Dr. O’Connor hosts panel discussing how the perception of risk in surgery can widen health disparities.

Risk is an intrinsic part of medical decision making. Every drug and every procedure must justify their benefit relative to any risks involved, so healthcare providers are very conscious of these risks and outcomes. In this podcast discussion with a panel of fellow orthopedic surgeons, Dr. Mary O’Connor (Yale New Haven Hospital) leads a discussion about ways that perceptions of risk can influence medical practice when additional financial consequences are added to the mix – a result of changing reimbursement and payment models. When patients are not considered an acceptable risk for surgery, does the selection and rejection assessment introduce bias, and are certain patient populations disadvantaged by this process? Featuring Dr. Ramon Jimenez, Dr. Charles Nelson, and Dr. Chick Yates.

Episode Transcription

Dr. O’Connor hosts panel discussing how the perception of risk in surgery can widen health disparities.
Published: January 27, 2021

Risk is an intrinsic part of medical decision making. Every drug and every procedure must justify their benefit relative to any risks involved, so healthcare providers are very conscious of these risks and outcomes. In this podcast discussion with a panel of fellow orthopedic surgeons, Dr. Mary O’Connor (Yale New Haven Hospital) leads a discussion about ways that perceptions of risk can influence medical practice when additional financial consequences are added to the mix – a result of changing reimbursement and payment models. When patients are not considered an acceptable risk for surgery, does the selection and rejection assessment introduce bias, and are certain patient populations disadvantaged by this process? Featuring Dr. Ramon Jimenez, Dr. Charles Nelson, and Dr. Chick Yates.

Dr. O’Connor: Welcome to a new year and a new episode of The Health Disparities Podcast produced by the Movement is Life Caucus. An initiative working to eliminate musculoskeletal health disparities so that everyone has an equal opportunity to enjoy a long life of movement and mobility free of pain. I’m Dr. Mary O’Connor chair of the Movement is Life Caucus and Professor of Orthopedics and Rehabilitation at Yale School of Medicine. Our podcast today focuses on the fascinating topic of whether perception of risk by physicians can influence medical practice, not just risk of the patient having a less than desirable outcome, but whether the risk of the cost of providing care to that patient would exceed a payment established by the patient’s medical insurer, either a private insurance company or Medicare. We will discuss these concepts in the context of a fascinating study recently published in the Journal of Arthroplasty, which is a leading medical publication. This research focused on how hip and knee replacement surgeons are being judged regarding both their quality and cost outcomes by payers. And how these surgeons, when they’re being compared to one another, how these comparisons don’t take into account that some patients are sicker than others. And how some patients have fewer personal resources or social support to help them recover after surgery. And whether these differences influence surgeons, perception of risk and their comfort level with risk. For full disclosure, I’m the senior author of the study, and I’m joined today by four of my co-authors who I’m going to ask to introduce themselves. First, Dr. Chick Yates, who is the first author on the study. Chick, tell us a little bit about you.

Dr. Yates: Mary, thank you for inviting us to participate tonight. I am an adult reconstruction surgeon. In other words, I perform total hip and total knee replacements at the University of Pittsburgh where I’m a professor and vice chairman. I’ve had an interest in risk adjustment and performance measures that have been put forth, going on over six or seven years and have helped to support the American Association of Hip and Knee Surgeons and asking for both better medical risk adjustments and also socioeconomic risk adjustment for those people that have less than great resources. The fact of the matter is that the Medicare not just the payers, at large, but Medicare, specifically, measures our hospitals in terms of their performance on complications and total joint replacement, re-admissions, under joint replacement, and also the cost of joint replacement. And in the next few years, there’s going to be subsequent measurement of individual surgeons, under the same, various different metrics. And unfortunately, it’s not an even playing field. These measurements of how well we take care of people after hip or knee replacement, carry cost implications for the hospitals where they may have to pay back up to millions of dollars of their Medicare reimbursement.

