JBJS | Recent Socioeconomic Trends in Orthopaedic Practice

The Journal of Bone & Joint Surgery, Volume 83, Issue 7

The Orthopaedic Forum | July 01, 2001

Recent Socioeconomic Trends in Orthopaedic Practice

James H. Herndon, MD, MBA; Stephen M. Davidson, PhD; Alexios Apazidis, MBA

James H. Herndon, MD, MBA
Partners HealthCare System, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB 624, Boston, MA 02114

Stephen M. Davidson, PhD
Boston University School of Management, 595 Commonwealth Avenue, Boston, MA 02215

Alexios Apazidis, MBA
Boston University School of Medicine, 12 Rose Way, Randolph, MA 02368

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone & Joint Surgery. 2001; 83:1097-1105

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Introduction

In the last fifteen years, there have been great changes in the American health-care system. Driven by an increasingly persistent concern about double-digit increases in expenditures, large employers have led a mass migration from indemnity insurance to managed care¹. The transition process has not been particularly smooth, however, leading to a backlash against managed care on the part of the general public and physicians^2,3. In this article, we examine socioeconomic trends in orthopaedic practice that occurred during this period, including issues related to the workforce, the changing population, and managed care.

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Fig. 1:: Bar graph showing trends in the demographic makeup of the population according to changes in age⁹.

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Fig. 2:: Graph showing trends in arthroplasty of the knee, hip, and ankle¹¹.

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Fig. 3:: Graph showing trends in the reduction of fractures¹¹.

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Fig. 4:: Graph showing trends in arthroplasty of the upper extremity and hand¹¹.

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Fig. 5:: Graph showing trends in the prevalence of orthopaedic conditions from 1980 to 1995¹².

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Fig. 6:: Profiles showing variations in the use of surgical treatment for different conditions in 1996 and 1997. The use of surgery for the treatment of hip fracture showed the least variation; nearly all hip fractures were treated surgically. The range of variation in the surgical treatment of other types of musculoskeletal problems was far greater; lumber discectomy was the most variable. Each point represents the range of the procedure in each of the 306 hospital referral regions. (Reprinted, with permission, from: Dartmouth Medical School, Center for the Evaluative Clinical Sciences. The Dartmouth atlas of musculoskeletal health care. Chicago: American Hospital Association Press; 2000. p 141.)

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TABLE I: Trends in Population, Number of Orthopaedists, and Number of Office Visits to Orthopaedists from 1975 to 19977,8

Year	Population	No. of Orthopaedists	No. of Orthopaedic Office Visits	No. of Visits/Orthopaedist	No. of Visits/1000 Persons
1975	215,972,000	8120	19,000,000	2340	?88.0
1980	226,546,000	10,700	27,600,000	2579	121.8
1985	237,923,000	13,000	31,500,000	2423	132.4
1990	248,764,000	14,200	32,900,000	2317	132.3
1995	262,764,000	17,100	40,426,000	2364	153.8
1996	265,189,000	17,600	35,800,000	2034	135.0
1997	267,746,000	18,500	34,400,000	1859	128.5
% change	24.0	127.8	81.1	—20.6	?46.0

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TABLE I: Trends in Population, Number of Orthopaedists, and Number of Office Visits to Orthopaedists from 1975 to 19977,8

Year	Population	No. of Orthopaedists	No. of Orthopaedic Office Visits	No. of Visits/Orthopaedist	No. of Visits/1000 Persons
1975	215,972,000	8120	19,000,000	2340	?88.0
1980	226,546,000	10,700	27,600,000	2579	121.8
1985	237,923,000	13,000	31,500,000	2423	132.4
1990	248,764,000	14,200	32,900,000	2317	132.3
1995	262,764,000	17,100	40,426,000	2364	153.8
1996	265,189,000	17,600	35,800,000	2034	135.0
1997	267,746,000	18,500	34,400,000	1859	128.5
% change	24.0	127.8	81.1	—20.6	?46.0

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TABLE II: Data on Selected Orthopaedic Procedures Performed from 1982 to 19979*

*Except for the total number of orthopaedic procedures, the values are given as thousands of procedures per year.

