Social Determinants of Health, Payment Reform, and the Role of the Orthopaedic Surgeon

Addressing a patient’s socioeconomic needs is key to improving their overall health. Lack of access to housing, food, transportation, and employment has significant effects on both healthy patients and those managing chronic diseases. As we better understand the importance of social determinants of health (SDOHs), the debate about our role as doctors and surgeons will continue to evolve.

The authors’ recent article on procedure-based bundles and the commoditization of elective orthopaedic care discussed condition-based bundled payments as a possible solution as value-based payment models evolve (to learn more, read the article “Are Procedure-Based Bundled Payments Leading to the Commoditization of Elective Orthopaedic Care?” in the January issue of AAOS Now). Despite all their potential, condition-based bundles and other value-based payment models make us wonder how far upstream surgeons should or will play a role.

One must ask the questions: How much should orthopaedic surgeons seek to influence patients’ overall health? And how much can we effectively intervene? The former typically evokes a reflection of one’s ideals. The latter is a harsher reality—a reminder that to do good sustainably, we must all operate within a set of constraints that can temper even the loftiest aspirations.

How we answer these questions is partly rhetorical and partly philosophical, but also has direct impacts on things such as the patient-surgeon relationship or compensation for services. For example, in the condition-based model, the orthopaedic surgeon’s episode begins with the first clinic visit when a patient is typically seen for a specific condition, such as chronic knee osteoarthritis. First-line treatments for this and other chronic conditions are typically lifestyle changes such as exercise and weight loss, with possible medication use. However, many patients do not have access to healthy groceries and cannot afford medications. If SDOHs are critical to that patient’s outcomes with the condition in question, should the surgeon be partly responsible for those factors after meeting that patient in clinic?

On one hand, being fully responsible for SDOHs can lead to uncomfortable questions about the line where a person becomes a patient. Expanding the traditional bounds of patient interactions can lead to ethical dilemmas, where the healthcare system permeates every small decision impacting an individual’s health outcomes. Doing so can also hold physicians and healthcare systems liable for outcomes that they have no effective means of addressing.

On the other hand, if we play no role in upstream SDOHs despite our knowledge of their importance, we risk being too reactive and potentially missing critical opportunities to make a meaningful difference in the patient’s health. Preventative care is arguably the most important way to help people get and stay healthy, reducing overall healthcare costs downstream. The fact that our incentive system is largely reactive or based on “sick care” is a large part of the problem. Where is the sweet spot for orthopaedic surgeons to fit in?

AAOS recently adopted a new Strategic Plan to emphasize the leadership of orthopaedic surgeons in advancing musculoskeletal health. The word “health” was deliberately chosen over “healthcare,” representing a profound shift in how we view our role in caring for patients. With this shift in focus, we should also clearly articulate the bounds of our ability to effectively intervene. Doing so has important implications for not only value-based payment models but also the role of the surgeon in patient care. 

Understanding SDOHs
Historically, most health-related risk factors have fallen within a physician’s bounds for intervention. Most of these risk factors have been distinct characteristics or quantifiable parameters that can be addressed through lifestyle changes, medication, or procedures. SDOHs (e.g., access to education, employment, housing, or food) are far more abstract. Intervening on these factors is not something physicians are explicitly taught, as medical schools have only over the past decade added them to their curricula. Furthermore, SDOHs are commonly multifactorial and largely stem from elements outside of physicians’ area of influence. Even if we had the appropriate qualifications, attributable outcomes are more often linked to social policy, as opposed to individual patient-physician interactions, however meaningful they may be.

With longer-term relationships that encompass an individual’s full health, the primary care physician in the right setting is better equipped to address SDOHs. The American Medical Association has made addressing upstream SDOHs a part of its strategic vision. The vision entails that once patients are screened for SDOHs, healthcare professionals can connect them to appropriate resources. Medicare's current focus on developing accountable care organizations led by primary care physicians is aligned with this philosophy. It behooves the specialist to become part of the delivery system addressing SDOHs rather than being sidelined as purely problem-focused.  

