American Academy of Orthopaedic Surgeons - Strykerimaging.stryker.com/imaging2006/media/OrthoPad_2004 opus report.pdf · American Academy of Orthopaedic Surgeons Orthopaedic Practice

American Academy of Orthopaedic Surgeons

Orthopaedic Practice and Medical ♦ Final Report Income in the US 2004-2005 Prepared by: Date Survey & Information Analysis Team November 2004 Sylvia Watkins-Castillo, PhD, Manager James Frankowski, Analyst Heidi Schmalz, Analyst

Department of Research and Scientific Affairs

page ii Orthopaedic Practice and Medical Income in the US 2004-2005 January 11, 2005 Copyright 2004 American Academy of Orthopaedic Surgeons

Orthopaedic Practice and Medical Income in the US 2004-2005 page iii Copyright © 2004 American Academy of Orthopaedic Surgeons January 11, 2005

Table of Contents EXECUTIVE SUMMARY ................................................................................................................................... 1 INTRODUCTION/RATIONALE.......................................................................................................................... 3 METHODOLOGY AND RESPONSE................................................................................................................. 3 SURVEY FINDINGS .......................................................................................................................................... 4

Orthopaedic Surgeon Characteristics ..................................................................................................................... 4 Gender....................................................................................................................................................................4 Age ........................................................................................................................................................................4 Race .......................................................................................................................................................................5 Orthopaedic Surgeon Density ................................................................................................................................6 Non-Medical Advanced Degrees............................................................................................................................7 Language Fluency ..................................................................................................................................................7 Organization Membership.......................................................................................................................................8

Certifications and Professional Status..................................................................................................................... 8 Current Work Status ...............................................................................................................................................8 ABOS and Specialty Certification ...........................................................................................................................8

Practice Characteristics........................................................................................................................................... 9 General Orthopaedic Surgery vs. Specialization....................................................................................................9 Practice Setting.....................................................................................................................................................10 Academic Appointment.........................................................................................................................................11 Orthopaedic Specialists vs Academicians............................................................................................................12

Practice Focus ...................................................................................................................................................... 12 Multiple Focus Areas versus Primary Focus ........................................................................................................12 Geographic Areas of Focus..................................................................................................................................13 Fellowships ...........................................................................................................................................................14

Clinical Research Activities ................................................................................................................................... 16 Retirement Expectations ....................................................................................................................................... 17 Practice and Professional Activities ...................................................................................................................... 18

Distribution of Professional Time..........................................................................................................................18 Average Hours Worked Per Week .......................................................................................................................19 Vacation Time.......................................................................................................................................................21 Total Number of Procedures Performed Per Month .............................................................................................22

Specific Procedures Performed Per Month ........................................................................................................... 23 Days Away from Orthopaedic Practice.................................................................................................................. 24 Services Provided in the Orthopaedic Surgeons' Office........................................................................................ 25 Patients Seen Per Week ....................................................................................................................................... 26 Issues Considered to be a Problem or Major Concern.......................................................................................... 28 Professional Compensation .................................................................................................................................. 32

Distribution of Patients by Payor Source ..............................................................................................................32 Orthopaedic Surgeon Income...............................................................................................................................32 2003 Income Compared to 2002 Income .............................................................................................................33 Private Facility Income..........................................................................................................................................33 Income Distribution...............................................................................................................................................33 Income by Work Status.........................................................................................................................................34 Income by Age......................................................................................................................................................34 Income by Census Division ..................................................................................................................................34 Income by Primary Focus Area ............................................................................................................................35 Income by Practice Type ......................................................................................................................................36 Income by Practice Setting...................................................................................................................................37 Income by Academic Appointment .......................................................................................................................37

APPENDIX A. AAOS 2004 ORTHOPAEDIC PHYSICIAN CENSUS QUESTIONNAIRE ......................... 38 APPENDIX B. PRACTICING ORTHOPAEDIC SURGEON DENSITY AND MEMBER CENSUS RESPONSE RATE BY STATE........................................................................................................................ 44

Orthopaedic Surgeon Density by US Census Division....................................................................................................45

APPENDIX C. OPEN-ENDED RESPONSES : OTHER LANGUAGE FLUENCY .................................... 46

page iv Orthopaedic Practice and Medical Income in the US 2004-2005 January 11, 2005 Copyright 2004 American Academy of Orthopaedic Surgeons

Orthopaedic Practice and Medical Income in the US 2004-2005 page 1 Copyright © 2004 American Academy of Orthopaedic Surgeons January 11, 2005

Executive Summary • The Orthopaedic Practice and Medical Income in the US 2004-2005 (OPUS 2004) report is based on

10,680 ABOS certified and practicing orthopaedic surgeons, estimated to represent more than 60% of all board certified practicing orthopaedic surgeons in the US.

• The diversity of orthopaedic surgeons is slowing increasing. Although only 3.3% of board certified orthopaedic surgeons are female, 7.5% of AAOS candidate members responding to the 2004 member census (not included in this report) were female. In 2004, for the first time, members were asked to identify their race. Although 89% of board certified practicing ortho surgeons reported their race as Caucasian, this proportion dropped to 80% among the candidate members.

• The average age of practicing orthopaedic surgeons in the US remained at 50.9 years, with the median 50 years. A slight movement in the distribution of orthopaedic surgeons by age group may indicate a reversal of the aging of orthopaedic surgeons that has been found in the past several member censuses.

• Density of orthopaedic surgeons is a frequently asked question. In 2004, the US density of orthopaedic surgeons was 6.2 per 100,000 population, continuing the slowly increasing availability of orthopaedic surgeons shown since 1990. Among nine census regions, the density varies from 7.8 in the New England states to 5.3 in the West South Central states.

• The proportion of orthopaedic surgeons holding an advanced degree other than their MD remained at approximately one in 25 doctors. The most common additional degree is an MBA, the least frequently held a JD.

• One in five orthopaedic surgeons is fluent in a language other than English. The range of languages is extensive, however, nearly one-half identified Spanish as their second language.

• More than 85% of AAOS members also belong to at least one of four national or state medical or orthopaedic organizations. State memberships are reported at much higher numbers than are AMA or America College of Surgeons memberships.

• Nine in 10 ABOS certified orthopaedic surgeons currently practice full-time orthopaedic surgery. Only 1% reported a full or part-time non-surgical practice.

• Nearly one-half of orthopaedic surgeons (49%) reported they have been ABOS re-certified, a significant increase from the 30% reported in 2002. About 8% reported a certification of specialty qualification (CSQ) in hand surgery, while nearly twice that number (14%) expected to test for the new CSQ in sports medicine.

• The trend toward specialized orthopaedic surgery continues, with 38% reporting they are specialists compared to 35% in 2002. The mean age of members who are general orthopaedic surgeons is six years older than the mean age of specialist orthopaedic surgeons.

• In 2004, members were asked to identify their practice type based on their source of income. Practice in a private orthopaedic group setting dominates the AAOS membership (50%), with solo or multi-specialty private group practice accounting for an additional 33%. The fourth largest group is members with an academic practice, but this accounted for only 8% of the members.

• For the first time, members were asked to specify if they hold an academic appointment. Two in five members report they spend some portion of their professional time teaching in an academic appointment, but the majority of these members (30%) do so in an adjunct, non-salaried capacity. Thus, 11% of AAOS members report they receive all or some portion of their income from an academic appointment. Academicians (full or part time salaried) are much more likely to be a specialist (96%) than they are to be a general orthopaedic surgeon.

• While adult knee (52%) and arthroscopy (51%) are reported most frequently among the areas of specialty, sports medicine (13%) and hand (10%) are designated as primary specialty areas by the highest proportion of members. Regional differences can be observed in the density of orthopaedic surgeons by specialty.

page 2 Orthopaedic Practice and Medical Income in the US 2004-2005 January 11, 2005 Copyright 2004 American Academy of Orthopaedic Surgeons

• More than one-half (54%) of members reported they have completed at least one fellowship, with sports medicine (27%) and hand (21%) the most frequently cited specialty areas for the fellowships.

• Approximately one in 10 orthopaedic surgeons report receiving clinical research funding in the past five years. The range of grant dollars was very wide, with $50,000 or less the median amount in all except Federal grants. Industry grants were the most frequently cited source of funding.