	1982	1983	1984	1985	1986	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997
Type of procedure
?Open reduction of fracture	434	423	436	492	459	481	456	479	391	418	417	423			432	428
?Closed reduction of fracture	256	237	241	240	214	205	183	192								214
?Excision or destruction of intervertebral disc	227	258	277	323	338	352	340	355	305	306	319	333			288	293
?All arthroplasties of knee	137	147	164	160	185	210	204	228	234	287	282	289	311	312	328
?All arthroplasties of hip	148	159	184	196	201	212	206		358	352	368	362	372	398	414	144
?All arthroplasties of ankle									??6	??9	??6	??4	??2	??5
?All arthroplasties of hand, fingers, and wrist									?14	?14	?11	??7	??8	??5	??3
?All arthroplasties of upper extremity (except hand)									?74	?82	?85	?88	?78	?82	?69
Total no. of orthopaedic procedures (in millions)	3.6	3.8	3.7	3.5	3.5	3.5	3.1	3.17	3.13	3.3	3.3	3.22			3.13	3.17

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TABLE II: Data on Selected Orthopaedic Procedures Performed from 1982 to 19979*

*Except for the total number of orthopaedic procedures, the values are given as thousands of procedures per year.

	1982	1983	1984	1985	1986	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997
Type of procedure
?Open reduction of fracture	434	423	436	492	459	481	456	479	391	418	417	423			432	428
?Closed reduction of fracture	256	237	241	240	214	205	183	192								214
?Excision or destruction of intervertebral disc	227	258	277	323	338	352	340	355	305	306	319	333			288	293
?All arthroplasties of knee	137	147	164	160	185	210	204	228	234	287	282	289	311	312	328
?All arthroplasties of hip	148	159	184	196	201	212	206		358	352	368	362	372	398	414	144
?All arthroplasties of ankle									??6	??9	??6	??4	??2	??5
?All arthroplasties of hand, fingers, and wrist									?14	?14	?11	??7	??8	??5	??3
?All arthroplasties of upper extremity (except hand)									?74	?82	?85	?88	?78	?82	?69
Total no. of orthopaedic procedures (in millions)	3.6	3.8	3.7	3.5	3.5	3.5	3.1	3.17	3.13	3.3	3.3	3.22			3.13	3.17

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TABLE III: Trends in Income for Orthopaedic Surgeons and Selected Other Physicians, 1987 through 1997*

*The values are given, after expenses and before taxes, in constant 1987 dollars as derived with use of the Bureau of Labor Statistics Inflation Calculator, found at stats.bls.gov.

Type of Specialists	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	% Change, 1987-1997
Average annual income (in thousands)
Orthopaedists	216.9	241.5	238.1	246.2	228.2	234.7	252.0	238.2	240.9	247.0	234.3	+8.0
All surgeons	187.9	199.3	202.0	205.5	195.0	202.8	206.5	195.7	200.8	199.3	185.0	—1.5
General internists	107.5	111.3	114.8	109.4	111.5	112.5	115.8	113.5	118.9	117.2	124.4	+15.7
Family practice	?91.5	?90.8	?87.9	?89.3	?93.0	?92.6	?91.8	?93.1	?97.8	100.7	?99.7	+9.0
All physicians	132.3	139.0	142.7	147.8	142.3	147.1	148.8	140.0	145.7	144.1	141.3	+6.8
Median annual income (in thousands)
Orthopaedists	200.0	212.2	206.1	234.7	195.2	202.4	212.3	208.5	186.4	202.7	194.6	—2.7
All surgeons	153.0	172.9	164.9	173.8	166.8	170.0	176.9	167.9	167.7	166.5	153.6	+0.4
General internists	100.0	104.7	109.9	104.3	104.3	106.9	117.9	115.0	111.8	108.6	106.2	+6.2
Family practice	?80.0	?81.6	?82.5	?80.8	?81.7	?81.0	?86.5	?84.3	?92.4	?94.1	?93.4	+16.8
All physicians	108.0	115.2	114.5	113.0	115.9	121.5	122.6	115.0	119.3	120.2	116.1	+7.5

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TABLE III: Trends in Income for Orthopaedic Surgeons and Selected Other Physicians, 1987 through 1997*

*The values are given, after expenses and before taxes, in constant 1987 dollars as derived with use of the Bureau of Labor Statistics Inflation Calculator, found at stats.bls.gov.

