Improving healthcare equity is quickly becoming a top priority throughout the healthcare industry. In the US, many disadvantaged populations experience systemic health care disparities that lead to higher rates of disease, disability, and death. Members of these groups face pervasive barriers due to their socioeconomic status, racial or ethnic identity, age, gender, location, and/or native language, and are more likely to have poor health, as well as more limited means and ability for access to care.
In orthopedics, disparities in care manifest primarily as lower rates of utilization among lower-income and minority populations. Although the prevalence of osteoarthritis of the knee and hip does not vary significantly by race or ethnicity in the United States, data show that black patients are more than 30% less likely to have a total hip or knee replacement than white patients, even after adjustments were made for age, sex, and income.
Patients with state-funded Medicaid and federally-funded Medicare face various barriers to obtaining musculoskeletal (MSK) care, including lower referral rates to orthopedic surgeons. Even after Medicaid expansion was codified into law through the Patient Protection and Affordable Care Act, a study found that patients with commercial insurance were twice as likely to be admitted for an orthopedic examination than patients with Medicaid.
For patients living with daily pain, the cost of no surgery can be overwhelming, leading to significant functional impairment in daily activities. Anyone who has suffered from low back pain understands how debilitating orthopedic conditions can be. When it is painful to get up and move, patients can become depressed and sedentary, leading to an increased risk of developing related comorbidities, including obesity, diabetes, and cardiovascular disease.
To reduce these health care disparities, orthopedic practices must consider how they engage underserved populations. By identifying new processes, policies, and technologies, orthopedic practices can promote greater health equity in the communities they serve.
Improving patient access to care
Federal legislation can help remove barriers to orthopedic care for lower-income patients. For example, in the two years since the passage of the Affordable Care Act, the use of Medicaid-funded total hip and knee replacement procedures increased by 19% in states that expanded Medicaid coverage.
New bundled payment models may also alleviate some of the disparity in reimbursement that results from an increase in the practice’s percentage of federally funded patients. The American Academy of Orthopedic Surgeons recommends this orthopedic episodes of care to be risk-adjusted for patient demographics, socioeconomic status, comorbidities, and disease severity to account for variable treatment costs.
Evolving reimbursement policies, including federal incentives to provide affordable digital care management tools, may also improve utilization of orthopedic care among underserved populations. Implementing remote management, monitoring and messaging tools eliminates the need for patients to attend multiple in-person appointments and keeps patients connected to their care teams regardless of their geographic location. In-person preoperative appointments can be replaced with virtual educational classes, while virtual physical therapy (PT) can supplement or replace traditional outpatient PT, saving patients copays, travel costs, and logistical challenges.
According to the American Hospital Association, transportation barriers — including long distances, poor mobility and lack of a vehicle — are among the leading causes of missed medical examinations for elderly patients. Digital care management tools make care more accessible to a variety of vulnerable populations, including patients in rural communities, patients who rely on a walker or other assistive device, and patients whose work or childcare limits their availability for in-person appointments .
Ensuring that technology is accessible to all population groups
In many rural and low-income communities, limited high-speed Internet and insufficient computer access hinder the use of digital care, telehealth, and remote monitoring solutions. According to the Pew Research Center, nearly one-third (27%) of adults living in households earning less than $30,000 a year are internet users only on smartphones.
The technology infrastructure of the care management platform must support all patient groups, including the 43% of lower-income adults without broadband services at home; it should also be mobile friendly and support SMS. Multimodal access, including two-way text messaging, is ideal for engaging patients with complex healthcare needs. Compared to other forms of communication, text messages have the greatest reach, with open levels of 95% or above.
Digital care management tools must also be easy to use by all populations, regardless of health literacy, technology savvy, or English proficiency. Older age, minority status, and low socioeconomic status are disproportionately associated with poverty health literacy in both urban and rural populations. For non-native English patients, the language barrier only compounds these challenges. That’s what a multi-year study on health care use among Hispanic adults found limited English proficiency functions as a major barrier to care, leading to underutilization of medical services.
Delivering the right content at the right time
Providing clear care management instructions on a digital platform, in the patient’s native language, can improve the experience of patients with a lack of understanding. One study found that 51% of patients they failed to recall their doctor’s verbal recommendations and treatment guidelines, due to limited participation during face-to-face meetings and lack of effective follow-up communication.
An effective digital care management system will push relevant information to the optimal point in the patient’s care journey. Segmented, tiered content delivery results in ongoing patient engagement, as does the ability to link caregivers or care partners to the patient account. For example, giving an adult child of an adult postoperative patient access to their parent’s care plan may help ensure better clinical outcomes.
Remote monitoring and physician messaging tools can keep patients connected to their care team throughout the care episode, enabling targeted interventions when needed. For example, doctors can be notified in real time when a post-operative patient is experiencing a setback. By monitoring patients remotely, orthopedic practices can determine which patients are sticking to their care plan and which need additional support. This streamlines the workflow of time-strapped navigators and nurses, who can then devote their time to the patients who need it most.
Direct doctor-patient messaging tools can also help reduce avoidable readmissions because patients have an open line of communication with their care team. Educating patients about what constitutes a medical emergency for their condition can prevent them from immediately going to the emergency department or urgent care clinic with a non-urgent problem.
Preparing for a fairer future
CMS recently issued its proposed Hospital Prospective Payment System and Long-Term Care Hospital Prospective Payment System rule for fiscal year 2023, which includes three measures targeting health equity for acceptance into the Hospital Hospital Quality Reporting Program. As health care equity becomes a major focus of federal policy, orthopedic departments, practices, and ambulatory surgery centers will need to prepare for regulatory changes.
In the near future, healthcare organizations will likely need to document how they collect health equity data, screen patients for social determinants of health, and address disparities in care.
Orthopedic teams also need to build strong relationships with their patients, particularly with members of at-risk groups who are likely to need additional support. Implementing affordable digital care management, remote monitoring and messaging applications can help orthopedic providers grow their business while consistently supporting all patients throughout their recovery.