And they’re also being accounted for and reporting mechanisms such as the CMS Hospital Compare website, where they get five-star ratings versus no star ratings. And unfortunately, if patients come to us with marginal or just a little more risk, but that risk isn’t assessed in a way that it keeps it an even playing field, then surgeons are going to be put in a situation where they feel like they have to assume that in a competitive setting, they are going to be competing against other surgeons that might not take on that risk. And unfortunately, the competition over this is very narrow differences. It means that a few patients might make a difference in terms of winning or losing if you will, in terms of payment to the hospital or to the surgeon, and as a result, because it’s effectively set up as a zero-sum game, meaning that somebody wins and somebody loses, patients that have very mild, increased risk might be avoided so that the hospital or the surgeon can compete efficiently against all the other hospitals and surgeons that they’re being put up against. So, the critical component of this is that there’s competition over this. The competition is very tight. And the fact of the matter is that the actual risk adjustment isn’t adequate for the medical problems that patients might have let alone, there’s no risk adjustment whatsoever for those, factors that make it harder for patients, to reach the hospital or to get care because of being poor or being in an environment where transportation or other healthcare issues are put at risk.

So that’s as best as I can put it in layman’s terms, in terms of how we were looking at this. And we wanted to see if the members of the American Association of Hip and Knee Surgeons, felt that same risk. And whether or not they were feeling pressure from their hospitals within their groups to not take on certain patients, because they were afraid of losing what is effectively an unfair game.

Dr. O’Connor: Absolutely. Dr. Nelson, give us a little bit about your background and why you were interested in participating and supporting this research?

Dr. Nelson: My name is Charles Nelson. I’m a professor of orthopedic surgery and the chief of the adult reconstruction division at the University of Pennsylvania Perelman School of Medicine in Philadelphia. And I’ve had a long interest in what I call health equity, addressing health disparities and creating an even playing field for all patients. And this has been a long-term, interest of mine. Back in 2006, I co-chaired a meeting in Europe, with one of my mentors addressing many of these issues, as far as health disparities and diversity, and achieving culturally competent care across populations. I have many of the same concerns that Chick just elaborated on because one of the challenges we have is that we want to maintain access for vulnerable patients to receive care and as less and less people are willing to care for patients that are at significantly higher risk of complications, that creates challenges for those patients to get care and the places that do care for them, and there have been a number of hospitals in rural America, even in some urban cities that take care of what we called safety net hospitals that have actually closed down in the last five or 10 years. And part of that is because of some of the economic challenges of some of the penalties that occur from taking care of more complex patients who have less social support, less resources and increased medical comorbidities. So, I think this is a very, very important study for us to understand how surgeons react to some of these pressures. And in order to try to get some of our policymakers to consider these things, when they’re trying to create value-based healthcare. I’m a fan of value-based healthcare. I think it’s good that people are compared, and that people get credit for better outcomes. However, you have to make sure that it’s an even playing field and when you don’t have an even playing field, then you need to make sure that you’re not limiting access with some of the rules.

Dr. O’Connor: Thank you, Charles. Dr. Ramon Jimenez. Ramon, give us a little bit about your background.

Dr. Jimenez: Thank you for your kind introduction. My name is Ramon Jimenez. I identify myself as a community orthopedic surgeon. I’m born and raised in San Jose, California, which happens to be the 10th largest city in the United States. It’s also approximately 38%, Hispanic/Latino, or the Latin X population, however, you want to term it. After my training, I came back and I started practice, and I was a general orthopedist, but I had been exposed to, total joint replacements. And I have been doing them since 1969. So, I had a very strong interest in doing them. And then in my practice, I got to see it from all viewpoints. In the sense that I had two large offices, one in East San Jose, which is about 70% Hispanic/Latino, and then, another one in West San Jose, which was, closer to maybe 35% Hispanic/Latino in a more affluent community, part of the community. So, I would see all sorts of levels and then practicing at two fairly large private hospitals, I happened to rise to chief of staff at both of the hospitals, was on the boards of each of the hospitals, and I got to see the bottom line thinking that goes on at the hospitals and how they are also very attuned to the cost of surgery. And they were beginning to bundle payments, obviously when the cost is all tied to a certain diagnosis or procedure, then you can see that you have to filter. And filtering is good for some people and it’s bad for others. And that’s what’s been called now with these bundled payments, cherry picking and lemon dropping.

In another part of my life, I’m also founder and president of the American Association of Latino Orthopedic Surgeons. And we make up about 300 or so orthopedic surgeons who happen to be Latin X, but my other mission in life is also like Dr. Nelson has said is decreasing musculoskeletal health healthcare disparities for the marginalized populations. And I’ll talk about that later.