Type of Specialists	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	% Change, 1987-1997
Average annual income (in thousands)
Orthopaedists	216.9	241.5	238.1	246.2	228.2	234.7	252.0	238.2	240.9	247.0	234.3	+8.0
All surgeons	187.9	199.3	202.0	205.5	195.0	202.8	206.5	195.7	200.8	199.3	185.0	—1.5
General internists	107.5	111.3	114.8	109.4	111.5	112.5	115.8	113.5	118.9	117.2	124.4	+15.7
Family practice	?91.5	?90.8	?87.9	?89.3	?93.0	?92.6	?91.8	?93.1	?97.8	100.7	?99.7	+9.0
All physicians	132.3	139.0	142.7	147.8	142.3	147.1	148.8	140.0	145.7	144.1	141.3	+6.8
Median annual income (in thousands)
Orthopaedists	200.0	212.2	206.1	234.7	195.2	202.4	212.3	208.5	186.4	202.7	194.6	—2.7
All surgeons	153.0	172.9	164.9	173.8	166.8	170.0	176.9	167.9	167.7	166.5	153.6	+0.4
General internists	100.0	104.7	109.9	104.3	104.3	106.9	117.9	115.0	111.8	108.6	106.2	+6.2
Family practice	?80.0	?81.6	?82.5	?80.8	?81.7	?81.0	?86.5	?84.3	?92.4	?94.1	?93.4	+16.8
All physicians	108.0	115.2	114.5	113.0	115.9	121.5	122.6	115.0	119.3	120.2	116.1	+7.5

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TABLE IV: Trends in Total Expenses for Orthopaedic Surgeons, 1987 through 1998*

*The values are given in thousands.

	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	1998	% Change, 1987-1998
Nominal dollars	175	206	221	211	222	257	302	291	305	290	310	324	+85.1%
1987 dollars	175	197.8	202.5	193.4	185.2	208.1	237.4	223.1	227.4	210.0	219.4	225.8	+29.0%

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TABLE IV: Trends in Total Expenses for Orthopaedic Surgeons, 1987 through 1998*

*The values are given in thousands.

	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	1998	% Change, 1987-1998
Nominal dollars	175	206	221	211	222	257	302	291	305	290	310	324	+85.1%
1987 dollars	175	197.8	202.5	193.4	185.2	208.1	237.4	223.1	227.4	210.0	219.4	225.8	+29.0%

The Number of Orthopaedic Surgeons

Between 1970 and 1997, the number of orthopaedic surgeons in the United States increased by 145%, from 7537 to 18,500⁴. The nation’s population increased during that period as well, but not nearly as fast, resulting in almost a doubling of the ratio of orthopaedic surgeons to the population, from 3.6 per 100,000 in 1970 to 6.9 per 100,000 in 1997. The distribution of orthopaedists is not uniform across the country; the highest density is in New England and the lowest, in the Midwest and South Central regions of the country. Among the areas with more than the national average of orthopaedists per 100,000 people are Evanston, Illinois (9.8); Hartford and New Haven, Connecticut (9.3 each); Providence, Rhode Island (9.3); and San Francisco, California (9.1). Those with fewer than the national average include Tucson, Arizona (6.1); Detroit and Ann Arbor, Michigan (5.7 and 4.9, respectively); Manhattan, New York (5.6); Las Vegas, Nevada (5.2); and Memphis, Tennessee (5.0)⁵.

An important implication of these trends is that orthopaedists today—especially those in areas with the highest density of orthopaedic surgeons—have fewer patients available to treat than did their counterparts thirty years ago. This raises many important questions. Was there a deficit in the number of orthopaedists in the 1970s that has been rectified by these trends? Has the prevalence of musculoskeletal conditions requiring the services of orthopaedists increased during this period? Has the development of new technologies made it possible to treat conditions that either were not amenable to treatment then or that can be treated more effectively now? If the answer to these questions is "yes," then the increased number of orthopaedists may be justified by conditions. If not, then how do orthopaedists today earn a satisfactory income? Do they do other things in addition to orthopaedic surgery? Do they provide additional services that they previously would have avoided? Do they charge more for their services today? Are they becoming more specialized as a result of technological developments? And how have they been affected by the countervailing forces generated by the cost-containment pressures of managed care?

In the discussion that follows, we will attempt to answer some of these questions. To the extent possible, given the available data, we will describe trends, try to explain them, and discuss implications for the future.

What Do Orthopaedists Do?

