TRAUMA CARE MODELS
Due to the changing healthcare system, several forms of on call contracts and models for the delivery of orthopaedic trauma care have been developed.1–3 These fall into 5 major categories.
- Academic practice model
- Solo practice model
- Private group model
- Trauma orthopaedist as a specialist within a group
- Entire group comprised of trauma orthopaedists
- Hospital-based model
- Hospital-based/private group hybrid model
Each of these models has its own risks and benefits and trauma program development will require different components depending on the situation of surgeons, hospitals, anesthesiologists, hospital staff, and support personnel. However, all models will contain the vital components of any trauma system discussed in this section. Two articles written by Bray et al4 describe most of these components.5
AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS/ORTHOPAEDIC TRAUMA ASSOCIATION POSITION STATEMENT
Independent of the trauma practice model, the American Academy of Orthopaedic Surgeons (AAOS) and Orthopaedic Trauma Association (OTA) have identified several requirements for the success of any orthopaedic trauma service in their AAOS/OTA Position Statement. These include:
- Emergency operating room (OR) access 24/7/365
- OR availability for orthopaedic trauma cases Monday through Saturday 7 AM–5 PM.
- Orthopaedic OR nursing staff lead for organizing implants, instruments, etc.
- One physician assistant (PA)/orthopaedic trauma surgeon full-time equivalent
- Adequate numbers of reliable, functioning image intensifiers and trained radiology technicians for OR support.
- Funded call support coverage (ie, stipend)
- Available equipment and implant systems for intramuscular nailing, external fixation, plating, and arthroscopy
- Support for orthopaedic trauma surgeon continuing medical education
- Clinic facilities to follow patients after discharge with adequate radiographic capacity, nurse staffing, and wheelchair/stretcher access
- Commitment from emergency department physician leadership to increase orthopaedic injury triage capabilities
- Support for a research coordinator assigned to orthopaedic trauma research in level I and level II centers which corresponds to patient volumes
- Reimbursement for indigent care
In exchange for these resources provided by the hospital, orthopaedic trauma panel members will provide a number of services which include:
- Quality assurance direction and leadership
- Must have hospital indemnification
- Morbidity and mortality conferences
- Responsibility for call schedule coverage and making the call schedule
- Commitment to limit variation in implant usage
- This can substantially reduce direct costs
- Explore gain sharing/comanagement agreements
- Serve on committee for new products and orthobiologics
- Continuing medical education leadership and involvement for OR staff, staff physicians, floor nurses, and clinic staff
- Include structured fracture conferences for trauma panel members to share cases
- Regular review of fiscal impact of the service with hospital administration
- Identify trends of overutilization by individual surgeons
- Agree to specific response times
- Follow legal precedents for Health Insurance Portability and Accountability Act and Emergency Medical Treatment and Labor Act
- Willingness to efficiently fill the orthopaedic trauma OR room with cases commensurate with the amount negotiated with the hospital
- Allowing the room to go unused will result in decreased OR time
- Surgeons must use this time rather than other convenient times when office/elective cases completed
As with any contract negotiation, many legal issues are involved in the provision of patient care. A sound knowledge of the basics is important. Consultation with an attorney familiar with healthcare employment contracting is essential. Common issues of concern include:
- Restraint of trade
- Noncompete agreements
- Collective bargaining
- Antitrust laws
- Physician indemnity
Many of these issues differ depending on state laws, precedent, and hospital bylaws.
Call is an important issue for any orthopaedic trauma surgeon. The laws surrounding call and physician rights regarding the provision of call are vital to understand.
- Physicians can provide call at several institutions simultaneously unless an agreement for unencumbered in-house call is required by the institution
- Physicians can schedule elective surgery while on call provided they are not encumbered (ie, backup call established)
- At many institutions call is required to maintain hospital privileges. This is a hospital bylaw, not a federal or state regulation
- American College of Surgeons certification does have guidelines for call depending of trauma designation level
These 4 points are important to remember as you negotiate for call, make call schedules, and establish contracts with providers and institutions.