Dr. O’Connor: Thank you gentlemen, for those great introductions. I want to go back one step to make sure that our audience, who may not be as familiar with some of these new payment models as we are, that we refresh a little bit on what a bundled payment is. So, Charles, I’m going to ask you when a patient comes in to have a joint replacement, a hip or knee replacement with you, how are you and the hospital paid for providing that care? And we’ll just pick a Medicare patient, a patient who has Medicare as their insurance, as the example, because the majority of the patients who have hip and knee replacements are over 65 and under Medicare.

Dr. Nelson: At my hospital, they went into a voluntary bundled payment program with Medicare a number of years ago. Now, there are certain regions of the country where there is a mandatory, where you have to, go into a bundled payment program. At our bundled payment program, the one advantage was because we had gone into it voluntarily before it became mandatory, we were compared to ourselves earlier. So, if we did better than we had done previously, and if we targeted resources to help ourselves do better than we did previously, then we were, quote, “Winners.” And in that setting, we could still take care of the same complexity of patients that we have been taking care of all along. The challenge for some of the places that are in the mandatory bundles are that they’re compared to their surrounding community. So, if they’re taking care of the complex patients and other places around them are cherry picking, then they’re at a big disadvantage. Over time, everybody has a situation whereas you do better, it becomes harder and harder to continue to do better because essentially you cut out the things that are less necessary or not necessary, which is a good thing. But at some point, you run out of things that are less necessary or unnecessary in trying to achieve these goals.

The way the bundled care for Medicare worked is, we had our normal charge this in fees, but then at the end of it, Medicare would see how much they ended up paying us, and if they paid us less than they had previously, we would get a percentage of that income back because we had quote, “Saved them money”. And it wasn’t just what they had paid us, it’s also what they had paid any type of physical therapist that went to see the patients afterwards during that first 90 days or any rehab facilities or skilled nursing facilities.

Dr. O’Connor: So, just for clarity, you are both rewarded in the bundle if there were fewer dollars spent on taking care of those patients.

Dr. Nelson: Yes.

Dr. O’Connor: Okay. Dr. Yates.

Dr. Yates: We were part of the 34 metropolitan statistical areas that was part of the mandatory bundle and being part of the mandatory bundle meant that there was effectively no risk adjustment other than that, did separate out hip fractures from those patients that were having elected hip replacement. And other than that, the risk adjustment on the cost analysis, very quickly evolved after just a year into being a competition across a region, not just your local area, but we were competing against all the hospitals in New York, New Jersey and Pennsylvania.

It’s important to realize that the only place where you can show Medicare savings in something like that, at any substantial rate is really the post-acute care cost, which in layman’s terms means, the cost of care after the patient leaves the hospital for 90 days. The cost to the hospital is fixed. The cost to Medicare, what they pay the hospital is fixed. And so, it’s very competitive to try to lower the number of patients that go to nursing homes, that go to rehab facilities because that then makes you more competitive. That’s great if you’re in an environment where people can go home, but for a lot of patients that have challenges in terms of being poor, they might live on the fifth floor of an apartment. They can’t get up to five floors. They need a nursing home more than somebody that’s living in a split-level ranch home out in the suburbs. And so, it becomes a squeeze as you try to compete, and you keep working your way down to a lower and lower costs. And as such, there is pressure to reduce reversible risk when possible, and then, there becomes a more subtle pressure, to avoid irreversible risks in some patients, because your hospital and your hospital system can be concerned about this type of competition. Unfortunately, it has not been well risk adjusted they’re going to change that, and they’ve heard us over the last five years. And moving forward, Medicare is going to change it so that there’s at least a collection of various different medical problems that are going to be used for risk adjustment. So that it might even the playing field between one hospital in one region versus another. It’s very important to realize that whether or not you’ve engaged in a bundled payment agreement, electively. Whether it’s non-elective like we are and mandated, or whether or not you’re in a bundled care program with Medicare Advantage or commercial insurers, it’s very important to realize that Medicare is measuring every hospital, even the bundled hospitals in terms of their complication rates for joint replacement, re-admissions for joint replacements and the cost of total joint replacements, and all of those measures, unfortunately only have a modicum of risk adjustment, and none of them adjust for poverty or for people with social issues that makes them more vulnerable. And that’s the reason for our paper was to show that all of those pressures combined, ongoing, put pressure on the surgeons in terms of expectations from hospitals and their partners. The overall risk to the hospital in terms of the value-based purchasing and re-admission measures from, Medicare, they add up to about 6% of all of their CMS reimbursement. And that goes on regardless of whether or not you’re bundled or not. So, we’re all in competition all the time.