In spite of the near doubling in the number of orthopaedic surgeons relative to the general population, a 1998-1999 survey conducted by the American Academy of Orthopaedic Surgeons found that almost all orthopaedic surgeons (86.1%) are engaged in full-time clinical practice. Moreover, the 10.6% who reported that they practice only part-time spend more than two-thirds of their time in clinical practice⁶. Full-time practitioners reported working an average of fifty-seven hours a week, seeing an average of twenty-two new patients each week, and providing seventy follow-up visits, twelve hospital visits, and six visits to hospital emergency departments⁶. In addition, they perform an average of fifty-two surgical procedures each month⁴.

Trends in Office Visits

Between 1975 and 1997, while the United States population increased by 24%⁷, the number of office visits to orthopaedists also increased, by 81.1%, a difference of 57%⁸ (Table I). This means that, on average, individuals used orthopaedists’ services in 1997 more than they did in 1975, as shown by the 46% increase in the number of visits per 1000 persons (Table I). As measured at five-year intervals, the number of visits per orthopaedist reached a high of 2579 per physician in 1980 and decreased gradually to 2364 in 1995. The downward trend continued in 1996 and reached a low of 1859 in 1997.

A possible explanation for these trends in orthopaedic practice is that the numbers of people who are vulnerable to problems that are treated by orthopaedists increased more than the rest of the population did. One such group comprises individuals who are sixty-five years of age or older; their numbers increased by more than nine million (37%) during that period⁹. The elderly are subject to higher rates of pain in the joints, falls, and bone cancer. However, the increase in the population of adults between the ages of twenty-five and sixty-four years dwarfed that of the elderly, in terms of both sheer numbers (almost eighty million) and percentage (134%) (Fig. 1). Since a lifestyle trend during much of this period was an increase in physical exercise, the rate of broken bones and related ailments undoubtedly increased as well. Thus, it is possible that the need for care grew as a result of increases in both the number of elderly individuals and the number of adults who exercise. We will explore this possibility below.

Trends in Surgery

Given the population trends just described, it is somewhat surprising that the total number of orthopaedic procedures in the United States has declined since 1982 (earlier data not available), from about 3.6 million in 1982 to 3.17 million in 1997¹⁰ (Table II). The utilization of certain procedures increased dramatically, however, probably reflecting advances in technology. Thus, between 1982 and 1996, the number of all arthroplasties of the hip, including replacements, increased by 180%, and that of all arthroplasties of the knee, including replacements, increased by 140%. The frequency of excision or destruction of intervertebral discs also increased considerably during this period but then decreased; thus, only 29% more of these procedures were done in 1997 compared with 1982, despite the population increase. The numbers of other procedures for which data are available tended to remain relatively constant or to decrease (Figs. 2, 3, and 4)¹¹.

The Prevalence of Conditions Treated by Orthopaedic Surgeons

The primary determinant of the number of orthopaedic procedures should be the prevalence of conditions for which those procedures are the treatment of choice. Determining what the "right" amount of surgery should be thus depends on two variables that are difficult to measure: the prevalence of specific conditions and agreement on the treatment of choice.

The best data that are available on the first variable, the prevalence of specific musculoskeletal conditions, come from responses to the National Health Interview Survey conducted each year by the National Center for Health Statistics. In this survey, representative samples of respondents are asked whether they or members of their family have had certain specific conditions, including several orthopaedic conditions. While this method may lack a degree of precision, if we assume that individuals overestimate or underestimate the presence of conditions similarly from year to year, then the responses from these annual surveys permit the construction of reasonable trends in the prevalence of those conditions. As seen in Figure 5, the prevalence of arthritis as well as that of "deformities and impairments" increased substantially after 1980, but most other reported conditions either decreased or remained relatively constant¹².

The other key variable determining what the rate of specific orthopaedic procedures should be is identification of "the treatment of choice." As shown in The Dartmouth Atlas of Musculoskeletal Health Care, there is considerable variation in the rates of different surgical procedures⁵. With some conditions, such as hip fracture, there is widespread agreement that surgery is the appropriate treatment; thus, there is little variation in surgical rates from region to region. With many other conditions, however, physicians have considerable discretion in choosing a treatment because of "underlying problems in medical decision making that occur because of inadequate science and failure to take patient preferences into account"⁵.