Another important agent is the institution, be that a clinic, hospital, or system. For instance, in the wake of several years of increased firework hand-blast accidents managed at Level I trauma centers, the Los Angeles County Department of Health Services held numerous community education sessions on firework safety. Procedure-based bundles for total joint arthroplasty have prompted greater attention to preoperative optimization at the institutional level. Closer attention from the surgical team on smoking status, long-term glucose control, and BMI have allowed some groups to institute a more holistic approach to osteoarthritis care, including employing social workers and dietitians to help address the socioeconomic factors that impact surgical outcomes. In the health maintenance organization setting, electronic medical records are constructed such that care gaps can easily be addressed at any encounter with automated order sets. Though previously applied to screenings and management of chronic diseases, the approach has more recently been applied to link patients with community resources pertinent to their identified social needs. 

Partnering with our institutions and primary care colleagues to share our knowledge of musculoskeletal conditions with the community is also an excellent manner to actualize AAOS’ Strategic Plan regarding leadership in musculoskeletal health. Some may argue that simply resorting to education as our means of intervention is a cop out, that doing so rids surgeons of any real accountability regarding SDOHs. We argue that such a view minimizes the value of expert-led education and does not fully appreciate the surgeon’s value, which is to apply deep knowledge about a specific system to one patient at a time. Surgical training emphasizes this depth of expertise, and the healthcare system enables surgeons to focus on one problem at a time. To deviate substantially from this model is arguably a change in the role of the surgeon as we know it. In certain situations, the critical issue impacting a person’s well-being may be a chronic orthopaedic condition. Though a surgeon may not have the exact tools to address the root causes of socioeconomic risk factors, they can be an ideal partner to help patients navigate these factors while managing their conditions.

Acknowledging the limits of our expertise and ability to intervene is noble. It is also extremely difficult for surgeons to do. But it is worth considering, given the importance of striving for optimal surgical outcomes and addressing socioeconomic factors critical to our patients’ health. Though we may not be able to fully address SDOHs as surgeons, simply identifying them and discussing their importance with a patient can serve an important role in any payment system, whether that be fee-for-service, bundled payment, capitation, or something in between. Furthermore, fully appreciating the role of social, economic, and environmental factors in health outcomes can help refine risk adjustment and stratification in any model, potentially mitigating existing inequities in caring for patients with many social needs and a high comorbidity burden.

SDOHs and the discussions around them are challenging. How to address them is hotly debated. They are new in the professional setting to the orthopaedic surgeon, and our role is uncertain. Through identification, education, and partnership, we can make a meaningful impact while staying within our area of expertise. Whichever payment model becomes dominant in orthopaedic care, it is worth considering our points regarding SDOHs in all discussions on payment reform. Our decisions in this matter are critical for the patient and the person.

Tanmaya D. Sambare, MD, is an orthopaedic surgery resident at Harbor–UCLA Medical Center in Torrance, California.

John Andrawis, MD, MBA, is an arthroplasty surgeon and the director of value-based healthcare for the Department of Orthopaedics at Harbor–UCLA Medical Center.

Ronald A. Navarro, MD, FAAOS, FAOA, is the regional chief of orthopaedic surgery for the Southern California Permanente Medical Group and professor of orthopaedic surgery for the Kaiser Permanente School of Medicine. He is also a member of the AAOS Now Editorial Board.

Karl M. Koenig, MD, MS, FAAOS, is an associate professor of surgery and perioperative care, division chief of orthopaedic surgery, and executive director of the Musculoskeletal Institute at Dell Medical School at the University of Texas at Austin. Dr. Koenig is also chair of the AAOS Health Care Systems Committee.

References

1. Sambare T, Adnrawis J, Navarro R, et al: Are procedure-based bundled payments leading to the commoditization of elective orthopaedic care? AAOS Now January 2024;1;14-16.
2. AAOS: AAOS Strategic Plan: 2024-2028. Available at https://www.aaos.org/strategicplan. Accessed March 26, 2024.
3. American Medical Association: The AMA’s strategic plan to embed racial justice and advance health equity. Available at https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity. Accessed March 26, 2024.