• The average age at which orthopaedic surgeons expect to fully retire from surgical practice is 63.3 years, and from non-surgical practice at 66.7 years. However, among members under the age of 50, the expected age of retirement drops by several years. A variety of reasons were cited as for retiring within the next two years.

• Orthopaedic surgeons report an average of 90% of their time in clinical care, with 50% devoted to office visits and 32% to surgery. Overall, teaching and research account for only 3% of members’ time.

• Orthopaedic surgeons are evenly split between those who work 50 or fewer hours per week, 51 to 60 hours per week, or over 60 hours per week. Academicians reported the highest mean number of hours worked per week (68), while surgeons in a non-military public institution work the least hours per week (42). The average orthopaedic surgeon takes 4 weeks of vacation per year. On average, they spend 7 days per year at business meetings or activities and 9 days per year attending CME.

• In 2004, the Census for the first time asked members about the volume of orthopaedic procedures they perform each month, as well as the number of several common procedures performed. Overall, the average orthopaedic surgeon performs 31 surgical procedures per month, with specialists performing slightly more than generalists. The number of procedures performed peaks between the ages of 40 and 49 years. While slight variations are found by practice setting, age, and specialization, the most interesting differences are in regional areas. Surgeons in the Pacific and New England states reported the lowest average number of procedures per month (26 and 27, respectively), while those in the West North Central and East South Central regions each reported an average of 36 procedures per month.

• The most frequently identified procedures performed are arthroscopy of the knee and spinal fusion. An unexpected result of the question was the number of surgeons reporting outpatient procedures for hip and knee replacement. Although the number reporting these procedures was very low compared to inpatient procedures, they reported nearly identical levels of total procedures performed.

• Overall, 85% of orthopaedic surgeons offer X-ray services in their office, 34% offer physical or occupational therapy, 25% offer MRI, and 21% offer EMG. Surgeons in a group practice are more likely to offer additional services than those in solo practice. Surgeons in academic, hospital, military or public institutions would likely have these services as part of the facility.

• The typical orthopaedic surgeons sees just over 22 new patients and 67 follow-up patients per week in the office. They also report 8 inpatient hospital visits or consultations and 5 ER visits weekly.

• The key areas of insurance reimbursement, paperwork, litigation, regulation, and rising practice expenses are of major concern to a large majority of members, although there is variation by practice setting and regional divisions.

• The 14-year trend toward movement of patients by payor source into managed care programs and Medicare/Medicaid continued in 2004. However, there was a slight increase in the share of patients from private payor sources over that reported in 2002.

• A higher proportion of members reported their gross income credited to them for medical and professional services and their personal income net of practice-related expenses than in the past, when income was asked in a more general question. Income figures represent 63% of all board-certified orthopaedic surgeons in the US, up from 42% representation in 2002. o Due to very wide ranging incomes reported, mean income is used as the comparison point. o Gross median income reported was $800,000. o Net median income reported was $320,000. o One in four (24%) of members reported a portion of their net income was received as shares or

compensation from a private facility, such as a specialty hospital, surgi-center, or radiology center, in which they had ownership.


Introduction/Rationale This report is 10th in a series produced by the American Academy of Orthopaedic Surgeons® (AAOS) to focus on the orthopaedic workforce and practice characteristics in the United States. Every two years since 1985, the AAOS has conducted a Member Census Survey to update information in the all member database. In 2002, the American Medical Association identified 23,211 orthopaedic surgeons in practice in the US. Information in this report is based on the most recent survey results of the 23,325 AAOS members at the time of the survey.

Methodology and Response

The 2004 AAOS Orthopaedic Physician Census is based on updated information on 12,887 AAOS member physicians in the United States, it’s territories, the United States Military overseas, and Canada. This represents 57% of the 22,598 members who received the survey sent in the first quarter of 2004. Surveys were sent via fax and US Postal Service mail. Non-respondent members were re-contacted three times during the data collection phase. Responses to the survey could be submitted via online, direct fax back, or hard copy. The 2004 AAOS Orthopaedic Physician Census was administered, processed and analyzed by the AAOS Research and Scientific Affairs Survey and Information Analysis team.

This report, Orthopaedic Practice and Medical Income in the US 2004-2005 (OPUS 2004), is based on data provided by 10,680 board certified (ABOS) orthopaedic surgeons currently practicing full or part-time clinical or non-surgical clinical orthopaedic medicine in the US, its territories or military posts. Response rates by state for board certified orthopaedic surgeons ranged from 51% to 79%, with a nationwide average response rate of 61%. The sample of active, practicing orthopaedic surgeons represents 83% of members responding in 2004, a ratio similar to all previous member censuses since 1988. Other member categories include orthopaedic surgeons who are currently taking fellowships, who are full-time research or administration, and retired fellows.

In addition to the demographic, practice and professional related information on orthopaedic surgeons presented in this report, reports are available under separate cover on Technology Use, Education Preferences, and Professional Liability Issues.

Because the AAOS 2004 Orthopaedic Physician Census is sent to all members, calculation of confidence intervals and margin of error in responses is not applicable. These calculations are based on responses to random samples of a larger population. However, the large number of members upon which this information is based provides a solid indication of the true demographics of the orthopaedic surgeon population in the US. As an example, a random sample with a 99% confidence level and a ±2% error level for the full AAOS membership would have required 3531 responses. Our sample is more than three times this large.

Basic demographic frequencies for all questions discussed in the OPUS 2004 report are available upon request from the Survey and Information Analysis Team, Research and Scientific Affairs Department, AAOS. The questionnaire used in the 2004 AAOS Orthopaedic Physician Census can be found in Appendix A.


Orthopaedic Surgeon Self-Reported Non-Caucasian Race by Gender, 2004

1.3%1.6%

3.8%

2.2%

3.4%

0.9%

4.6%

2.0%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

AfricanAmerican

Hispanic/Latino Asian American Other (includingMulti-Racial)

Self Reported Race

Prop

ortio

n of

Tot

al Male

Female

Survey Findings Orthopaedic Surgeon Characteristics Gender The AAOS began tracking on the gender of orthopaedic surgeons in 2000. Since that time the proportion of ABOS certified, practicing orthopaedic surgeons who are female has increased from only 2.7% to the current 3.3%, a ratio nearly identical to that found in 2002. Among all orthopaedic surgeons, however, the ratio is slightly higher (3.5%) and approaches that of the American Medical Association data (4%). This is largely due to the higher proportion found among Residents and Fellows. Of the 1375 AAOS candidate members responding to the census (not included in the sample for this report), 7.5% were female. Age The average age of practicing orthopaedic surgeons in the US in 2004 is 50.9, with a range of 31 years to 91 years. This is the same median age as reported in 2002. However, the distribution of orthopaedic surgeons shifted slightly, with more surgeons under the age of 40 represented, while a smaller proportion were found in the age range of 40 to 49 years. The median age was 50, with 4% of practicing orthopaedic surgeons age 50 in 2004, 49% under the age of 50, and 47% over the age of 50. Nearly one in 10 (9%) of currently practicing orthopaedic surgeons is over the typical retirement age in the US of 65. Since 1994, shifts in the age of orthopaedic surgeons have steadily shown higher proportions in the 60 and over age range. It would appear that a significant number of currently practicing orthopaedic surgeons entered the practice field 20 to 30 years ago, and as this cohort ages, they were not replaced with an equal number of younger doctors. The small increase in the proportion of orthopaedic surgeons found in the under 40 age groups, balanced by the moderating of those age 60 and over, may indicate the emergence of more younger doctors again.


