1. Robert M Orfaly, MD, FRCS(C) Associate Professor Department of Orthopaedics & Rehabilitation Portland, Oregon

2. Disclosures Consulting and royalty agreement with Acumed, LLC No conflicts related to this topic

3. Background Our practice 20 full-time faculty surgeons 3 sports medicine physicians 2 physical medicine (PM&R) physicians 9 PAs ~ 90% of compensation plan based on clinical productivity; ie. very little salary component

4. Background Our practice Level 1 trauma center – 1 of 2 for the state Elective practice actively managed for uninsured/Medicaid care Large percentage of high complexity cases – orthopaedic and general medical

5. Background Our practice PAs see most new OHP/uninsured patients Majority do not need surgery PAs see all non-operative ER follow-ups and many routine post-op patients Physical therapy/hand therapy on site Bracing on site No ownership of imaging, ASC

6. What are CCOs really about? Gov Kitzhaber sees the old paradigm of balancing the books in public health care: Reduce reimbursement Reduce number of covered lives Reduce number of services covered First 2 seen as cost shifting since they decrease access to care and lead to more ER visits But what about the 3 rd option (more on this in a moment)

7. Value of CCOs Primary preventive medicine (decrease obesity, exercise, smoking cessation, etc) Poorly done in a doctors office Probably more to do with school programs than medicine Long time horizon: very little pay-off in the next 5 years when federal governments $1.9 billon investment comes due

8. Value of CCOs Secondary/tertiary prevention (prevent worsening and secondary sequelae of chronic disease) Eg. Better management of diabetes and hypertension to keep people out of the ER and avoid strokes, MIs This is the big push for CCOs with team concept to allow physicians to spend more time with patients; follow up by case workers to maximize compliance Much greater potential for realized cost savings in next 5 years

9. Value of CCOs Will it work? No one knows Orthopaedic surgeons should be on board If it works, better for the population Decreased number of medically unwell patients with high complication rates Being in the business of keeping people moving – this could be more of a boon than a threat to the bottom line

10. Value of CCOs So whats the problem? The money for all these extra services has to come from somewhere Global budget is frozen and specialist compensation is already being decreased (from a level that was below overhead to begin with) Value of much of what we do is being questioned (Potentially biggest challenge in my mind)

11. Value of CCOs So whats the problem? More government involvement – a good thing? Complexity of care environment likely to hasten shift to physicians salaried by large health care organizations. What will be the basis for any incentives? Governors example: Woman with CHF, lives in South, no A/C Summer temperature could cause her CHF to worsen; therefore use tax dollars to buy her A/C! Any concerns for abuse/misdirected dollars here?

12. Reducing number of services covered We saw a clear example of this with health plan offered to public employees last year Tiers of services established based on perceived cost vs benefit All of orthopaedics except tumor and trauma placed in 3 rd tier Increased deductibles to decrease state liability for each surgical procedure and decrease demand for surgery 4 th tier not covered at all

13. Reducing number of services covered We need to work as a profession to better establish/document the value of our services Orthopaedics should be seen as part of preventive medicine Painful joints less exercise greater obesity greater burden of chronic disease (DM, CHF, etc) Decreasing access to orthopaedic services should be seen as cost shifting in same way that knocking people off public assistance is

14. Reducing number of services covered We also need to understand the current need for cost containment and make sure that we can demonstrate cost efficiency ASC billing rates Use of MRIs, PT, etc Team approach (surgeons, non-interventional MDs, PAs) to decrease overall cost

15. Conclusion I like to argue that a consultation with me is cheaper than a PCP ordering misguided tests and therapy. They also stand to potentially miss the opportunity for early intervention. We need to make sure that these assertions are true by providing cost effective care, communicating well with other care providers, and making efforts to care for the entire population.