Hospital for Joint Diseases (New York City), Johns Hopkins Hospital (Baltimore, Md.), Northwestern Memorial Hospital (Chicago), Thomas Jefferson University Hospital (Philadelphia), Cedars-Sinai Medical Center (Los Angeles) and Rush University Medical Center (Chicago).

9. Work hours: The majority of orthopedists work more than 40 hours per week, with 27 percent working between 30 and 40 hours, 32 percent working between 41 and 50 hours and 22 percent working between 51 and 60 hours, according to Medscape.

10. Patient scheduling: The majority of orthopedists see between 50 and 124 patients weekly, with 24 percent seeing between 50 and 75 patients, 23 percent seeing between 75 and 99 patients and 22 percent seeing between 100 and 124 patients. Approximately 70 percent of orthopedists spend between 9 and 16 minutes with each patient, according to Medscape.

11. Paperwork: When not seeing patients, employed orthopedists spend more time on paperwork, with the plurality (36 percent) spending between 5 and 9 hours on paperwork per week, while a plurality (33 percent) of their self-employed counterparts most frequently spend only between 1 and 4 hours on paperwork, according to Medscape.

12. ASC orthopedic case mix: In a 2013 HealthCare Appraisers survey, orthopedics and sports medicine was the most desirable specialty in an ASC, with 100 percent of respondents saying it was desirable. It was the only specialty of those surveyed to be universally desired. According to the 2011 VMG Intellimarker survey, as a percentage of total cases, orthopedics case mix volume is 17 percent, equivalent to ophthalmology and behind GI/Endoscopy (29 percent).

13. ASC orthopedic case volume: According to the VMG Intellimarker survey, for ASCs with between one and four operating rooms, orthopedics made up between 18 percent and 19 percent of case volume. For ASCs with 4 ORs, it made up only 14 percent of case volume. Conversely, for centers with less than 3,000 cases annually, orthopedics made up 24 percent of case volume, while in centers with 6,000 or more annual cases it made up 15 percent of case volume. Centers seeing between 3,000 and 6,000 cases each year had 17 percent orthopedic cases.

14. Average reimbursement: On average, the gross charges per case on average for orthopedics in ASCs is $9,398, with average net revenue per case of $2,585 and a discount to charges per case of 71.1 percent. Net revenue per case is highest in the Midwest at $2,890 and lowest in the Northeast at $2,303. In a recent CMS release of Medicare billing data, it was revealed the average surgeon reimbursement for a total joint replacement is $6,041, according to a report from nerdwallet.

15. Attitudes toward reimbursement: Orthopedic surgeons are particularly conscious of reimbursements: 51 percent of orthopedic surgeons say they will drop poorly paying insurers, according to Medscape's 2014 Physician Compensation Report.

16. Zimmer-Biomet Merger: Recently, Zimmer and Biomet, two leading orthopedic and spine device companies, merged in a deal worth nearly $13.4 billion. The companies profess to be working toward more cost-effective solutions to meet healthcare needs; however, it's uncertain how exactly the merger will affect the downward trend in the cost of orthopedic devices, particularly artificial joints.

17. Surgeons on biologics and research and development: Four orthopedic surgeons remark on trends they have noticed in the industry:

Bert Mandelbaum, MD, Co-Chair of Medical Affairs for the Institute of Sports Sciences (Los Angeles): The progressive application of regenerative orthobiological interventions are the most exciting trends in orthopaedics today. The use of bone marrow aspirates, new scaffold technologies and PRP are the cornerstones of the regenerative trilogy for bone, joint and cartilage disorders. Systematic steps and future research will design efficient algorithms and solutions to today's challenges.

Stuart Miller, MD, MedStar Union Memorial Hospital (Baltimore): The difficulty in getting new devices to market (FDA scrutiny and overprotective approach) has led to the current wave of consolidation as smaller companies are finding R & D costs prohibitive. Such situations are limiting innovation in the orthopedic world at a time which should be so exciting!

Tariq A. Neyfeh, MD, MedStar Harbor Hospital (Baltimore): Due to the cost of research and development, orthopedic surgeons need to partner with industry to help guide and develop safe new technologies. Often the company's economic drive conflicts with the creation of new and safe implants and tools.

Lew Schon, MD, Director of MediStar Union Memorial Foot and Ankle Program (Baltimore): More recently the orthopedic industry and surgeons have been focusing on innovative devices that optimize safety, improve the functionality in a wider range of patients (age and co-morbidities), enhance mastery over complex musculoskeletal challenges and improve outcomes through understanding biomechanical and biologic tenets. Integration of optimized plastics, metals, synthetic and natural (tissues, cells, scaffolds, growth factors) materials are areas of concentrations for new implants.  In addition imaging technologies, "smart" devices and more anatomically specific variations may drive developments.

18. Surgeons on orthopedics and quality of care: Two surgeons remark on trends they have noticed in the industry:

Jason Stein, MD, Medstar Union Memorial Hospital (Baltimore): Orthopedic surgeons are currently caught in the middle between industry and hospital profits and government cost cutting measures, while still providing cutting-edge patient care.

James E. Wood Jr., MD, Chief of Orthopedics, MedStar Harbor Hospital (Baltimore): Mobility-maintaining total joint replacement for obese patient is becoming more challenging, as government, hospitals and medical groups demand outcomes with few or no complications. Because obesity is linked to a higher percentage of adverse post operative events, a selection bias has developed away from these patients. With the obesity epidemic in full bloom, a whole segment of the population will find itself systematically denied the opportunity to take full advantage of this quality-of-life enhancing technology. Orthopedics needs a strategy to get and keep these patients moving.

19. Satisfaction: Sixty-four percent of orthopedists would choose the specialty again, the second highest behind dermatology, but only 44 percent of orthopedists would choose medicine again. Only 51 percent are satisfied with their careers, according to Medscape.

20. Financial stability: Orthopedists are the specialty with the most savings, with nearly 80 percent reporting having "more than adequate" or "adequate" savings, though only 45 percent of orthopedic surgeons feel fairly compensated, and according to Medscape.


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