Racial Distribution of Practicing and Candidate Orthopaedic Surgeons, 2004

89.0%

1.3% 1.5% 3.8%0.2% 1.9% 2.2%

80.0%

2.9% 2.6%8.0%

0.4%3.6% 2.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Caucasian African American Hispanic/Latino Asian American Native American Other (including Multi-Racial)

No Response

Self Reported Race

Prop

ortio

n of

Tot

al

Certified, Practicing Ortho SurgeonsCandidate Ortho Surgeons

Orthopaedic Surgeon Self-Reported Non-Caucasian Race by Gender, 2004

1.3%1.6%

3.8%

2.2%

3.4%

0.9%

4.6%

2.0%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

AfricanAmerican

Hispanic/Latino Asian American Other (includingMulti-Racial)

Self Reported Race

Prop

ortio

n of

Tot

al Male

Female

The mean age in all states had a range from 48.4 to 53.8 years, or less than ±3 years from the national mean age. This reflects the age distribution found two years ago. States with the oldest orthopaedic population are West Virginia (53.6 years mean age), Maine (53.3), and California (53.1). These states are closely followed by Oregon and Arkansas (both 52.9), and New Mexico and Louisiana (both 52.8). Only West Virginia and Oregon were in the highest mean age states for orthopaedic surgeons in 2002. States reporting the lowest mean age in 2004 for their orthopaedic surgeon population are Montana (48.4), Wisconsin (48.5), Wyoming and North Carolina (both 48.6) and Nebraska (48.8). Only Wyoming was in the group of states with the youngest mean age for orthopaedic surgeons in 2002. Race In 2004, for the first time, the AAOS requested information on member orthopaedic surgeon race in the biennial census. Among certified practicing orthopaedic surgeons, 89% reported Caucasian as their race. Of the remaining 11%, 2% did not report a race and 9% identified a minority race. Among the candidate members who are not yet certified or a practicing orthopaedic surgeon (N=1395), the proportion of young orthopaedic surgeons, where the average age is 37, reporting their race as Caucasian dropped to 80%. Again, 2% did not respond to the question.

Although the proportion of minorities among female orthopaedic surgeons is only 2% greater than it is for males (89% vs 91*), the distribution among the various minority groups reported is significantly different, particularly in the proportion of African Americans and Asian American represented.


Density of Orthopaedic Surgeons per 100,000 Population: 1990-2004

(Source: Populat ion est imat es U.S. bureau of t he Census, 2000. Densit y calculat ed f rom AAOS membership dat abase.)

5.6 5.8 5.9 5.8 6.26.15.35.3

0.01.02.03.04.05.06.07.08.0

1990 1992 1994 1996 1998 2000 2002 2004

Year

Den

sity

/ 10

0,00

0 Po

pula

tion

Density of Orthopaedic Surgeons per 100,000 Population by Census Division, 2004

(Source: Population estimates U.S. bureau of the Census, 2000. Density calculated from AAOS membership database.)

5.56.2 6.6

6.0 6.4 6.2

7.8

6.1

5.3

7.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

NewEngland

MidAtlantic

East NorthCentral

WestNorth

Central

SouthAtlantic

EastSouth

Central

WestSouth

Central

Mountain Pacific Total US

US Census Division

Den

sity

/ 10

0,00

0 Po

pula

tion

Orthopaedic Surgeon Density A frequent question asked of the AAOS is the density of orthopaedic surgeons by location. Several estimates of this number exist from a number of sources. Most are very close. The information included in this report is based on AAOS membership of board certified active and candidate orthopaedic surgeons as of March 2004.

In 2004, the overall density of orthopaedic surgeons in the United States rose to 6.2 per 100,000 population base, continuing the slow rise in availability of orthopaedic surgeons evidenced over the past decade and more.

States with the highest density of orthopaedic surgeons continue to be among the lower population states, with Wyoming and Montana again at the top with 10.9 and Alaska with 10.2 orthopaedic surgeons per 100,000 population. The District of Columbia also remains in the top four areas, with 10.0. An additional eight states have an orthopaedic surgeon density of 8.0/100,000 or more.

Michigan (4.2), Mississippi (4.5) and West Virginia (4.5) also remain as the states with the lowest density of orthopaedic surgeons per 100,000 population. An additional six states have an orthopaedic surgeon density of 5.5/100,000 or less.

The US Census of Population and Housing identifies nine divisions, or groupings of states. Looking at the orthopaedic surgeon density by census division, the New England states have the highest density of orthopaedic surgeons, with 7.8 per 100,000 population compared to the 6.2 found in US overall. The East North Central and West South Central divisions report the lowest density of orthopaedic surgeons per 100,000 population base.

A complete listing of the density of orthopaedic surgeons by state and division, along with individual state response rates on the member census, can be found in Appendix B of this report.


Non-Medical Advanced Degrees

Multipleadvanceddegrees

2%

Other Doctorate17%

Doctorate Engineering

8%

Doctorate Biological Sciences

21%

MPH13%

MBA35%

JD4%

Proportion of Orthopaedic Surgeons Proficient in Language other than English

2.0%

18.7%

13.3%

2.4% 2.9%5.4%

1.4% 2.1% 1.4%

46.8%

15.8%

2.7% 3.3%2.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Arabic Chinese Farsi French German Greek Hebrew Hindi Italian Japanese Korean Portuguese Spanish Other language

Language

Prop

ortio

n of

Tot

al wi

th A

dditi

onal

Lang

uage

Pr

ofici

ency

Non-Medical Advanced Degrees The proportion of orthopaedic surgeons identifying one of six advanced degrees listed in the survey (3.6%) was nearly identical with that reported in 2002, with the ratio remaining at approximately one in 25. The degrees include a doctorate in a non-medical field, a JD degree, an MBA, or an MPH. A number of doctors reported they hold master’s degrees not included in the list.

Nearly all the orthopaedic surgeons reported holding only one additional degree, with ten (10) indicating they hold two of these degrees.

The most frequently held non-medical advanced degree is an MBA (35%), followed by a Doctorate in the Biological Sciences (21%). Remaining advanced degrees held are a Doctorate in an other field (17%), an MPH (13%), a Doctorate in Engineering (8%), and a JD (4%).

Language Fluency One in five orthopaedic surgeons in the US are fluent in a language other than English. Among orthopaedic surgeons with fluency in a language other than English, 17% are fluent in more than one additional language.

The most common additional language is Spanish (47%), followed by French (19%) and German (13%). Other languages identified in the member survey were Italian (5%), Chinese (3%), Arabic (3%), Japanese (1%), and Portuguese (1)%.

A total of 67 languages were included in the list of ‘other’ languages in which 594 orthopaedic surgeons are proficient. The most frequently identified ‘other’ languages were Hebrew and Hindi, both spoken by 3% of the membership, Greek (2.4%), Korean and Farsi (2% each), and Dutch (1%). The complete list is found in Appendix C.


Other Orthopaedic Organization Memberships, 2004

80% 81%

14%

39%

68% 69%

46%

17%

0%

20%

40%

60%

80%

100%

America College of Surgeons

Americn Medical Association

State Medical Society

State OrthopaedicSociety

Organization

% o

f tot

al

% of thosereportingmembership

% of totalorthopaedicsurgeons

Mean Age by Practice Status

49.0

64.4 62.2

50.9

0

10

20

30

40

50

60

70

Full-timeorthopaedic

practice

Part-timeorthopaedic

practice

Non-surgicalorthopaedic

practice (full- orpart-time)

All practicingorthopaedic

surgeons

Practice Status

Mean

Age

Organization Membership More than 85% of certified, active orthopaedic surgeons reported they belong to at least one of four national or state orthopaedic organizations identified in the census, with 2 out of 3 surgeons belonging to more than one. Membership is highest in state organizations (80% or more), while 46% report belonging to the American Medical Association (AMA). Only 16% of surgeons with an additional membership belong to the American College of Surgeons.

Certifications and Professional Status

Current Work Status Nearly 9 in 10 (88%) of board certified orthopaedic surgeons are currently practicing full time orthopaedics. Another 11% practice orthopaedic surgery on a part time basis. Only 1.3% of members reported they currently practice only non-surgical orthopaedics, either full or part time. This is a smaller proportion of members in non-surgical practice than was reported in 2002 (2%).

The mean age of members in non-surgical practice was two years younger than for those reporting part-time surgical orthopaedic practice.

ABOS and Specialty Certification The proportion of actively practicing board certified AAOS members responding to the 2004 Member Census who have been certified since 2000 increased significantly over that of the 2002 survey, 17% vs 8%, respectively. Respondents with certification in all other decades prior to 2000 were reported at lower levels than found in previous year’s censuses.


