Decreasing care disparities in orthopedics


Improving health equity is rapidly becoming a top priority across the healthcare industry. In the U.S., many disadvantaged populations experience systemic healthcare disparities that result in higher rates of disease, disability, and death. Members of these groups face pervasive obstacles due to their socioeconomic status, racial or ethnic identity, age, gender, location, and/or native language, and are more likely to have poor health status as well as more limited means and ability to access care.

In orthopedics, disparities in care manifest primarily as lower utilization rates among lower-income and minority populations. While the prevalence of knee and hip osteoarthritis does not vary greatly by race or ethnicity in the U.S., the data indicates that Black patients are more than 30% less likely to receive a total hip or knee replacement than White patients, even after adjustments are made for age, sex, and income.

Patients with state-funded Medicaid and federally funded Medicare encounter various barriers to securing musculoskeletal (MSK) care, including lower referral rates to orthopedic surgeons. Even after Medicaid expansion was codified into law by the Patient Protection and Affordable Care Act, one study found that patients with commercial insurance were twice as likely to be accepted for an orthopedic appointment as patients with Medicaid.

For patients living with daily pain, the cost of not having surgery can be tremendous, leading to significant functional impairment in the activities of daily living. Anyone who has suffered from low back pain understands how debilitating orthopedic conditions can be. When it is painful to get up and move, patients can become depressed and sedentary, leading to an increased risk of developing related comorbidities, including obesity, diabetes, and cardiovascular disease.

To reduce these healthcare disparities, orthopedic practices must consider how they engage disadvantaged populations. By identifying new processes, policies, and technology, orthopedic practices can promote greater health equity in the communities they serve.

Improving patient access to care

Federal legislation can help remove barriers to orthopedic care for lower-income patients. For example, in the two years after the Affordable Care Act was passed, utilization of Medicaid-funded total hip and total knee arthroplasty procedures increased by 19% in states that expanded Medicaid coverage.

New bundled payment models can also alleviate some of the reimbursement disparity that results from increasing a practice’s percentage of federally funded patients. The American Academy of Orthopaedic Surgeons recommends that orthopedic episodes of care be risk-adjusted for patient demographics, socioeconomic status, comorbidities, and severity of illness to compensate for variable treatment costs.

Evolving reimbursement policies, including federal incentives to provide accessible digital care management tools, can also improve orthopedic care utilization among disadvantaged populations. Implementing remote care management, monitoring, and messaging tools eliminates the need for patients to attend multiple in-person appointments, and keeps patients connected to their care teams regardless of their geographical location. In-person preoperative appointments can be replaced with virtual education classes, while virtual physical therapy (PT) can supplement or replace traditional outpatient PT, saving patients co-pays, travel costs, and logistical challenges.

According to the American Hospital Association, transportation barriers—including long travel distances, poor mobility, and the lack of a vehicle—are one of the leading causes of missed medical appointments for elderly patients. Digital care management tools make care more accessible for a variety of vulnerable populations, including patients in rural communities, patients who rely on a walker or other assistive device, and patients whose work or childcare circumstances limit their availability for in-person appointments.

Ensuring technology is accessible for all populations

In many rural and low-income communities, limited high-speed internet and insufficient access to a computer impedes the use of digital care, telehealth, and remote monitoring solutions. According to the Pew Research Center, almost a third (27%) of adults living in households earning less than $30,000 a year are smartphone-only internet users.

The technological infrastructure of a care management platform must support all patient populations, including the 43% of lower-income adults without broadband services at home; it  must also be mobile-friendly and SMS-enabled. Multimodal access, including two-way text messaging, is ideal for engaging patients with complex healthcare needs. Compared to other forms of communication, texting has the greatest reach, with open rates of 95% or above.

Digital care management tools must also be easy to use for all populations, regardless of health literacy, technological prowess, or English proficiency. Older age, minority membership, and low socioeconomic status are disproportionately correlated with poor health literacy in both urban and rural populations. For patients who are not native English speakers, the language barrier only compounds these challenges. A multi-year study on healthcare utilization among Hispanic adults found that limited English proficiency functions as a major barrier to care, resulting in the underuse of medical services.

Delivering relevant content at the right moment in time

Delivering clear care management instructions on a digital platform, in the patient’s native language, can improve the comprehension gap patients experience. One study found that 51% of patients failed to recall their physician’s oral recommendations and treatment guidance, due to limited participation during in-person appointments and a lack of effective follow-up communications.

An effective digital care management system will push out relevant information at the optimal point in the patient’s care journey. Segmented, phased content delivery drives continued patient engagement, as does the ability to link caregivers or care partners to the patient’s account. For example, providing the adult child of an elderly postoperative patient with access to their parent’s care plan can help ensure better clinical outcomes.

Remote monitoring and physician messaging tools can keep patients connected to their care team throughout an episode of care, enabling targeted interventions when necessary. For example, physicians can be notified in real time when a postoperative patient experiences a setback. By monitoring patients from afar, orthopedic practices can determine which patients are adhering to their care plan and which require extra support. This optimizes the workflow of time-starved navigators and nurses, who can then spend their time on the patients who need them most.

Direct physician/patient messaging tools can also help to reduce avoidable readmissions, as patients have an open line of communication with their care team. Educating patients on what constitutes a medical emergency for their condition can prevent them from heading immediately to the ER or urgent care clinic with a non-emergent issue.

Preparing for a more equitable future

CMS recently issued its proposed Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System rule for fiscal year 2023, which includes three health equity-focused measures for adoption in the Hospital Inpatient Quality Reporting program. As health equity becomes a major focus of federal policy, orthopedic departments, practices, and ambulatory surgical centers will need to prepare for regulatory changes.

In the near future, healthcare organizations will likely need to document how they collect health equity data, screen patients for social determinants of health, and address disparities in care.

Orthopedic teams must also build strong relationships with their patients, especially members of at-risk populations who are likely to need additional support. Implementing accessible digital care management, remote monitoring, and messaging applications can help orthopedic providers scale their business while consistently supporting all patients throughout their recovery.



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