Dr. O’Connor: Chick, I’m going to come back to the findings of this study, but first I want to turn to Ramon. And Ramon I’d like for our listeners to expand a little bit on what we’re talking about when we’re talking about risks relative to socioeconomic status.

Dr. Jimenez: I think I can do that best by coming up with a scenario in which, my name is Juan Valdez, and I am here in the United States working. But my primary language is Spanish. My culture happens to be Mexico. 64% Hispanic, Latinos in the United States, are Mexican Americans. And so, I’m from Mexico. And, automatically I am probably one of these essential workers that are not paid well, but I do develop problems even after being here for 10 years, 15 years, and end up with a need for a hip replacement, according to what my doctor says. So, at that point, I have to trust my doctor. I have to trust the system that I am not going to be, I tend to use the word filter. Filtered out or dropped by the wayside because I happen to be overweight. And maybe my BMI is greater than 30 or 35 or 40, and, therefore, I’m an increased risk. It is well known and documented that; Hispanic Latinos have a much greater increase in diabetes mellitus Type 2. And I happen to have diabetes mellitus Type 2. It’s pretty well controlled. I think, because I talked to my doctor and the doctor says, “Well, you’ve got to keep working on it because 7.8, for a hemoglobin A1c is not that good. You got to get it down closer to 7 or below 7.” And so, I’m working on that. Because I am overweight. I have high blood pressure. So that’s three things going on for me. And my home is comfortable for me, but not since my daughter and her family living here. And so, it’s three bedrooms, nine individuals living here. And so, it increases the risk and increases the lack of support, the lack of being able to participate in post recovery care. So, all those mitigating factors really pile up on me. I feel like I’m the victim. I feel like I either have to trust the system that they’re not going to filter me out. There are intended consequences that occur because the healthcare providers and the facilities need to make a profit. So, even some of the religious orders are run hospitals, the Daughters of Charity, I know one of the hospitals came up with, I heard it at a board meeting, no profit, no mission because that’s what it really comes down to the bottom line.

Dr. O’Connor: So just for clarity, that individual, gentlemen would be better off going to a rehab facility where he stayed for another five days or seven days to just be a little more recovered after the joint replacement surgery. So, it was safer for him to return to that very congested home environment.

Dr. Jimenez: Exactly.

Dr. O’Connor: He would be walking safer. He would be at less risk of falling. What is the negative pressure on the surgeon to send that patient to a rehab facility after they leave the hospital? Why would the surgeon not do that?

Dr. Jimenez: Because it adds to the cost that goes into this bundled payment or this one figure that they want to keep within that limit because if they spend over the limit, because of rehab, it is difficult. Outpatient come to the in-house type of physical therapy is good. In fact, I had that myself in my own total knee revision, but there’s only two of us in a 3,000 square foot house. And so that’s completely different. The word you use were very accurate, safer. And I think the surgeon is risking safety. The whole situation, the healthcare is risking that additional added cost. If I fall down, break the hip, you have, what’s called a fracture around the prosthesis. And then you’re really in problems.

Dr. O’Connor: Charles.

Dr. Nelson: Just to follow up on that. You can make arguments about the safety of going home versus going to rehab and there’s pluses and minuses for each situation. But for some patients it’s just not safe for them to go home. So, imagine you have a patient who lives on the fourth or fifth floor walk-up in a dangerous neighborhood in the city where even walking with a cane is dangerous because somebody is likely to mug you. And this person has limited or no social support, nobody to help go bring food, so, he has food that he can get up. He can’t go up the stairs, five flights of stairs with no elevator carrying a bag of groceries a few days after surgery. That’s just not a possibility. And the situation gets even further magnified because in some cases, they got rid of what they call the inpatient only roll. So, now, some insurances will require that that patient be done as an outpatient to be discharged the same day and not provide payment for the hospital for the person to stay overnight. So that creates a further situation where some of these patients that the hospital is already concerned about taking care of, because they’re going to be an increased cost. There may be even further a tendency to not take care of those patients. So, it’s a very dangerous situation that really, compromises potential access to some of the marginalized patients, which if we look back historically have had less access to joint replacement even before these rules.

Dr. O’Connor: So, I want to explore for our listeners and a little bit more clarity who we see as those marginalized patients, Dr. Yates?

Dr. Yates: Well, the first thing I want to make really clear to anyone listening is that total joint replacement is a very safe operation and a very high rate of satisfaction for patients.

