Treating mental and social health: A call for alternative payment models in orthopaedic trauma

Introduction

The United States spends nearly 18% of its gross domestic product on healthcare, accounting for the highest spending of any other nation.¹ Despite this spending and advances in medical care, the United States has the worst health outcomes among high-income countries² and is not ranked anywhere near the top 10 of global health.³ It is now well understood that access to quality clinical care accounts for only about 20% of patient outcomes, while the remaining 80% are influenced by psychosocial and other nonmedical factors.⁴ This recognition calls for a reassessment of traditional standards of care and a shift beyond the conventional fee-for-service medical model toward a whole-person approach that integrates physical, mental, and social health. In an effort to reduce cost and improve care delivery, the Patient Protection and Affordable Care Act of 2010 proposed the National Pilot Program on Payment Bundling, suggesting alternative, value-based care models that prospectively provide a fixed payment for an episode of care, shifting responsibility of cost saving and improvements in care delivery to hospitals and providers.⁵ While effective in meeting these objectives in episodes of care related to total joint replacement,^6–8 this model has not fully translated to meeting the unique, complex needs of patients with orthopaedic trauma, particularly mental and social health needs.

Multiple studies indicate the profound adverse effect of untreated mental health disorders on surgical outcomes and overall cost of care, particularly in orthopaedics. Depression, for example, has been linked to poorer surgical outcomes and higher cost in orthopaedic joint replacement and traumatic injury repair when compared to nondepressed populations.^9–12 Orthopaedic patients who have sustained traumatic injury are also at higher risk of developing anixety, acute stress or postraumatic-stress disorder (PTSD), further interrupting functioning and impeding ability to engage in recovery activities if left untreated.^13–15

Social health's impact on mental health and recovery in orthopaedic trauma

Orthopaedic trauma is uniquely focused on the care of fractures after a traumatic event that often require urgent surgery. The traumatic event may be the result of risky behaviors (drug/alcohol influence, extreme sports), unsafe environments/situations (gunshot wounds, assault), or mental health conditions (suicide attempt). In such patients, preoperative risk factor modification of mental health disorders may not be possible, adversely affecting surgical outcomes.^10,16 While untreated mental health may be the direct causal link to sustaining orthopaedic injury, symptomology can also be the result of the event itself. Patients with orthopaedic trauma are at higher risk of developing psychological distress,¹⁵ depression,^9,14 anxiety,¹⁷ and PTSD¹³ secondary to the traumatic event and the substantial effect unanticipated surgery and recovery has on multiple aspects of life.

Many patients with orthopedic trauma with untreated mental health disorders experience symptoms that are directly caused or worsened by social health determinants such as food insecurity,^18,19 social isolation,^20,21 unsafe neighborhoods,²² and economic instability.^23,24 Social stressors can negatively affect health by indirectly changing health behaviors²⁵ and damaging bodily tissues through over exposure of stress hormones.^25–27 When such stressors are ongoing, mental health becomes adversely affected, putting individuals in a state of chronic stress and higher risk of inducing anxiety and depression,^28–30 negatively affecting recovery and overall quality of life.

Recent literature has given much attention to social determinants of health (SDoH) leading to the Centers for Medicare and Medicaid Services requirement that admitted patients be screened for 5 SDoH domains.³¹ While inpatient settings have medical social workers available to support patients with brief intervention and resource linkage, outpatient clinics often do not as these services are not reimbursed, thus, unsustainable. Additionally concerning, patients with orthopaedic trauma who screen negative for these domains upon admission may experience a decline in social health during recovery, directly connected to unanticipated injury and functionality barriers. Thus, screening for SDoH and mental health symptomology in the outpatient setting may be an important step towards a whole-person approach to health care and should exist within a health care system that can sustainably provide patients with what they need to address these modifiable risk factors.

Conclusion

The level of complexity associated with orthopaedic trauma patient surgery, treatment, and recovery is not solely correlated to medical complexity, thus should not be reimbursed as such. Despite the bidirectional, interrelated nature of mental/social health and physical health, the American approach to orthopaedic trauma remains siloed as current health care reimbursement policies only pay for direct medical care of specific physical diagnoses, while not supporting resources to promote care of the substantial mental health conditions and social determinants of health that also make major contributions to patient outcomes.^4,22 Untreated mental and social health dramatically increase healthcare cost and have adversely affected outcomes in orthopaedic trauma, calling for a risk-adjustment payment model that enables providers the resources needed to address the mental and social health issues that increase treatment complexity and can adversely affect patient outcomes. Without this radical shift in healthcare billing, policy, and care models, spending will increase in orthopaedic trauma and contribute to America's risk of declining further from its already low place in global health rankings.