Partly for these two reasons, there is considerable variation in the rates at which specific orthopaedic procedures are performed throughout the United States. Another factor is the ratio of surgeons to the population, as shown in a series of studies of small-area variations in health-services utilization, begun by Wennberg in the early 1970s^13,14. Figure 6 shows dramatically different profiles of variation in the use of specific surgical procedures. Thus, on the left of the figure, there is a relatively narrow range in the rates of surgery for hip fractures, while the elongated range on the right shows great differences in the rates of lumbar discectomy from one geographic area to another. Hopefully, as optimum procedures are identified and this information is shared, initially in local health-care systems and eventually regionally and nationally, these variations will diminish.

Another area of increasing need that has been filled in part by orthopaedists is the treatment of severe pain that often accompanies increasingly prevalent chronic conditions. In a recent study in Connecticut, for example, 32%, 64%, and 33% of patients with cancer, arthritis, and neuropathy, respectively, reported having been referred to orthopaedists for treatment of the pain¹⁵. In fact, orthopaedists were the most common referral specialists for treatment of the pain associated with all three conditions.

Impact of the Growth in Managed Care

The proportion of the population covered by managed-care plans increased dramatically during the period under study. In 1996, the national prevalence was 29.2%, but that figure understates the impact of managed care in at least two ways. First, a number of states with large cities and a correspondingly large share of physicians had considerably higher rates; examples include Massachusetts (51.9%), Minnesota (47.1%), and California (45.6%). Second, these figures represent not only a substantial fraction of some markets but also rapid growth. Thus, nationally, seventy-seven million Americans were enrolled in various types of managed-care organizations in 1996, almost double the 40.4 million who were enrolled in 1991¹⁶. Even with considerable room for continued growth, managed-care organizations represented a force to be reckoned with in many of the nation’s largest health-care markets in 1997.

These are important observations because, as one of several cost-containment strategies, managed-care organizations were expected to redistribute services from more expensive specialists, including orthopaedic surgeons, to less costly primary-care physicians. Indeed, from the evidence presented, it appears that, throughout much of the period since the mid-1970s, orthopaedists performed fewer procedures and that, beginning in the mid-1980s, the average number of office visits per orthopaedist also decreased (Table I). In spite of these data, many orthopaedists feel that they are working harder than ever. The growth of managed care may have contributed to these developments, not only by imposing barriers to specialty care, including orthopaedists’ services, but also by increasing administrative burdens¹⁷. Although there are no direct quantitative data yet to substantiate that possibility (and although managed-care organizations may have increased the role of primary-care physicians in rationing the use of specialty services), complaints from both physicians and patients about the activities of managed-care organizations have proliferated, giving rise to a backlash against managed care^2,3.

Trends in Orthopaedists’ Earnings

Despite the dramatic growth in the orthopaedist-to-population ratio reported earlier, and despite reductions in both the number of office visits and the number of procedures performed, net annual incomes for orthopaedic surgeons from 1987 through 1997 increased by 52.6% in nominal dollars, from $217,000 to about $331,000¹⁸. Average net annual incomes for family practitioners and for orthopaedists increased at about the same rate during that period of massive increases in managed care. In terms of purchasing power, orthopaedists’ net average income rose by 8%, as expressed in constant 1987 dollars, despite a decrease in 1997, the last year of this period (Table III). Over the same period, tax-deductible professional expenses increased by 85% in nominal dollars and by 29% in 1987 dollars (Table IV). When the median is used instead of the average, however, orthopaedists in the middle of the distribution lost 2.7% in terms of purchasing power. The median is a better measure of the overall impact on orthopaedists because it does not give extra weight to the very high incomes earned by a relatively small number at the top of the distribution. In this regard, orthopaedists are not much different than the other physicians represented in the table, except for family practitioners, whose income distribution is less variable than that of physicians in other specialties. Although these figures represent the national picture as a whole, substantial regional variations may exist and orthopaedists in some areas may have had a better financial experience than those in other areas.

Overview

The number of orthopaedists has been increasing faster than the population for many years. Although we cannot answer our first question as to whether this increase erases a deficit or reflects a surplus, we can conclude that, unless other compensatory changes also occurred, that fact alone would create serious challenges for orthopaedic surgeons trying to maintain the same level of productivity as in the early 1970s. Even if the increasing number of elderly individuals moderates this tendency, each physician will continue to have a smaller pool of patients from which to draw. A recent study suggests that chronic disabilities among older Americans, including conditions with implications for orthopaedic practice, are decreasing¹⁹. Consistent with this trend, the average number of surgical procedures per physician decreased somewhat, although the mix of procedures changed, and the average number of office visits held steady through much of the period before it began to decrease in the mid-1990s. In spite of the decreases in surgical procedures and office visits and the dramatic increase in managed care, orthopaedists’ incomes continued to increase; however, in terms of purchasing power, the median income decreased slightly between 1987 and 1997. In contrast, the median incomes of other physician groups increased in constant 1987 dollars.