Dr. O’Connor: Absolutely.

Dr. Yates: And as an example, hip replacement is going to make a patient happy 95% of the time. Now the issue is that if there isn’t a way to level the playing field for all the problems we’ve talked about, somebody might go from a seven in a thousand chance of complications to a 15 in a thousand chance of complications and be seen as having twice the risk, and because everyone is under the assumption that all the other surgeons are avoiding that patient with risk, they pull their punches, they hold back. They don’t necessarily offer surgery to that patient. And that increase in risk could be their perception of that increase in risk from the literature. Or from their own experience for the patient being overweight for not having their sugars as well controlled as possible for having a mental health problem for being poor or having poor healthcare literacy or for living in a poor environment. Again, we’re talking about subtle changes in risk, but the overwhelming chance that they’re going to be made much better and their life is going to be improved ordinarily would outweigh that increased risk and between the surgeon and the patient, they would come to, what’s known as a shared decision that it’s worth a little bit more risk for that overwhelming chance that they’ll do well. Now that gets influenced when surgeons don’t feel like their hospital or they are going to be judged correctly in competition with all the other surgeons and hospitals that feel the same way that they’re in a zero-sum game. And so, for that small risk, those patients become marginalized, and they become what I call value refugees in the value-based medicine. And I think we have to figure out ways to increase the risk adjustment, which can be done. We’ve demonstrated that adding a few other elements to the medical risk adjustment can make it a much more powerful and even playing field. And I think for the sake of those patients that are being cared for by surgeons like Dr. Nelson in his state and Dr. Jimenez and my patients, I would like to be able to say that certain hospitals are recognized for taking on those patients and given a break or being told that you’re protected from the competition between each other. And perhaps you only compete against your historical self in terms of, how you do and how well you do with your patients. And that’s something that’s been rejected by CMS over the years. But it’s something that we do message to them and we do bring up and we go to the hill.

Dr. O’Connor: So, what I want to make sure that our audience understands is normally I would say that we would all agree conceptually, that we want to reward better behavior and not reward, or even penalize poor performance. And that’s kind of, I would say a very appropriate thing that as a culture, as a society in America, we would say that makes sense. That’s what we should do. Just for people to understand in the current payment model, you can get rewarded if your performance is better, but even if your performance is better, you may not actually be rewarded, meaning financially rewarded, because it would depend on how you compare to a whole bunch of other groups. And therein lies this issue of, I think, a greater perception of risk.

Dr. Yates: And let me just add Mary that one of the great things that came out of the paper is that effectively almost 99% of the responding surgeons said that if risk adjustment was better, they felt that access to care would be better. So, that’s one of the big take homes that we’re not talking about surgeons having significant biases against classes of patients or condition classes, medically. They’re very anxious to have it be an even playing field. And I think it’s, very reassuring that they all agreed for the most part, that would be a good goal to achieve.

Dr. O’Connor: Dr. Nelson. You want to comment on that?

Dr. Nelson: That is a critical finding. I actually was going to comment on the prior comment, but I think just to expand on what was being said about some of the marginalized patients, I had a patient that came in maybe a couple of months ago. So, this poor gentleman had been seeking care for three years, trying to get somebody to take care of his hip because he was extremely overweight. The guy drove to work three hours early every day. So, he could park close enough that he could walk to where he was working because otherwise, he wouldn’t be able to work. And he was busy working to try to support his daughter’s future college education and unfortunately, his wife had passed from breast cancer. So, this poor gentleman couldn’t get anybody to take care of him while he is driving to work two to three hours early every day, just to park close enough. That’s the kind of situation that some patients face themselves if there’s less people who are willing to take care of those patients until they find somebody who’s willing to care for them. So, it’s a big, big issue.

Dr. O’Connor: So, Charles, I’m going to go down in the weeds a little bit here. Exactly, what is it about that patient, you mentioned his obesity that makes him, someone that a surgeon would not want to take care of basically, or not want to offer the surgery to. Why is obesity a factor that surgeons look at and see higher risk?