ECONOMICS OF CONTRACT NEGOTIATION
Contract negotiation is always difficult. It is often said that at the end of a successful negotiation, both sides are never completely satisfied. In many cases, utilizing a mediator can be helpful to avoid adversarial interactions between physicians and hospital administration. The key elements of negotiating a good contract include:
- Own the whole contract to provide all orthopaedic trauma care
- Negotiate as a corporate entity
- Process of contract negotiation usually takes 6–12 months
- Contracts last 2–3 years
- Consider adding a provision for extensions to the existing contract so the entire process does not need to be repeated in 2 years
- Termination clauses
- “Not for cause” clause is a way out for either party if they just are not satisfied with agreement
- Make this as long as possible (eg, 6 months) to allow for rearranging workflow
- “For cause” clause is for a violation of the contract; a resolution is often found before this is enacted
- Often 90 days or less
- Once a contract is terminated, it may be illegal for that entity to renegotiate with the hospital for 1–2 years
- Prevents “blackmail” by termination
The key to any successful negotiation is knowing what each side wants and what each is willing to give up. Most hospitals are seeking consistent call coverage, efficient patient flow out of the emergency room (ER), decreased length of stay, control of costly implants and materials, and development of physician led quality measures. Most orthopaedic surgeons seek acceptable compensation for providing services that are disruptive to an elective practice, compensation for services performed for indigent patients, appropriate resources and personnel support to provide high quality care, and compensation for participation in hospital committees and cost savings programs. Each of these requests will cost money and, to have a successful negotiation, physicians must know the numbers before entering into discussions with hospital administration.
ON CALL STIPENDS
A key element of any contract is the call stipend. The concept behind this is to pay the surgeon for their availability during a time period when he/she could be performing elective surgery or presiding over elective clinic.
- Stipends vary across the United States from $500 to $3500/24 hours
- Stipend is usually based on amount of expected admissions and linked to fair market value assessment. Stipends can be adjusted to incorporate other benefits for the service (ie, PA support), provided the stipend still falls within a hospital's self-imposed cap—such as, under 75th percentile of similar programs surveyed.
- Normal values for stipends can be found on OTA Web site and through the Medical Group Management Association
- Some hospitals assume that stipend assigns all ER follow-up to the on-call trauma orthopaedist
- Must be directly addressed within the contract
- Some contracts also contain a consult fee in which each trip to ER results in an agreed upon amount (eg, $200) to incentivize physicians to come to ER to see consults.
- This can effectively increase the stipend without being visible to fair market value surveyors
- Some institutions have included payment for indigent care in the stipend to ease billing and administrative issues regarding the unfunded patient population
Many facilities employ a physician as a trauma director. This should be part of any trauma contract negotiation and should be a paid position.
- Trauma director works with trauma nurse program coordinator to administrate the entire service.
- Time intensive position
- More so during site verification visits from the American College of Surgeons
- Director creates protocols and policies related to the trauma service's interface with the entire hospital, not just orthopaedics
- Utilized to facilitate formal morbidity and mortality conferences (M&M)
- Reimbursement average $200 to $275/h
- Held to certain performance metrics
The trauma director should be an individual with good political sense who can interface well with both surgeons and administration. An advanced degree in business (eg, MBA or MHA) is ideal; however, there is no substitute for clinical experience and good interpersonal skills.
DEDICATED ORTHOPAEDIC TRAUMA OR
Multiple authors have shown the value of a dedicated orthopaedic trauma OR.6–8 This room has been shown to decrease night time surgery, improve morbidity and mortality rates, decrease complication rates, increase personal and professional lifestyles, improve physician recruitment, and increase surgeon retention rates.6 Bhattacharyya et al7 demonstrated decreased operative times and complication rates for daytime procedures with the addition of a dedicated trauma OR. Wixted et al8 showed decreased use of after-hours services and a greater proportion of cases done by fellowship-trained traumatologists. This is good for a hospital system because Althausen et al9 demonstrated that when staffed by fellowship-trained traumatologists, fracture cases are able to be performed much faster with lower staffing and supply costs. All of these issues lead to improved efficiency and better care of the orthopaedic trauma patient.