If both the supply of surgeons and the restraints on spending continue, whether through managed care or other mechanisms, orthopaedists will continue to face daunting constraints, primarily because they will have access to fewer patients. In addition, other providers of musculoskeletal health care will continue to compete for the same patients, and the effects of new nonoperative treatments facilitated by advances in biotechnology are unknown. The picture could improve for orthopaedic surgeons if the demand for underutilized services, such as joint-replacement surgery for degenerative conditions, especially among minorities and women⁵, increases; if technological developments increase the capacity to treat patients who have musculoskeletal conditions; if new treatments for pain associated with increasingly prevalent chronic conditions are developed; or if trends in the physician-population ratio reverse. Barring these or similar developments, however, it is likely that orthopaedists will find the demand for their services, their traditional autonomy, and perhaps their incomes, under continuing pressure.

References

Jensen GA, Morrisey MA, Gaffney S,Liston DK. The new dominance of managed care: insurance trends in the 1990s. Health Aff (Millwood),1997;16: 125-36. 16125 1997 [PubMed]

Blendon RJ, Brodie M, Benson JM, Altman DE, Levitt L, Hoff T, Hugick L. Understanding the managed care backlash. Health Aff (Millwood). 1998;17:80-94.

The Managed Care Backlash. Special Issue. J Health Polit Policy Law,1999;24: 24 1999

Dartmouth Medical School. Center for the Evaluative Clinical Sciences. The Dartmouth atlas of health care. Chicago: American Hospital Publishing; 1996. p 87-103

Dartmouth Medical School. Center for the Evaluative Clinical Sciences. The Dartmouth atlas of musculoskeletal health care. Chicago: American Hospital Association Press; 2000. p 19-26, 138, 140

American Academy of Orthopaedic Surgeons. Orthopaedic practice in the United States, 1998/99. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1999. p 2, 23.

Bureau of the United States Census. Statistical abstract of the U.S.: 1999. Washington, DC: United States Government Printing Office; 1999. p 8.

National Center for Health Statistics:National Ambulatory Medical Care Survey: 1975-1998. Summary. Washington, DC: Division of Health Care Statistics, CDC/National Center for Health Statistics.

Bureau of the United States Census. Statistical abstract of the United States: 1970-1999. Washington, DC: United States Government Printing Office.

National Center for Health Statistics: National Ambulatory Medical Care Survey: 1982-1998. Summary. Washington, DC: Division of Health Care Statistics, CDC/National Center for Health Statistics.

National Center for Health Statistics: National Hospital Discharge Survey: 1982-1998. Summary. Washington, DC: Centers for Disease Control and Prevention, National Center for Health Statistics.

National Center for Health Statistics: Current estimates from the National Health Interview Survey: 1975-1988. Series 10. Washington, DC: National Center for Health Statistics.

Wennberg J,Gittelsohn A. Small area variations in health care delivery. Science,1973;182: 1102-8. 1821102 1973 [PubMed]

McPherson K, Wennberg JE, Hovind OB,Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med,1982;307: 1310-4. 3071310 1982 [PubMed]

Davidson SM et al. Chronic pain in the State of Connecticut. Unpublished data.

Hoechst Marion Roussel. HMO-PPO/Medicare-Medicaid digest. Kansas City, MO: Hoechst Marion Roussel; 1997. p 8.

Mechanic D, McAlpine DD,Rosenthal M. Are patients’ office visits with physicians getting shorter?. N Engl J Med,2001;344: 198-204. 344198 2001 [PubMed]

American Medical Association: Trends in the physician market, AMA Socioeconomic Monitoring System, 1988-1989. Chicago: American Medical Association.

Freudenheim M. Decrease in chronic illness bodes well for Medicare costs. New York Times 2001 May 8; www.nytimes.com/2001/05/08/health.

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Fig. 1:: Bar graph showing trends in the demographic makeup of the population according to changes in age⁹.

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Fig. 2:: Graph showing trends in arthroplasty of the knee, hip, and ankle¹¹.

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Fig. 3:: Graph showing trends in the reduction of fractures¹¹.