ABOS Certification

25%

33%

17%21%

4%

0%

10%

20%

30%

40%

50%

Prior to 1970 1970s 1980s 1990s 2000 or later

Year of ABOS Certification

Prop

ortio

n of

Tot

al

44.2%

34.9%

20.9%

41.3%

35.5%

23.2%

38.5%

36.0%

25.6%

35.3%

37.1%

27.6%

33.4%

37.1%

29.5%

31.7%

37.4%

30.8%

30.6%

34.7%

34.7%

29.0%

32.8%

38.2%

0%10%20%30%40%50%60%70%80%90%

100%

Prop

ortio

n R

epor

ting

1990 1992 1994 1996 1998 2000 2002 2004

Time Period

Orthopaedic Practice Description

General Orthopaedic Surgeon General w/Specialty Orthopaedic Specialist

Slightly more than one-half (51%) of orthopaedic surgeons reported they are not ABOS re-certified. Among the 49% presumed to be ABOS re-certified (eg, they did not indicate NOT certified), 39% reported the year of re-certification. The group was split nearly evenly between surgeons re-certified in the 1990s (45%) and in 2000 or later (52%). Less than 3% of orthopaedic surgeons reported re-certification before 1990. The proportion of orthopaedic surgeons who are now ABOS re-certified increased significantly from two years ago, when only 30% reported re-certification. Correspondingly, a much higher proportion were re-certified since 2000, with 15% occurring in 2003 or 2004.

As in 2002, only about one in 12 or 13 orthopaedic surgeons (7.7%) reported a Certification of Specialty Qualification (CSQ) in hand surgery. Nearly one-half (48%) of those receiving a CSQ in hand surgery did so since 2000. About one in seven orthopaedic surgeons (14%) reported they expect to test for the new CSQ in orthopaedic sports medicine.

Practice Characteristics

General Orthopaedic Surgery vs. Specialization The steady trend toward specialization in orthopaedic surgury seen since 1990 continues in 2004. In 1990, general orthopaedic surgeons comprised more than 44% of members; in 2004 they accounted for only 29%. At the other extreme, in 1990, orthopaedic specialists represented only 21% of the members; in 2004 the proportion had nearly doubled to 38%. General orthopaedic surgeons with a specialty have held fairly steady at about one-third of the membership since 1990.


54.154.6

50.450.0

48.648.6

50.950.9

40 42 44 46 48 50 52 54 56 58 60Mean Age in Years

General Orthopaedic Surgeon

General w/Specialty

Orthopaedic Specialist

All OrthopaedicSurgeons

Prac

tice T

ype

Mean Age of Orthopaedic Surgeons by Practice Type

2002 2004

Practice Specialty by Age Group

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Under 35 35-39 40-44 45-49 50-54 55-59 60-64 65 and overAge Group

Prop

ortio

n in

Pra

ctic

e Ty

pe

Generalist Generalist w/Specialty Specialist

In 2002, a significant difference in the mean age of orthopaedic surgeons was observed by practice type. This difference holds in the 2004 Member Census. General orthopaedic surgeons are, on average, six years older than the average orthopaedic specialist.

The trend in younger orthopaedic surgeons moving into specialization can be seen even stronger when comparing the proportion of surgeons who are generalists versus specialists by age group classification. The peak age for orthopaedic specialists and for generalists with a specialty is between 40 and 44 years, while the peak age for generalists is 65 and over.

Practice Setting Questions related to practice setting and academic appointments were modified in the 2004 Member Census in order to better identify member characteristics. As a result, a direct comparison with previous census data can only be generalized.

In 2004, members were asked to identify their practice setting based on the source of their salary or income. Following the trends of previous years, 83% of members report they work in private practice. Among the surgeons in private practice, 3 in 5 orthopaedic surgeons work in an orthopaedic group setting. About one-third (32%) of members are in solo practice. The remaining private practice members (9%) are in a multi-specialty practice group. Because of the question change, which removed surgeons in multi-specialty practice groups who are not in the private sector from the equation, the share of members in multi-specialty groups is lower than in previous years.


Academic Appointment

59%

8%

3%

30%

No academic appointment Full-time salaried

Part-time salaried Adjunct (non-salaried)

Practice Setting Based on Source of Salary

2%

1%

2%

4%

50%7%

8%

26%

Private solo practice

Private orthopaedic group practice

Private multi-specialty grouppractice Academic practice

Hospital/medciatl center practice

Pre-paid plan/HMO practice

Military practice

Public institution practice

The remaining 17% of orthopaedic surgeons work in a variety of practice settings. These include

• Academic practice (8%) • Hospital/Medical Center practice (4%) • Military practice (2%) • Pre-paid Plan/HMO practice (2%) • Public institution practice (1%).

Academic Appointment In order to identify the number of orthopaedic surgeons who spend some portion of their professional time in teaching, members were asked about their academic appointments.

Two out of five (41%) orthopaedic surgeons spend some portion of their professional time teaching orthopaedic surgery in an academic appointment. The majority of members (30%) teach in a non-salaried adjunct position

However, 8% have full-time salaried academic appointments, while another 3% have part-time salaried academic appointments.


39%

37%

25%

3%12%

84%

12%

27%

61%

20%

33%

47%

29.0%

32.8%

38.2%

0%

20%

40%

60%

80%

100%

Prop

ortio

n of

Mem

bers

No academicappointment

Full-timesalaried

Part-time salaried

Adjunct (non-salaried)

All Members

Academic Appointment Status

Orthopaedic Specialist in Academia

General Orthopaedic Surgeon General Ortho Surgeon w/Specialty Specialist Orthopaedic Surgeon

A majority of orthopaedic surgeons (82%) with an academic practice also have a full-time salaried academic teaching position.

The majority of members (76%) with a part-time salaried academic appointment are in private practice, both solo practice and group practice. Surgeons with adjunct appointments are even more strongly from the private practice setting (88%).

Orthopaedic Specialists vs Academicians Orthopaedic surgeons who are specialists are more likely to have an academic appointment at any level than are surgeons who are generalists. Among the full-time salaried academicians, 84% are orthopaedic specialists while only 3% consider themselves to be a generalist. The remaining 12% are generalists with an orthopaedic specialty.

The relative proportions move toward the overall distribution of orthopaedic surgeons among fellows with part-time salaried or adjunct academic appoints. However, even among those who have adjunct appointments, 47% are specialists compared to the 38% of all orthopaedic surgeons.

Practice Focus

Multiple Focus Areas versus Primary Focus Members were asked to identify all areas of practice focus, and then to identify one area they consider their primary focus.

More than one-half of orthopaedic surgeons identify the adult knee (52%) and arthroscopy (51%) as focus areas within their practice. However, the areas of sports medicine (13%) and hand (10%) are the two areas with the highest proportion of primary specialty focus.

The listing of focus areas and a graphic representation show the significant variation in the proportion of orthopaedic surgeons practicing in the various specialty areas.


Focus Area of Practice: All Areas versus Primary Focus

30%

52% 51%45% 44%

37%28% 26%

22%12%

7% 5% 4%5% 6%13%

3% 2% 3%10%

4%9% 8%

4% 2% 1% 2% 1%

16%17%

41%

29%

0%

25%

50%

75%

Gene

ralis

t, all a

reas

Adult

knee

Arthr

osco

py

Spor

ts me

dicine

Shou

lder a

nd el

bow

Adult

hip

Trau

ma

Hand

Foot

and a

nkle

Othe

r

Adult

spine

Pedia

tric or

thopa

edics

Disa

bility

/lega

lor

thopa

edics

Pedia

tric sp

ine

Reha

bilita

tion/p

rosth

etics

Ortho

paed

ic on

colog

yFocus Area

Prop

ortio

n of

Tot

al Area of focusPrimary specialty

Orthopaedic Surgeon Areas of Specialty Area of practice focus Primary specialtyGeneralist, all areas 30% 29%Adult knee 52% 5%Arthroscopy 51% 6%Sports medicine 45% 13%Shoulder and elbow 44% 3%Adult hip 41% 2%Trauma 37% 3%Hand 28% 10%Foot and ankle 26% 4%Other 22% 9%Adult spine 17% 8%Pediatric orthopaedics 16% 4%Disability/legal orthopaedics 12% 2%Pediatric spine 7% 1%Rehabilitation/prosthetics 5% 2%Orthopaedic oncology 4% 1%

Geographic Areas of Focus Distribution of orthopaedic surgeons by focus area, in general, reflects the overall density found among orthopaedic surgeons across the nine census divisions in the US. The New England region, with a total orthopaedic surgeon density of 7.8 per 100,000 population based on the AAOS membership totals and the 2000 US Census of Population and Housing population figures, also has the highest density of orthopaedic surgeons reporting a specialty in the focus areas.

