Roy W. Sanders, MD, is a board-certified orthopedic surgeon, focused on acute trauma and posttraumatic reconstruction, as well as foot and ankle surgery.
Dr. Sanders earned his medical degree at the New York University School of Medicine in New York City, and completed his residency at the Hospital for Joint Diseases Orthopaedic Institute, N.Y. He is president and CMO of Florida Orthopaedic Institute, director of the Orthopaedic Trauma Service and current chairman of University of South Florida's (Tampa, Fla.) department of orthopedic surgery.
He has also served as president of the Orthopaedic Trauma Association and is the current editor-in-chief of the Journal of Orthopaedic Trauma.
Dr. Sanders provides his insight into the challenges facing orthopedic surgeons today, how new payment models are affecting orthopedics and where he sees the biggest opportunity to advance the field.
Question: What are the one or two biggest challenges for you as an orthopedic surgeon today? What keeps you up at night?
Dr. Roy Sanders: Well to be fair, I sleep well at night now that I stopped taking trauma call. But the issues at hand are the continued loss of independence for a practitioner. This is coupled with the other issue which is downward price pressures. You understand that we are educated in patient care, not the business of medicine. But the business of medicine is the issue at hand which determines our ability to stay independent. Very few surgeons can develop a boutique fee for service cash business. As a result, many who cannot remain independent due to high overheads are forced into hospital employment. This is extremely demoralizing to most surgeons. Especially since hospital administrator incomes keep rising while that of the surgeon keeps falling. This is happening while the health system of the country is no better than before this all started, yet the hospital system mega-mergers won't stop anytime soon. Perhaps the physicians coming out of medical school now will have lowered expectations, but this has driven many older surgeons in to an earlier retirement than planned. All that wisdom and skill set lost. What a waste.
Q: How do you see bundled payments, value-based care and other new payment models affecting orthopedics?
RS: Again, it sounds good and it is helpful, however this is another method of forcing downward pressure on pricing. Many bundled payments started with modest incentives. Now that the efficiency has been baked in, the incentive and the price for those bundles keeps dropping. This puts surgeons in a difficult position as they need the revenue, so they have to see more patients. And the average visit time is now 11 minutes. How is that going to help patient satisfaction? In addition, the squeeze on their margins are so tight that many cannot afford to practice independently any longer. What profession are you aware of that is not allowed to raise its prices even just to keep up with cost of living? This occurs with every vendor we have to deal with as a business, but the price of our services goes down, not up. Hence the emergence of the last vestige of independent practice; the large single specialty practice.
Q: Where is the best opportunity for orthopedic surgeons to advance the field?
RS: This is also very interesting. In the past, surgeons had solutions to difficult problems and went to the implant manufacturer and developed product. This accounts for the explosion of orthopedics over the last 30 years. Trauma, arthroplasty, sports medicine and spine surgery have all benefitted from the entrepreneurial and imaginative surgeon improving patient care. Now there are just a handful of large companies that limit their resources for research and development because they claim it is too expensive, so they buy proven technology instead. This has resulted in the emergence of surgeon-engineer partnerships, addressing one or two issues with novel solutions. While this is the way the industry is going, and it sounds great, most surgeons do not have the time or funds to finance design, development, patent applications, FDA approval, manufacturing, sterile packaging and legal costs before they can even start selling the product to get EBIDTA to attract a buyer. But at this point, I would say this is the only way to advance the field going forward and it is happening more and more.
So, to me the overarching issue at hand is that medicine has become big business. Insurers, hospital systems, EMR providers, big pharma and implant manufacturers, not to mention venture capital and private equity, make all the decisions. They have the lobbyists, and the funds to shape policy. The doctors are no longer really in charge of their own practices. The repercussions of this approach will be seen in the next decade.
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