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Fig. 4:: Graph showing trends in arthroplasty of the upper extremity and hand¹¹.

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Fig. 5:: Graph showing trends in the prevalence of orthopaedic conditions from 1980 to 1995¹².

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TABLE I: Trends in Population, Number of Orthopaedists, and Number of Office Visits to Orthopaedists from 1975 to 19977,8

Year	Population	No. of Orthopaedists	No. of Orthopaedic Office Visits	No. of Visits/Orthopaedist	No. of Visits/1000 Persons
1975	215,972,000	8120	19,000,000	2340	?88.0
1980	226,546,000	10,700	27,600,000	2579	121.8
1985	237,923,000	13,000	31,500,000	2423	132.4
1990	248,764,000	14,200	32,900,000	2317	132.3
1995	262,764,000	17,100	40,426,000	2364	153.8
1996	265,189,000	17,600	35,800,000	2034	135.0
1997	267,746,000	18,500	34,400,000	1859	128.5
% change	24.0	127.8	81.1	—20.6	?46.0

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TABLE I: Trends in Population, Number of Orthopaedists, and Number of Office Visits to Orthopaedists from 1975 to 19977,8

Year	Population	No. of Orthopaedists	No. of Orthopaedic Office Visits	No. of Visits/Orthopaedist	No. of Visits/1000 Persons
1975	215,972,000	8120	19,000,000	2340	?88.0
1980	226,546,000	10,700	27,600,000	2579	121.8
1985	237,923,000	13,000	31,500,000	2423	132.4
1990	248,764,000	14,200	32,900,000	2317	132.3
1995	262,764,000	17,100	40,426,000	2364	153.8
1996	265,189,000	17,600	35,800,000	2034	135.0
1997	267,746,000	18,500	34,400,000	1859	128.5
% change	24.0	127.8	81.1	—20.6	?46.0

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TABLE II: Data on Selected Orthopaedic Procedures Performed from 1982 to 19979*

*Except for the total number of orthopaedic procedures, the values are given as thousands of procedures per year.

	1982	1983	1984	1985	1986	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997
Type of procedure
?Open reduction of fracture	434	423	436	492	459	481	456	479	391	418	417	423			432	428
?Closed reduction of fracture	256	237	241	240	214	205	183	192								214
?Excision or destruction of intervertebral disc	227	258	277	323	338	352	340	355	305	306	319	333			288	293
?All arthroplasties of knee	137	147	164	160	185	210	204	228	234	287	282	289	311	312	328
?All arthroplasties of hip	148	159	184	196	201	212	206		358	352	368	362	372	398	414	144
?All arthroplasties of ankle									??6	??9	??6	??4	??2	??5
?All arthroplasties of hand, fingers, and wrist									?14	?14	?11	??7	??8	??5	??3
?All arthroplasties of upper extremity (except hand)									?74	?82	?85	?88	?78	?82	?69
Total no. of orthopaedic procedures (in millions)	3.6	3.8	3.7	3.5	3.5	3.5	3.1	3.17	3.13	3.3	3.3	3.22			3.13	3.17

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TABLE II: Data on Selected Orthopaedic Procedures Performed from 1982 to 19979*

*Except for the total number of orthopaedic procedures, the values are given as thousands of procedures per year.

	1982	1983	1984	1985	1986	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997
Type of procedure
?Open reduction of fracture	434	423	436	492	459	481	456	479	391	418	417	423			432	428
?Closed reduction of fracture	256	237	241	240	214	205	183	192								214
?Excision or destruction of intervertebral disc	227	258	277	323	338	352	340	355	305	306	319	333			288	293
?All arthroplasties of knee	137	147	164	160	185	210	204	228	234	287	282	289	311	312	328
?All arthroplasties of hip	148	159	184	196	201	212	206		358	352	368	362	372	398	414	144
?All arthroplasties of ankle									??6	??9	??6	??4	??2	??5
?All arthroplasties of hand, fingers, and wrist									?14	?14	?11	??7	??8	??5	??3
?All arthroplasties of upper extremity (except hand)									?74	?82	?85	?88	?78	?82	?69
Total no. of orthopaedic procedures (in millions)	3.6	3.8	3.7	3.5	3.5	3.5	3.1	3.17	3.13	3.3	3.3	3.22			3.13	3.17

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TABLE III: Trends in Income for Orthopaedic Surgeons and Selected Other Physicians, 1987 through 1997*

*The values are given, after expenses and before taxes, in constant 1987 dollars as derived with use of the Bureau of Labor Statistics Inflation Calculator, found at stats.bls.gov.