However, some variation can be found in the distribution in other census divisions. The West North Central division is high in the adult hip and pediatric focus areas, while the Mountain division is high in all focus areas related to sports injuries and trauma. The West South Central area, with the lowest density of orthopaedic surgeons overall, also reports fewer surgeons in all focus areas than other areas.

The density of orthopaedic surgeons is lowest in the pediatric areas, both pediatric spine and general pediatric orthopaedics, and in the foot and ankle specialty area.


2004 Surgeon Density per 100,000 Population by Orthopaedic Focus Areas*

Division General

Orthopaedics Adult Hip Adult Knee Adult Spine Arthroscopy Foot and Ankle HandNew England 2.3 3.1 3.9 1.4 4.0 1.9 2.2Mid Atlantic 1.8 2.5 3.1 1.1 2.9 1.5 1.6East North Central 1.7 2.4 2.9 0.8 2.8 1.3 1.4West North Central 1.8 3.0 3.5 1.1 3.4 1.6 1.7South Atlantic 1.8 2.5 3.2 1.0 3.1 1.7 1.8East South Central 2.0 2.3 2.8 1.0 3.0 1.7 1.7West South Central 1.6 2.1 2.8 0.9 2.7 1.4 1.3Mountain 1.7 2.7 3.6 1.1 3.6 1.8 1.9Pacific 1.7 2.5 3.2 1.0 3.2 1.5 1.8Total US 1.8 2.5 3.2 1.0 3.1 1.6 1.7

* Density based on 2000 US Census Population and reported focus areas, adjusted for response rate of 61%.

2004 Surgeon Density per 100,000 Population by Orthopaedic Focus Areas*

Division Pediatric

Orthopaedics Pediatric SpineShoulder and

Elbow Sports Medicine Trauma

Total Orthopaedic

Surgeons New England 1.3 0.6 3.4 3.6 3.0 7.8 Mid Atlantic 0.9 0.5 2.6 2.6 2.2 6.1 East North Central 0.9 0.4 2.3 2.4 2.0 5.5 West North Central 1.2 0.6 2.8 2.8 2.6 6.2 South Atlantic 1.0 0.5 2.7 2.8 2.2 6.6 East South Central 0.9 0.4 2.6 2.5 2.1 6.0 West South Central 0.7 0.3 2.2 2.4 1.8 5.3 Mountain 1.0 0.4 3.3 3.2 2.7 7.0 Pacific 0.9 0.4 2.7 2.8 2.2 6.4 Total US 0.9 0.5 2.7 2.7 2.2 6.2

* Density based on 2000 US Census Population and reported focus areas, adjusted for response rate of 61%.

Fellowships Slightly more than one-half (54%) of members completed at least one fellowship. The mean number completed was 1.2 fellowships, with 85% of members completing one fellowship. Another 13% reported completing two fellowships, while the remaining 2% reported more than two fellowships.

The average length, in months, of fellowships reported was 13 months. However, 69% of members completing fellowships did so in 12 months. Another 11% reported six month fellowships, with 5% reporting 24 months total fellowships. The remaining 15% reported between 1 and 48 months total fellowship time.

Among the 54% of orthopaedic surgeons who have or have completed an orthopaedic fellowship, more than one-fourth (27%) completed it in sports medicine. Nearly as many (21%) completed a fellowship in hand surgery. The remaining specialty areas with more than 10% of total fellowships are adult spine (13%), joint replacement (10%), and pediatric orthopaedics (10%).

Among the ‘other’ list of fellowships, arthroscopic surgery, bioengineering/biomechanics, and rehabilitation were the identified as the most frequent specialties. Topics and the number reporting follow.


Fellowship Specialty Areas

10%

8%7%

5% 5% 5% 5% 4%3% 3% 3% 2% 2% 1%

10%

13%

21%

27%

0%

5%

10%

15%

20%

25%

30%

Spor

ts m

edic

ine

Han

d su

rger

y

Adul

t spi

ne

Join

t rep

lace

men

t

Pedi

atric

orth

opae

dics

Trau

ma

and

fract

ures

Foot

and

ank

le

Adul

t rec

onst

ruct

ion

Pedi

atric

spi

ne

Scol

iosi

s

Shou

lder

and

elb

ow

Oth

er

Adul

t kne

e

Orth

opae

dic

rese

arch

Adul

t hip

Tum

ors

Arth

ritis

Gen

eral

orth

opae

dics

Specialty Area

% o

f Tot

al F

ello

wsh

ips

Other Fellowship Specialities:

Arthroscopic surgery (n=32) Bioengineering/biomechanics (n=23) Rehabilitation (n=21)

Microsurgery (n=14) Spinal cord injury (n=11) Basic science (n=7)

Oncology (n=7) Pathology (n=7) Other area (n=110)


Basic or Clinical Research Projects Funding in Past 5 years

9% 9%

3%

29%

23%

18%

9%

0%

5%

10%

15%

20%

25%

30%

1 2 3 4 5 6 to 10 Morethan 10Projects Funded

% o

f Mem

bers

Fun

ded

(n=8

17)

Clinical Research Activities

Slightly over one in ten (11%) orthopaedic surgeons report they have received basic or clinical research funding in the past 5 years. The number of projects reported funded ranged from 1 to 95, but 96% reported ten or fewer projects funded.

The highest level of funding received was reported from Federal sources, with a range of $1,000 to $750 million reported. As a result of a few very high levels of funding, the median funding level, $200,000, provides a stronger measure than the mean. It should also be noted that the number of orthopaedic surgeons reporting funding from the Federal government was substantially smaller than the number receiving funding grants from industry, foundations or their institution. Grants from industry were the most frequently reported, with a median of $50,000 received.

Grant Amount (in $1000s) Number

Receiving Minimum Maximum Mean MedianFederal grants 137 $ 1 $ 750,000 $ 42,111 $ 200Foundation grants 366 $ 1 $ 500,000 $ 16,305 $ 50Industry grants 671 $ 1 $ 1,000,000 $ 17,388 $ 50Endowment grants 100 $ 1 $ 200,000 $ 8,093 $ 25Institutional grants 302 $ 1 $ 500,000 $ 6,967 $ 25Other grants 88 $ 1 $ 200,020 $ 8,172 $ 15


Anticipated Mean Age of Retirement by Member Age Group

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Under 40 40 to 49 50 to 59 60 to 69 70 and over All age groupsAge Group

Mea

n A

ntic

ipat

ed A

ge o

f R

etire

men

t

Partially from Surgical Partially from Non-Surgical Fully from Surgical Fully from Non-Surgical

Reason Cited for Early Retirement from Orthopaedic Practice

10% 10%

7%

2%

13%

3%

0%

5%

10%

15%

Bureaucracy &paperwork

Age Malpracticeconcerns/cost

Time for family Other Second career

Reason for Retirement

% o

f Tot

al M

embe

rs

Retirement Expectations

As members age, the age at which they expect to retire from active orthopaedic surgery practice increases. Significant differences are found in retirement expectations between members under the age of 40 and over the age of 70.

Based on current age and reported age of anticipated retirement, 6% of members are currently partially retired from surgical practice, and 5% are partially retired from non-surgical practice. Just over 3% are partially retired from both surgical and non-surgical practice.

Anticipated Age of Retirement from Orthopaedic Practice by Age Group

Member Age Total

N

Partiallyfrom

Surgical

Partially from

Non-Surgical

Fullyfrom

Surgical

Fully from

Non-SurgicalUnder 40 1411 59.3 60.9 63.5 64.740 to 49 3418 60.1 61.8 64.1 65.450 to 59 2687 61.9 63.7 65.1 67.060 to 69 1493 64.9 66.1 67.1 69.670 and over 278 68.9 70.6 70.5 76.3All age groups 9287 61.5 63.3 65.0 66.7


The most frequently cited reason for retiring by orthopaedic surgeons who plan to retire with in the next 2 years was bureaucracy and paperwork, with 13% of members identifying this as a reason for early retirement. This was followed by age (10%) and malpractice concerns/cost (10%). Time for family was cited by 7%, with ‘other’ given as a reason given by 3%. Only 2% indicated they would be retiring to start a second career.

