The Journal of Bone and Joint Surgery

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Commentary & Perspective

Commentary & Perspective on
"Orthopaedic Surgeons Do Not Increase Surgical Volume After Investing in a Specialty Hospital"
by G. William Woods, MD, et al.

Commentary & Perspective by
Merrill Anderson Ritter, MD*,
Center for Hip and Knee Surgery, Mooresville, Indiana

In my view, there is no question that the development of specialty hospitals has been driven in part by financial incentives of individual physicians. Although the report by Woods et al. seems to show that this is not the case, there are many concerns that are not answered in their paper. First of all, the surgeons in the specialty group that was studied were already very busy; thus, it is probable that they could not increase their volume much. Secondly, we are not given sufficient information on the status of the patients with regard to Medicare/Medicaid eligibility or comorbidity. Thirdly, there were many surgeons in the group, each of whom likely had a different level of productivity.

We (the medical community) have probably contributed to the emergence of specialty hospitals by acquiescing to the changes in reimbursement and control that we face today. In the 1930s until the 1950s, my father, an internist, was paid a "fee-for-service." When I began the practice of orthopaedic surgery in 1969, I was also paid a "fee-for-service," but only to a degree. Over time, insurance companies have slowly reduced the reimbursements they pay while increasing the premiums to all those individuals needing health insurance. If reimbursements better reflected the work involved, and if the cost of malpractice insurance were more reasonable, this commentary might not have been necessary.

It is true that full-service hospitals have problems. For years, hospital administrators and physicians barely talked, and when they did, the conversation was often adversarial. Only recently, as a result of the rapid growth of the specialty hospitals, have administrators listened to the needs of physicians and patients. Unfortunately for full-service hospitals, the most substantial growth of specialty hospitals has been in the fields of orthopaedics and cardiovascular disease, both of which are very financially productive. Specialty hospitals have listened to the needs of physicians and patients with the understanding that, if something is broken—they will fix it. In fairness, the full-service hospitals would like to do the same thing, but they are encumbered by the bureaucracy inherent in a large institution that must strive to meet the needs of many deserving departments.

If specialty hospitals truly do not hurt the system, then they are offering a great service to the health-care community. The real costs to the health-care system are in the care of patients who receive Medicare or Medicaid, in the care of uninsured patients who come to the emergency room instead of a doctor's office for what are really outpatient needs, and in the care of uninsured inpatients. It is in this area of patient care that the specialty hospitals may be hurting the system.

Somehow both types of hospitals need to work together to develop a system in which everybody wins. This will only happen when it is financially acceptable to all parties.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Biomet) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.