HOSPITAL EMPLOYED TRAUMA PAs
The use of physician extenders such as PAs and nurse practitioners has become increasingly common at both academic and nonacademic medical centers. This has occurred due to loss of residents, 80-hour work week restrictions, and increasing financial pressures. In 2009, the annual census data from the American Academy of Physician Assistants reported an increase in the number of PAs working in trauma centers.10 In 2010, approximately one-third of all major trauma centers reported utilizing physician extenders. The use of hospital employed physicians assistants has been shown to be beneficial to any trauma program. The ability of physician extenders to assist in patient care and improve efficiency in part is based on their scope of practice. PA responsibilities are often governed by state laws or hospital regulations. An understanding of privileging is vital to optimal utilization of their services. In general, PAs are able to respond to trauma activations, assist in the OR, attend multidisciplinary rounds, interface with discharge planning, perform rounds, and dictate discharge summaries. Several authors have shown that these activities decrease the workload of attending physicians up to 4 hours a day, increase patient satisfaction scores, and increase adherence to Surgical Care Improvement Project protocol-driven metrics such as postoperative antibiotics and deep vein thrombosis prophylaxis.11,12 A study by Althausen et al12 demonstrated that although the PA's collections do not directly cover their salary, the indirect economic and patient care impacts are clear. By increasing ER efficiency and decreasing times to OR and lengths of stay while improving overall patient care, their existence is clearly beneficial to hospitals, physicians, and patients as well.
HOSPITAL-SUPPORTED POST-DISCHARGE TRAUMA CLINIC
This is an important part of any trauma service formation, especially in private practice due to the fact that many trauma patients are underfunded. A well run clinic can be financially beneficial to both the hospital and physicians alike. Integral components include:
- Multidisciplinary clinic for all specialties involved in trauma service
- An alternative to bringing the patients to the physician's private office
- All trauma patients are seen, not just unfunded/underfunded patients
- Significant fees generated for the hospital in diagnostic radiology (x-ray/computed tomography/magnetic resonance imaging), facility fees, durable medical equipment, and returns to the OR for follow-up procedures. Revenue positive for the hospital.
- Hospital-employed PAs/nurse practitioners can help staff clinic to decrease costs and provide continuity of care.
Orthopaedic trauma surgeons depend on a competent ER staff to perform initial triage of patients with bony injury to provide adequate patient care. Ordering appropriate radiographs and performing sound clinical exam is a must. Efficient and competent ER staff are also key components of a successful trauma system.
- Orthopaedic surgeons can be involved in teaching ER staff about compartment syndrome, vascular injury, and other orthopaedic emergencies
- Many ERs are known for poor splinting techniques that can harm patients and impact care. Orthopaedic surgeons can address this.
- Orthopaedic response time to consults is important for patient care, ER pull through, and time to OR.
- PAs hired by the trauma service have been shown to improve response time, decrease total ER time, and decrease time to the OR for orthopaedic trauma patients.12
- Ensure that ER has pelvic binders, traction pin setups, portable fluoroscopy for reductions, and adequate splinting and casting material.
- Interventional radiologists are important players in the management of pelvic and acetabular trauma. Make sure hospital has one.
- Plastic surgeon coverage for flaps and difficult wounds is a nice benefit.
- Very helpful to be able to view ER radiographs from home when on call.
Remember that this will not happen alone. Good communication between orthopaedic surgeons, trauma surgeons, and ER physicians is paramount. Establishing protocols and algorithms for common injury patterns and decision tree analysis for conditions such as pelvic fractures can be extremely helpful to reduce errors and improve care.
SUPPLY CHAIN MANAGEMENT
In the current era of healthcare crisis, every effort should be made by physicians to collaborate with hospitals to decrease costs and preserve quality patient care. Healthcare costs, per capita, in the United States are nearly twice that of our European counterparts and threaten our ability to compete in a global economy. Equally important is the financial burden these costs place on businesses and individuals. Although much is talked about with regard to rising healthcare costs, little effective change has been made. The costs of orthopaedic implants continue to rise, over 13% annually, in a market in which hospital profit and physician reimbursement continue to decline.
One study looked at the economics of total joint replacements over a 10-year period and found that while implant prices increased 171%, surgeon reimbursement declined 39% and hospital profit declined 92%.13
Hospitals have implemented various cost containment strategies but few have directly involved surgeons. Traumatologists must take an active role in supply chain management and resource utilization to preserve choice and access to adequate implants for fracture fixation
- Surgeon owned and managed distribution is a novel business model that may substantially reduce hospital implant costs by reducing the need for sales and marketing efforts while also improving the efficiency of distribution functions.