Practice and Professional Activities Distribution of Professional Time Members reported the distribution of their professional time in the areas of "clinical care," "teaching/ research," and "administration." Three out of ten respondents (30%) reported all of their time under the area of clinical care. The percentage of members reporting all of their time as clinical care was higher for the general orthopaedic surgeon (42%) and lower for the specialist (21%). Also notable was that among those members who reported doing "part-time clinical work," over half (54%) reported all of their time as clinical care.

Across all responding practicing orthopaedic surgeons, nine-tenths of their time (90%) is spent in clinical care, while three percent (3%) is devoted to teaching/research and seven percent (7%) is administration-related.

This general pattern of time distribution is similar when looking at responses based on age of member and practice type. Specialists spend slightly less time in clinical care (87%) and more time doing teaching/research (6%) and administrative (8%) work.

The largest deviation from this general pattern is when the hours are examined by practice setting. Those in academic settings spend less time doing clinical care activities (74%), with the difference fairly equally distributed to doing more teaching/research (14%) and administrative work (12%); those in military practice similarly spend less time on clinical care activities (73%) but they report a greater portion of time for administrative work (20%).

On average, one-half (50%) of orthopaedic surgeon’s time is considered to be "office time" and nearly one-third (32%) of it is for "surgery." Five percent or less time is devoted to rounds and other clinical work. Less than two percent of surgeon’s time is spent on any given teaching/research or administrative tasks.

Distribution of Professional Time by Practice Setting

92

74 73

83

94

83

2

14

7

7

2

7

612

20

105

10

0

10

20

30

40

50

60

70

80

90

100

Private practice Academic Practice Military Practice Public Institution (non-militarygovt)

Pre-paid Plan/HMO Hospital/Med Center

Perc

ent o

f Pro

fess

iona

l Tim

e

Clinical Care Teaching/Research Administrative


Distribution of Professional Time Across All Respondents

Clinical: Office 49.8% Clinical: Other

3.7%

Total Teaching/Research3.0%

Clinical: Rounds5.0%

Clinical: Surgery31.5%

Total Administrative7.0%

Clinical Care Teaching/Research Administrative Total % of Time 90.0% Total % of Time 3.0% Total % of Time 7.0% Office 49.8% Classroom/lab teaching 0.8% Practice related admin 4.0% Surgery 31.5% Teaching rounds 1.1% Hospital related admin 1.6% Rounds 5.0% Research 1.2% Academic related admin 0.7% Other clin. 3.7% Other admin 0.6%

Average Hours Worked Per Week Members were asked to report how many hours per week they spent on all work-related activities excluding hours for on-call time. Responses were truncated at 120 hours/week (ie, over 17 hrs/day 7 days per week). Less that one percent indicated that they work under 10 hours per week and just over four percent indicated that they work 100 hours/week or more.

Across all responding practicing orthopaedic surgeons, the mean number of hours worked per week is 58.1 (median of 60).

After aggregating hours into ranges, almost one-third (31%) of all respondents work between 51 and 60 hours per week with the remaining two-thirds being nearly evenly divided among those working under 50 hours per week (36%) and those working more than 60 hours per week (33%).

The average number of hours worked varies somewhat by degree of specialization, decreases with I increasing surgeon age, and is somewhat higher for those in a group practice relative to those in solo practice.

Most notable is the variation in hours worked per week by practice setting.

At 68 hours per week, orthopaedic surgeons in an Academic practice report working the greatest number of hours while those in a public institution (non-military government) reported the lowest number of work hours per week at 42.


11%

25%

31%

15 %1 4%

4%

0%

5%

10%

15%

20%

25%

30%

35%Pe

rcen

t of A

ll R

espo

nde

nts

Under 40 h rs/wk 40 - 50 h rs/wk 51 - 60 hrs/wk 61 - 70 hrs/wk 71 - 90 hrs/wk Over 90 hrs/ wk

Ra nge of Hour s Wo rke d P e r W e e k

Numbers of H ours Worked Per Week (Excluding On-Ca ll Hours )

Average Number of Hours Worked/Wee

All Respondents 58.1 Age of Orthopaedic Surgeon Work Status Under 40 64.7 Full time 61.3 40 to 49 62.7 Part time 27.0 50 to 59 58.5 Degree of Specialization 60 to 69 48.8 General Orthopaedic Surgeon 52.5 70 and over 32.8 General Ortho w/Specialty 58.8 Practice Setting Specialist 61.8 Private Practice 57.5 Practice Type Academic Practice 68.1 Solo Practice 55.1 Military Practice 62.1 Orthopaedic Group 58.6 Public Institution (non-military) 42.0 Multi-Specialty Group 58.7 Pre-Paid Plan/HMO 50.3 Hospital/Medical Center 56.8


58

68

62

42

50

57

0

10

20

30

40

50

60

70H

ours

Wor

ked

Per

Wee

k

Private practice Academic Practice Military Practice Public Institut ion (non-military govt )


Pr actice Setting

Average Number of Hours Worked Per Week By Practice Setting

Average Number of Vacation Weeks in 2003

All Full-Time Respondents 3.9

Degree of Specialization General Orth Surgeon 3.9 General Orth Surgeon w/Spec Interest 4.0 Specialist 4.0

Age of Orthopaedic Surgeon Under 40 3.4 40 to 49 4.0 50 to 59 4.1 60 to 69 4.3 70 and over 3.9

Practice Setting Private practice 4.0 Academic Practice 3.5 Military Practice 3.3 Public Institution (non-military govt) 3.9 Pre-paid Plan/HMO 4.6 Hospital/Med Center 4.0

Practice Type Solo Practice 3.6 Orthopaedic Group 4.2 Multi-spec. Group 4.0

Vacation Time

Members were asked how many total weeks they spent away from orthopaedic practice for vacation. Across all full-time orthopaedic surgeons, the average number of vacation weeks in 2003 was just under four (3.9). Among those in the full-time practice of orthopaedics, there is little variation in the data based on other practice characteristics.

As seen in the table, respondents in full time practice who are under 40 took somewhat less vacation time (3.4 weeks in 2003); those in an academic or military practice took a similar amount of vacation time (3.5 and 3.3 weeks, respectively); and those in a solo practice took 3.6 weeks of vacation time.


Average Number of Procedures Done During a Typical Month

All Respondents 30.8

Degree of Specialization General Orth Surgeon 25.7 General Orth Surgeon w/Spec Interest 32.6 Specialist 33.0Age of Orthopaedic Surgeon Under 40 32.1 40 to 49 35.1 50 to 59 31.9 60 to 69 23.1 70 and over 11.1Practice Setting Private practice 31.6 Academic Practice 29.0 Military Practice 21.6 Public Institution (non-military govt) 19.4 Pre-paid Plan/HMO 25.8 Hospital/Med Center 27.0Practice Type Solo Practice 26.6 Orthopaedic Group 33.8 Multi-spec. Group 34.5

32

29

22

19

2627

0

5

10

15

20

25

30

35

40

Private practice Academic Practice Military Practice Public Institution (non-military govt)


Practice Setting

Total Number of Procedures Performed Per Month by Practice Setting

Total Number of Procedures Performed Per Month

Members were asked to estimate the total number of surgical procedures performed per month, followed by how many procedures were for twelve specific ICD-9 codes (both inpatient and outpatient). In instances where the sum of the twelve procedures exceeded the estimated monthly count or where the monthly total was missing, the summary value was substituted. This occurred in roughly 16% of all cases. As the individual procedure list was not inclusive of all orthopaedics procedures, this number should be interpreted as an estimate of the minimum number of procedures performed per month as it is highly likely that respondents performed other orthopaedic procedures not presented.

Overall, the average orthopaedic surgeon performs approximately thirty-one (31) procedures monthly. The number of procedures varied somewhat by specialization, with specialists and general orthopaedic surgeons with a specialty interest report performing about six more procedures monthly than do general orthopaedic surgeons.