Dr. Nelson: So, there’s a number of different things. There’s a study that came out of the Mayo Clinic, that was done whereas the patient’s weight goes up, the risk of infection and complications increases predominantly because there’s challenges of getting the wound to heal properly. It’s deeper, there’s more layers. The fat can [32:56 inaudible], and it has a tendency to drain for a longer period of time. The surgery itself is technically more challenging. It’s harder for the surgeon to do. They need more assistance. And in some cases, some surgeons genuinely may not have the assistance that they need if they work at a small hospital without a lot of support. So, I’m not saying that surgeons should take care of those patients automatically, but I think there needs to be risk adjustments so that people who have the facilities to take care of them well and do so at an acceptable risk profile, aren’t penalized for doing so because those people, they need care. And as Dr. Yates mentioned earlier, yes, the risk is higher and the Mayo Clinic study BMI of 50, the risk was three times higher than a normal BMI but the risk of infection in a normal BMI is one in 200. So, if you go from one in 200 to three in 200. Is the average patient going to say, “Wow, if it was one in 200, I would want that surgery, but now that it’s three in 200, I don’t.” And most people who have been suffering a long period of time, they’re not going to want that. So, I think it’s our job to provide good care for our patients when they deserve good care.

Dr. O’Connor: Ramon.

Dr. Jimenez: So, I wanted to ask a question of the other two, just because it’s perplexing to me is that we talk about leveling the playing field. We talked about, you can decrease the risk, adjust the risk somewhat if it’s reversible, but then we talk about incentivizing. I think there are surgeons out there who would take the time and take the effort and select the patients if the incentive, the pay or their financial fees were covered was conventionally increased for those types of patients. I think there would be more even the hospital might take that risk, for sure. What do we mean by incentivizing the patient or incentivizing the issue?

Dr. Yates: To be quite honest, I think that if at minimum, if patients with that much higher risk were excluded from the performance measures, I think you would see an explosion of people with those kinds of problems getting cared for, regardless of whether the surgeon got paid more or not.

Dr. Jimenez: Exactly.

Dr. Yates: I think that was one of the take-homes from what we reported in the paper. I won’t go into the weeds, but there are ways to ask for more payment if somebody, for instance, heavier or has a very complicated previous surgery that you’re revising, but for this particular question, for all the things we’re talking about, just excluding them from the environment of a zero-sum game of competing against each other, would be enough to help protect those patients. So that’s one, sort of a broad stroke way of trying to make this all work better as opposed to trying to make mathematical models that perfectly predict what complications are going to be and trying to use that. I don’t think surgeons will ever trust risk adjustment in terms of a competitive environment, but they will trust exclusions. I think they’ll trust, being rewarded for taking on, the value of refugees and being the life raft for them.

Dr. Nelson: I agree with that. I think exclusions would work and even a temporary period of time where there are exclusions while we get better data, so, we can more appropriately risk adjust. Once we have the ability to compare people at similar centers with different medical comorbidities, socioeconomic factors, etc., but I agree with that a hundred percent, I think that’s really all it would take to at least protect the access for this patient population.

Dr. O’Connor: Dr. Yates, I’m going to ask as we’re drawing to a close on this podcast to give us what you think are the top two or three findings of the research study. I’d like you to share what you think the top two or even three takeaways are.

Dr. Yates: The three takeaways that I would bring up are that number one, it is now not just the heart surgeon, but it’s very much almost all surgeons are using various different criteria that are reversible risk factors to a judge when it’s time to operate and that’s become pervasive perhaps in a good way, because if you can get some reversible risk factors corrected, you’re making the patient safer.

