Equity360: Gender, Race, and Ethnicity—Trapped in the Joint Pain Vicious Cycle (Part II)

Although individual factors such as genetics and behavioral choices impact each person’s health, the length and quality of our lives is strongly influenced by the social determinants of health, which are the circumstances into which people are born, age, live, and work [1]. Generally, the social determinants of health consist of five main categories: (1) Economic stability, (2) neighborhood and physical environment, (3) education, (4) community and social context, and (5) the healthcare system (Table 1). Simply put, our living and working conditions are very powerful forces that can influence how vulnerable we are to disease and injury [1].

Table 1.

Five Key Social Determinants of Health

In my previous column [7], I discussed the joint pain vicious cycle. Within this cycle, we know that decreased levels of physical activity can lead to the development of life-threatening comorbid conditions like diabetes, heart disease, hypertension, and depression.

The joint pain vicious cycle is an equal opportunity employer—the affluent white man can become trapped just as easily as the low-income woman of color. But overall, women and individuals of color are much more likely to become trapped in this cycle because of the influence of social determinants of health [8] and this difference creates musculoskeletal health disparities. Surrounding and influencing both the joint pain vicious cycle and the ring of social determinants is private and public health policy (Fig. 1).

Fig. 1.

The Movement is Life Extended Vicious Joint Pain Cycle. The inner most vicious cycle is influenced by both the middle ring of social determinants and the outer ring of private and public health policy. (Published with permission from Zimmer Biomet.)

The Affordable Care Act (ACA) is an obvious example of policy impacting social determinants like “access to care”. The ACA expanded Medicaid in many states, resulting in millions more Americans obtaining health insurance. But having an insurance card does not mean one has equal or full access to health care [3, 12]. Patients with Medicaid have less access to health care compared to patients with Medicare. One study [11] found that only four of 29 musculoskeletal urgent care centers in Connecticut had unrestricted access for Medicaid patients, and 19 refused all patients with Medicaid. Many of these centers are owned by private physician groups. And so, for most patients with Medicaid in Connecticut, urgent care means going to the emergency room. I suspect that this is similar for most states in the nation.

Considering that emergency rooms have emergency medicine-trained physicians and specialists on call as well as advanced imaging capabilities, one could argue that going to a hospital emergency room offers patients greater peace of mind compared to an urgent care center, which may not be as fully equipped. But access to hospitals, and thus emergency rooms, is becoming more limited. What if your hospital is not within a reasonable driving distance for an emergency or an overcrowded emergency room resulted in delayed care compromising your health or physical function? We all have seen stories of the human cost of such scenarios and the data supports such adverse outcomes. Rural hospital closures increase inpatient mortality by a shocking 5.9% [6]. A total of 155 rural hospitals have closed since 2005 [10] and 46% are operating at a financial loss, making about 700 more at high risk of closure [9].

But access of care is not just a rural problem. The recent highly publicized closure of Hahnemann University Hospital in Philadelphia, PA, USA disrupted access to care for the urban under-insured in one of the largest cities in the United States. Dr. Kevin D’Mello, a former hospitalist at Hahnemann, recently wrote that safety-net hospitals “play an important role in maintaining the health and safety of the public, just as police and fire departments do” [4].

As individual orthopaedic surgeons, we cannot change the low reimbursement rates of Medicaid or fund safety-net hospitals. But there are some actions we can take to address some of these challenges:

1. Provide care for patients with limited insurance benefits. I understand surgeons can actually lose money by treating patients with limited insurance, but if your practice does not accept patients on Medicaid, for example, consider seeing such patients at a federally qualified health center a half a day once a month. In my opinion, we have a responsibility to care for those less fortunate in our communities and every orthopaedic surgeon can afford to donate such a small amount of time.

2. Do not discriminate against patients trapped in the joint pain vicious cycle. The reality is that obesity is less of a modifiable risk factor than we may think and far more challenging for the individual with adverse social determinants of health [5]. Restrictions based on BMI have been fueled by new payment models in which the surgeon can have a financial interest in the bundled cost of care, encouraging “cherry picking” of health patients and “lemon dropping” of high-risk patients. I agree with a recent editorial on BMI cutoffs that “surgeons don’t have to operate on anyone we don’t want to treat, and increasingly we’re being held to financial account for the complications that result from our elective procedures. I believe this combination can result in surgeons setting unrealistic or impossible health goals for patients who seek particular interventions, and withholding those interventions from patients when they inevitably (or nearly inevitably) fall short” [5]. Beyond the financial ramifications in play here, I also believe that surgeons have an unconscious bias to contend with. White men still dominate orthopaedic surgery—is there discomfort when an obese woman of color presents with severe knee osteoarthritis? Let us look at patients first as human beings and not as risk factors for adverse outcomes.

3. Educate your patients on how essential movement is to their health. As stated in Part I of this column [7], we can and should counsel our patients to increase their levels of physical activities.

4. Support your local hospital. Recent Centers for Medicare & Medicaid Services (CMS) policy changes removed both TKA and THA from the in-patient only list, which further challenges the margin generated by orthopaedic procedures for hospitals. Hospitals must now find alternative ways to maintain a financial margin on patients who undergo TKAs or THAs. As orthopaedic surgeons, we should support our local hospital’s efforts to lower implant costs and improve hospital quality processes that can potentially decrease the risk of readmission. Hospitals that fail to decrease readmission rates are at risk of financial penalty from CMS, particularly if the hospital is in a bundled payment model.

5. Support adding risk adjustments to medical payments based on social determinants of health and medical comorbidities through your professional organizations. Insurance companies who provide Medicare health maintenance organization plans receive differing levels of payment from CMS based on the risk profile of their population. Yet hospital and surgeons do not. Medicaid payments must increase to promote access for these patients. Our voice must be heard by government and elected officials. Underserved patients depend on us.