The number of procedures performed monthly peaks at the ages of 40 to 49 (35 per month), then declines to a low of 11 per month for those 70 and older.

Across practice settings, members in a military practice or working in a public, non-military government practice performed fewer procedures monthly (22 and 19 per month, respectively) while those in a private practice performed the most procedures at 32 per month.

Orthopaedic surgeons in a solo practice perform just under 27 procedures monthly; those in either an orthopaedic group or multi-specialty group perform about 7 more than this on average each month (34 and 35, respectively).

Interestingly, examining the results according to geographic regions, the data reveal the fewest average number of orthopaedic procedures to be performed in the Pacific region (26 per month) while the highest numbers of procedures performed is seen for orthopaedic surgeons working in either the West North Central or East South Central regions of the US (36 per month).


Total Number of Procedures Performed Per Month by Geographic Region of Orthopaedic Surgeon

27

3436

30

36

3232

2628

0

5

10

15

20

25

30

35

40

New England Mid Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacif icRegion

Specific Procedures Performed Per Month

The following table shows the average number of procedures done per month for the twelve pre-selected ICD-9-CM procedure codes. Note that outpatient procedures were not requested for the shaded cells below, but quite a few respondents voluntarily reported specific values, which are shown here. The average number of procedures performed on an inpatient and outpatient basis, along with the number of respondents included in the average are presented below.

Average Number of Selected Conditions Done During a Typical Month

Inpatient Outpatient Procedure Name and ICD-9-CM (Vol.3) Procedure Code

3.7 (N=205) 4.5 (N=5689) Release of Carpal Tunnel (ICD-9-CM Procedure Code 04.43)

6.8 (N=338) 9.5 (N=6577) Arthroscopy of knee (ICD-9-CM Procedure Code 80.26)

4.2 (N=659) 4.4 (N=544) Excision of Intervertebral Disc (ICD-9-CM Procedure Code 80.51)

7.1 (N=1229) 9.0 (N=4) Spinal Fusion (all regions/techniques; ICD-9-CM Procedure Code 81.0x)

2.3 (N=668) 2.7 (N=3677) Other Repair of Cruciate Ligament (ACL; ICD-9-CM Procedure Code 81.45)

3.8 (N=4823) 3.0 (N=41) Total Hip Replacement (ICD-9-CM Procedure Code 81.51)

2.7 (N=4150) 3.2 (N=37) Partial Hip Replacement (ICD-9-CM Procedure Code 81.52)

1.8 (N=1591) 1.5 (N=11) Revision of Hip Replacement (ICD-9-CM Procedure Code 81.53)

5.3 (N=5527) 5.4 (N=53) Total Knee Replacement (ICD-9-CM Procedure Code 81.54)

1.9 (N=1437) 1.9 (N=16) Partial Knee Replacement (unicompartmental; ICD-9-CM Procedure Code 81.54)

1.7 (N=1608) 1.4 (N=13) Revision of Knee Replacement (ICD-9-CM Procedure Code 81.55)

3.3 (N=2648) 5.2 (N=4393) Rotator Cuff Repair (ICD-9-CM Procedure Code 83.63)


Average Number of Days Away from Orthopaedic Practice for:

Business-related

meetings

Education/Training

reasons

All Respondents 9.0 9.1

Degree of Specialization

General Orth Surgeon 7.8 8.2

General Orth Surgeon w/Spec Interest 7.8 8.8

Specialist 10.5 9.9

Age of Orthopaedic Surgeon

Under 40 7.5 8.1

40 to 49 8.3 9.0

50 to 59 9.1 9.4

11.1 9.4

7.8 8.6

9.7 8.3

9.7 9.0

12.9 11.2

8.4 8.9

0 5 10 15 20 25

Numbe r of Da y s Awa y

Privat e pract ice

Academic Pract ice

Milit ary Pract ice

Public Inst it ut ion (non-milit ary govt )

Pre-paid Plan/ HMO

Hospit al/ Med Cent er

Days Away From Practice for Orthopaedic-Related Activities by Practice Setting

Meetings CME

Days Away from Orthopaedic Practice

Respondents reported the number of days they spent away from their practice at Orthopaedic business-related meeting activities and volunteer work, as well as time at oOrthopaedic education/training (CME, including CMEs taken at Annual Meeting). Across all responses, orthopaedic surgeons typically spend just over seven days at business meetings and almost nine days in education/training (CMEs). However, limiting the data to only those who spend time away (i.e., removing "0" responses), the averages increase to approximately 9 days each for business meetings and education/training. The remaining comments are based only on those who spent time away.

A greater degree of specialization corresponds to spending more time away as shown by specialists spending a total of four more days away from their practice than general orthopaedic surgeons, and four more days away than general orthopaedic surgeons With a specialty interest.

Days away from practice for business-related meetings tends to increase as the orthopaedic surgeon's age increases, and does not vary greatly across practice types.

The other notable finding is that those in an academic practice setting spend the greatest number of days away both at business-related meetings (13 days) as well as at CMEs (11 days) among the various practice settings.


88%

68% 68%

48%

76%75%

4%

13%

24% 26%

19%

13%16%

12%

38%

26%

33%

18%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

ent

Prov

idin

g

X-ray CT Ambulatory surgeryType of Service

Percent Providing Selected Services By Practice Setting

Private practice Academic Practice Military Practice Public Institution (non-military govt) Pre-paid Plan/HMO Hospital/Med Center

Services Provided in the Orthopaedic Surgeons' Office

Members were asked to indicate which of seven types of services they provide at within their office. The most commonly provided service is X-Ray with more than four out of five orthopaedic surgeons (85%) offering this service while less than one out of ten provide CT services in their office. The services asked about and percentage of all respondents offering them are:

Service Percent Providing

X-ray 85%

Phys. or Occup. Therapy 34%

MRI 25%

EMG 21%

Ambulatory surgery 16%

Pain Management 14%

CT 6%

This pattern of service provision is fairly constant across degree of specialization and declines somewhat with increasing age of the orthopaedic surgeon.

However, the types of services offered do vary according to practice setting of the orthopaedic surgeon. Those who are in private practice are almost twice as likely as those in a public (non-military government) practice to provide X-rays (88% vs 48%). Conversely, a much higher number of orthopaedic surgeons in a public (non-military government) practice are likely to offer CT (26% vs 4%). Those in a military practice are three times more likely to provide ambulatory surgery services than are those in an academic practice (38% vs 42%).

Orthopaedic surgeons in a multi-specialty group are more likely to provide six of the seven services, with the exception being X-rays, whereas those in an orthopaedic group are slightly more likely to provide X-ray services (93% vs 90%). The most significant differences are noted for MRI, with only one out of 25 members in a solo practice providing this service while nearly two in five surgeons in an orthopaedic group or multi-


Services Provided in Orthopaedic Surgeons' Offices by Practice Type

4%1%

5%

42%

93%

2%

20%

28%

50%

90%

42%

28%

40%

24%

16%

77%

7% 6%

37%

16%

27%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Phys. or Occup.Therapy

X-ray MRI CT Ambulatory surgery EMG Pain Management

Type of Service

Perc

ent P

rovi

ding

Solo Practice Orthopaedic Group Multi-spec. Group

specialty group (37% and 42%, respectively) report offering MRI. Also notable is that one in four (26%) members in a multi-specialty group offer CT while only one in 50 orthopaedic group members (2%) and one in 100 solo practice members (1%) do so.

Patients Seen Per Week

Members were asked to report the number of patients they see at their office (both new and followup patient visits) as well as those seen in a hospital setting (inpatient, including consultations and emergency room visits). Note that all missing and 0 values are excluded and these results reflect the numbers of patients seen for those who reported seeing a given type of patient.

The typical orthopaedic surgeon sees just over 22 new patients and 67 followup patients per week in the office. The orthopaedic surgeon has eight inpatient visits (including consultations) and over five ER visits weekly.

New Office Patients. The number of new office patients seen per week varies somewhat in that it decreases among those orthopaedic surgeons over 50 years old. Among the various practice settings, those in a public (non-military government) practice see fewer new office patients (18 per week) while those in private practice see the most new patients (23 per week). Also, solo practitioners tend to see slightly fewer new patients per week than those in either an orthopaedic or a multi-specialty group.