One good example of that is hepatitis C. It takes three months to get treated for hepatitis C and be cured in 2020 and it makes a huge difference in terms of the outcomes and according to data out of the Veterans Administration study. And so that’s an example, the moral equation is that it’s very important to do that. Now for those things that patients can’t necessarily change overnight or may never be able to change because they’re more fixed, and difficult problems to reverse.
For instance, morbid obesity is a very hard thing to reverse and there are studies showing that the patients that are refused surgery because of morbid obesity, it may be only 11, 12, 15% of them ever get their weight down or ever get the surgery that they’re looking for, depending on what region of the country they’re living in. So, I think it’s important to realize that all surgeons picked up the message that, try to get the risks down, try to reverse those things that can be made better before they operate. And that’s a good thing. And that’s something that we see. However, there are some things that patients just quite, frankly, can’t change. We can’t make patients all of a sudden, rich. We can’t make patients all of a sudden, give them the opportunity to move. They can’t all move to Malibu and have inheritances that will keep them comfortable for the rest of their lives. And so, there are patients that have fixed incomes and fixed environments, and they need to be on Medicaid and life hasn’t been as great for them as we would fight for everybody, and those patients unfortunately, are perceived and that’s one of the important things from the study, whether it’s because of, the surrogate for poverty that might be ethnicity or race, or simply being impoverished, per se, I think that those patients are seen as being at higher risk and because there’s no way of evening that playing field on that perception. I think that’s one of the important things we found in this study is that it’s right up there with somebody being way overweight or having a problem with diabetes. And although there’s attempts to risk adjust medical problems, and unfortunately, they’re not ideal, there’s no attempt to risk adjust for the perception that patients might be more costly or have more complications, whether it’s true or not, if they’re in socioeconomic, challenged positions. And then the third thing is that our surgeons that we pulled, again, I’m going to reiterate this. They don’t perceive the risk as in and of itself a reason not to help. It’s the competition to perform under the microscope of everyone, observing them from the government and elsewhere in terms of how their outcomes are judged. It’s that perception that is causing them to feel pressure, in terms of accepting that risk and they almost unanimously reported that if there was a way to adjust for that, an alternative would be to exclude that risk, they would take care of those patients, without that sense of pressure. The study does not show that patients aren’t getting cared for. It captured that perception that they’re losing out in competition to others and it actually captured the desire to have that competition tempered in some ways so that it doesn’t hurt people.

Dr. O’Connor: Absolutely. Charles.

Dr. Nelson: I think that many of those patients are still getting care at places that are willing to care for them, but it takes them a while to find places, and some of those places are closing down because they can’t compete. And there was another study that was published, in the Journal of American Medical Association, Open Journal, where basically they showed that the hospitals that took care of the safety of those patients that did joint replacements, they improved their ability to take care of patients with decreased costs, just as much as other hospitals. However, because they were taking care of more complex patients, they actually lost money in this zero-sum game that Dr. Yates has been talking about while the other hospitals gain money. So those hospitals that were struggling more to take care of more of the patients that are vulnerable, they have been penalized and they’re being further penalized by these rules, which have caused some of these hospitals now to close down, which creates a greater concern for access for these patients moving forward, unless this problem is corrected.

Dr. O’Connor: Yes, Charles, thank you for bringing that up again because that’s the point I was trying to make because it is a payment neutral policy, you can be rewarded financially if your costs are less and it’s easier to have lower costs if you are taking care of healthier patients who have more personal resources and personal support, so that there’s less risk that they’ll have a complication after surgery and they do not need to go to a facility, but can go safely to home, after surgery. And so, therein lies the terminology that we use for cherry-picking of those healthier patients and then lemon dropping the patients who are less healthy and have fewer resources because those are the patients who are going to more likely need additional medical resources, which then costs more money. And because it is a payment neutral approach, you could still improve your outcomes, but be penalized.

Dr. Nelson: Correct.

Dr. O’Connor: And, honestly, I find that troubling, because it doesn’t reward our healthcare system teams and our doctors and nurses who are trying to take better care of patients and trying to improve outcomes. If my team has improved, but then you slap me down and say, “Well, you just didn’t improve enough compared to everybody else.” And I say, “But wait, look at the patients that I’m taking care of, they’re sicker. They have fewer resources.” And the answer is, ‘It doesn’t matter.” So that’s to me, very troubling.

Dr. Jimenez: So, Mary, the answer to that, it’s not a good answer, the answer to that is the orthopedist in this case who is doing the joint replacements decides this is not paying out for me. This is not working out for me. In the sense, I don’t get the satisfaction of treating a patient and knowing they’re going to have a good outcome because they don’t have support at home, etc., maybe I’m better off not treating these patients. And then you have the facilities who are doing the same thing. So, lemon dropping, as we have defined it, is really victimizing that patient and it’s, increasing musculoskeletal disparities. It is not ethical. It’s not moral. It’s not right.

Dr. O’Connor: I know we can all agree on that and I want to just thank all of you for the generosity of your time and your commitment to addressing these disparities, and what I think was the excellent work that we have done, with this research and publishing this paper. I’m just going to close with thanking our listeners to tuning into this episode of the Health Disparities podcast. I want to ask them to please take a moment to subscribe in iTunes or Spotify, so, you don’t have to miss any episode in the future. I am sure we will be returning to this subject of risk and perception of risk and cherry picking and lemon dropping again in the future and assessing how the changing landscape can open up opportunities for more equitable healthcare provision. So, until next time, thank you and goodbye.

(End of recording)

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