Type of Specialists	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	% Change, 1987-1997
Average annual income (in thousands)
Orthopaedists	216.9	241.5	238.1	246.2	228.2	234.7	252.0	238.2	240.9	247.0	234.3	+8.0
All surgeons	187.9	199.3	202.0	205.5	195.0	202.8	206.5	195.7	200.8	199.3	185.0	—1.5
General internists	107.5	111.3	114.8	109.4	111.5	112.5	115.8	113.5	118.9	117.2	124.4	+15.7
Family practice	?91.5	?90.8	?87.9	?89.3	?93.0	?92.6	?91.8	?93.1	?97.8	100.7	?99.7	+9.0
All physicians	132.3	139.0	142.7	147.8	142.3	147.1	148.8	140.0	145.7	144.1	141.3	+6.8
Median annual income (in thousands)
Orthopaedists	200.0	212.2	206.1	234.7	195.2	202.4	212.3	208.5	186.4	202.7	194.6	—2.7
All surgeons	153.0	172.9	164.9	173.8	166.8	170.0	176.9	167.9	167.7	166.5	153.6	+0.4
General internists	100.0	104.7	109.9	104.3	104.3	106.9	117.9	115.0	111.8	108.6	106.2	+6.2
Family practice	?80.0	?81.6	?82.5	?80.8	?81.7	?81.0	?86.5	?84.3	?92.4	?94.1	?93.4	+16.8
All physicians	108.0	115.2	114.5	113.0	115.9	121.5	122.6	115.0	119.3	120.2	116.1	+7.5

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TABLE III: Trends in Income for Orthopaedic Surgeons and Selected Other Physicians, 1987 through 1997*

*The values are given, after expenses and before taxes, in constant 1987 dollars as derived with use of the Bureau of Labor Statistics Inflation Calculator, found at stats.bls.gov.

Type of Specialists	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	% Change, 1987-1997
Average annual income (in thousands)
Orthopaedists	216.9	241.5	238.1	246.2	228.2	234.7	252.0	238.2	240.9	247.0	234.3	+8.0
All surgeons	187.9	199.3	202.0	205.5	195.0	202.8	206.5	195.7	200.8	199.3	185.0	—1.5
General internists	107.5	111.3	114.8	109.4	111.5	112.5	115.8	113.5	118.9	117.2	124.4	+15.7
Family practice	?91.5	?90.8	?87.9	?89.3	?93.0	?92.6	?91.8	?93.1	?97.8	100.7	?99.7	+9.0
All physicians	132.3	139.0	142.7	147.8	142.3	147.1	148.8	140.0	145.7	144.1	141.3	+6.8
Median annual income (in thousands)
Orthopaedists	200.0	212.2	206.1	234.7	195.2	202.4	212.3	208.5	186.4	202.7	194.6	—2.7
All surgeons	153.0	172.9	164.9	173.8	166.8	170.0	176.9	167.9	167.7	166.5	153.6	+0.4
General internists	100.0	104.7	109.9	104.3	104.3	106.9	117.9	115.0	111.8	108.6	106.2	+6.2
Family practice	?80.0	?81.6	?82.5	?80.8	?81.7	?81.0	?86.5	?84.3	?92.4	?94.1	?93.4	+16.8
All physicians	108.0	115.2	114.5	113.0	115.9	121.5	122.6	115.0	119.3	120.2	116.1	+7.5

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TABLE IV: Trends in Total Expenses for Orthopaedic Surgeons, 1987 through 1998*

*The values are given in thousands.

	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	1998	% Change, 1987-1998
Nominal dollars	175	206	221	211	222	257	302	291	305	290	310	324	+85.1%
1987 dollars	175	197.8	202.5	193.4	185.2	208.1	237.4	223.1	227.4	210.0	219.4	225.8	+29.0%

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TABLE IV: Trends in Total Expenses for Orthopaedic Surgeons, 1987 through 1998*

*The values are given in thousands.

	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997	1998	% Change, 1987-1998
Nominal dollars	175	206	221	211	222	257	302	291	305	290	310	324	+85.1%
1987 dollars	175	197.8	202.5	193.4	185.2	208.1	237.4	223.1	227.4	210.0	219.4	225.8	+29.0%