- Use of generic implants can also be very successful. At our facility, switching to generic cannulated screws alone saved $50,000/y14 Total savings on generics were over $330,000 in 2013 alone.
- Standardizing draping can also result in significant savings.
- Creating a matrix pricing system for vendors can result in a situation where choice is preserved but costs are decreased.15–19
- It is important that physicians plan ahead for more difficult cases or revisions. These cases can cost huge amounts of money. Physician request protocols for new products can cut unnecessary waste.
- Vendors attempt to control markets by offering volume discounts for institutions for an 80%–90% compliance rate. Hospitals never reach these numbers and usually never realize such savings.
- Implant companies are also now offering price discounts if surgeons agree to operate without sales representatives.
- Supply chain management also extends to floor activities such as durable medical equipment, switching wound vac companies, and standardizing cast/splinting/dressing materials.
Interestingly, hospitals view each change as a single year's savings. Administrators do not give credit for savings in the year following the change. This is important to realize in any hospital negotiations.
ROLE OF PHARMACY
Orthopaedic care and pharmacy services cross most commonly regarding perioperative antibiotics, anticoagulation, pain control, bowel care, and blood transfusions. Medication costs can be astronomical and attention to detail can result in massive savings. Attention to these issues is important in any comanagement agreement or hospital negotiations involving the value added proposition of the orthopaedic traumatologist.
One of the most common medications prescribed by orthopaedic surgeons is antibiotics. Antibiotic management is a significant cost center for hospitals for patient care, payment, and regulatory reasons.
- Orthopaedic surgical site infections prolong total hospital stays by a median of 2 weeks per patient, approximately double rehospitalization rates, and increase healthcare costs by more than 300%20
- Many insurance plans no longer pay for costs associated with postoperative infections
- Resistance is a growing problem that will add to healthcare costs
- Nonadherence to Surgical Care Improvement Project protocols will result in massive income loss
- Postoperative antibiotics are included in pay-for-performance measures
Developing a systemwide protocol based on scientific results, and not merely physician preference, is important from both a clinical and legal perspective.
Anticoagulation is a significant issue for orthopaedic trauma surgeons and arthroplasty surgeons in particular. No clear cut answers exist but a community standard should be developed. There have been guidelines proposed by the American College of Chest Physicians on which most lawyers base their cases. With regard to total hip (THA) and total knee arthroplasties, studies suggest that risk for developing these complications may exist for as long as 3 months following surgery. In 1 recent study, cost-effectiveness analyses were performed on 3 pharmacoprophylaxis regimens administered over a 30-day period using literature-reported values for incidences of deep vein thrombosis and pulmonary embolism in patients post-discharge following THA. A cost savings of $21,466.89 will occur for each thromboembolic event avoided if daily low-dose warfarin is used routinely compared to enoxaparin 40 mg daily. Additionally, a cost savings of $18,618.10 is experienced if enoxaparin 40 mg daily for 4 days plus low-dose warfarin daily is administered versus enoxaparin 40 mg daily. Authors concluded that clinicians may choose to continue prophylaxis post-discharge with enoxaparin 40 mg daily for 4 days in combination with warfarin for 30 days in these patients until results of more definitive studies become available.21 This is just 1 example of cost associated with anticoagulation management. The AAOS and OTA are working on current recommendations to protect surgeons in this complicated issue.
Blood transfusion costs have been the study of many recent investigations soon to be published. These studies suggest that a large number of unnecessary blood transfusions were being ordered by orthopaedic surgeons. Not only does this adversely affect patient care, it results in substantial hospital costs due to the cost of blood products themselves, treatment of transfusion reactions, and prolonged lengths of stay. Protocols based in scientific study should be adopted.
PAIN MEDICINE AND ADJUVANTS
Lack of pain control is one of the primary reasons for prolonged length of stay. Adherence to multimodal pain regimens is paramount. Consultation with anesthesia providers and hospital pharmacists can assist with creation of protocols within your institution.
For many trauma patients on narcotic medications, constipation is an issue that can significantly prolong length of stay and delay discharge. Multiple forms of bowel medications exist. Interestingly, their costs vary widely. Make sure you are using cost effective and clinical effective protocols. Check with your hospital pharmacist before adopting an orthopaedic order set for your institution.
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