Followup Office Patients. The number of followup patients seen in the office weekly only varied slightly by degree of specialization, with general orthopaedic surgeons with a specialty interest seeing about seven more patients than either general or specialist orthopaedic surgeons. Followup patient visits increases with age of orthopaedic surgeon up to 49 yrs. of age after which point it decreases with increasing age. Among the various practice settings, those in private practice see at least 14 more followup patients per week than those in other settings. Finally, those members who are part of an orthopaedic group see the greatest number of followup patients (74 per week), significantly more than those seen by solo practitioners (63 per week) or orthopaedic surgeons in a multi-specialty group (67 per week).


23

19 1918

20 21

70

52

43 42

5156

8 84

95

95 6 6 6

4 6

0

10

20

30

40

50

60

70

80

Num

ber o

f Pat

ient

s

New Office Patients/wk Followup Office Patients/wk Hospital InpatientVisits/Consultations/wk

Hospital ER Patients/wk

Patient Category

Numbers of Patients Seen in a Typical Week by Practice Setting

Private practice

AcademicPractice

Military Practice

Public Institution(non-militarygovt)

Pre-paidPlan/HMO

Hospital/MedCenter

Hospital Inpatient Visits (including consultations). The number of inpatient visits per week was fairly consistent across degree of specialization as well as practice type. The number of inpatient visits increased along with age of orthopaedic surgeon, with surgeons 50 years or older reporting at least nine visits per week. Not surprisingly, when these visits are examined relative to practice setting, surgeons in a hospital/medical center setting reported the greatest number of inpatient visits (nine per week) while those in a military setting reported the fewest inpatient visits at just over four per week.

Emergency Room Visits. The number of emergency room patients seen weekly was fairly similarly distributed whether looking at the responses in terms of degree of specialization, age of orthopaedic surgeon, or practice type. The only meaningful type of deviation is seen relative to practice setting such that surgeons in a pre-paid plan/HMO setting had the fewest number of ER visits (4 per week) while those in an academic or public (non-military government) setting had over 6 ER visits per week.

Average Number of Patients Seen During a Typical Week Office Patient Visits Hospital Patient Visits New Followup Inpatient ER

All Respondents 22.4 67.0 8.0 5.2Degree of Specialization General Orth Surgeon 21.6 64.9 8.7 5.6 General Orth Surgeon w/Spec Interest 23.2 71.6 8.3 5.2 Specialist 22.4 64.8 7.2 4.8Age of Orthopaedic Surgeon Under 40 23.4 67.4 5.9 5.0 40 to 49 23.5 72.3 7.3 5.2 50 to 59 22.8 70.1 9.3 5.2 60 to 69 20.5 57.4 9.4 5.6 70 and over 14.6 33.4 9.5 6.1


Average Number of Patients Seen During a Typical Week (cont.)

Office Patient Visits Hospital Patient Visits

New Followup Inpatient ER

Practice Setting Private practice 23.1 70.3 8.1 5.1 Academic Practice 18.6 51.9 7.9 6.3 Military Practice 19.4 43.0 4.4 5.7 Public Institution (non-military govt) 18.0 41.5 8.7 6.4 Pre-paid Plan/HMO 20.1 51.0 5.1 4.3 Hospital/Med Center 20.9 55.9 9.1 5.8 Practice Type Solo Practice 20.3 63.4 7.9 5.3 Orthopaedic Group 24.4 74.2 8.1 5.0 Multi-spec. Group 23.4 67.2 8.4 4.9 Work Status Full-Time 23.1 69.9 8.1 5.2 Part-Time 15.4 33.8 6.6 5.1

Issues Considered to be a Problem or Major Concern

Members were asked to indicate whether each of the following five issues is or is not a problem or major concern for their practice:

• Insurance or CMS reimbursement Levels • Volume of paperwork • Concern about litigation • Increasing regulation (eg, Fraud and Abuse/Stark, HIPAA) • Rising practice expenses (salaries, benefits, overhead)

All five areas were reported as a concern to an overwhelming majority of orthopaedic surgeons. The percentage of members identifying each issue as a major concern or problem ranged from 80% to 95%, and was maintained for all subcategories of surgeons analyzed, including degree of specialization, practice type and age. The only exception was found among orthopaedic surgeons who are 70 years and older, where the issues identified as problems by 65% to 75% of orthopaedic surgeons in this age group.


91%

86%81% 83%

89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

ent

Endo

rsin

g it

as a

Pro

blem

Insurance or CMSreimbursement levels

Volume of paperwork Concern about litigation Increasing regulat ion Rising practice expenses

Specific Concern/Problem

Issues Considered to be Major Concerns or Problems to Orthopaedic Surgeons

The most notable variations emerge when examining the issues relative to practice setting. Across all practice settings, the majority of respondents indicated the issues of "volume of paperwork," and "increasing regulation" as concerns or problems.

The issues of "insurance or CMS reimbursement" and "rising practice expenses" were reported as concerns by less than one-half of orthopaedic surgeons in either a military practice, a public (non-military government) setting, or pre-paid plan/HMO.

Similarly, less than half of respondents in military or public (non-military government) practice settings reported "concern about litigation" as a major problem/concern while more than three-fifths of those across other practice settings reported this as a concern.

Little variation in reporting of issues was found across geographic regions. "Concern about litigation" shows the most variation, with only 70% of orthopaedic surgeons in the Pacific region identifying this as a concern, while it is a concern to 90% of surgeons in the Mid-Atlantic.


95%

90%

28%

42%

31%

77%

86% 87%88%

64%

69%

80%84%

75%

35%

48%

63%

73%

85% 84%

68%

57%

65%

75%

93%

85%

31%

42%

49%

73%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

ent E

ndor

sing

as

a Pr

oble

m

Insurance or CMSreimbursement levels

Volume of paperwork Concern aboutlitigation

Increasing regulation Rising practiceexpenses

Specific Concern/Problem

Issues Considered to be Major Concerns or Problems to Orthopaedic Surgeons By Practice Setting

Private practice

AcademicPractice

Military Practice

Public Institution(non-military govt)

Pre-paidPlan/HMO

Hospital/MedCenter


Percentage endorsing each of five issues as a major concern or problem

Insurance/CMS reimbursement Paperwork

Litigation Concern Regulation

Practice Expenses

All Respondents 91% 86% 81% 83% 89%

Degree of Specialization

General Orth Surgeon 89% 84% 81% 82% 87%

General Orth Surgeon w/Spec Interest 93% 87% 83% 84% 91%

Specialist 92% 86% 80% 83% 89%

Age of Orthopaedic Surgeon

Under 40 90% 85% 78% 79% 87%

40 to 49 93% 87% 83% 84% 90%

50 to 59 93% 87% 83% 86% 91%

60 to 69 88% 83% 79% 82% 88%

70 and over 72% 70% 65% 68% 75%

Practice Setting

Private practice 95% 86% 84% 85% 93%

Academic Practice 90% 87% 75% 84% 85%

Military Practice 28% 88% 35% 68% 31%

Public Institution (non-military govt) 42% 64% 48% 57% 42%

Pre-paid Plan/HMO 31% 69% 63% 65% 49%

Hospital/Med Center 77% 80% 73% 75% 73%

Practice Type

Solo Practice 93% 84% 81% 82% 90%

Orthopaedic Group 97% 87% 86% 86% 96%

Multi-spec. Group 90% 85% 80% 84% 88%

Work Status

Full-Time 93% 87% 82% 84% 90%

Part-Time 76% 73% 72% 74% 78%

Geographic Region

New England 92% 87% 79% 80% 92%

Mid Atlantic 94% 88% 87% 82% 92%

East North Central 92% 84% 82% 83% 90%

West North Central 92% 86% 76% 83% 88%

South Atlantic 93% 87% 85% 85% 91%

East South Central 93% 85% 84% 84% 93%

West South Central 94% 86% 83% 86% 91%

Mountain 91% 83% 82% 84% 89%

Pacific 83% 84% 71% 81% 82%


23.3%

26.4%

11.6%

38.7%

24.9%

26.6%

16.8%

31.7%

24.9%

26.5%

20.6%

28.0%

24.1%

27.1%

25.5%

23.3%

24.3%

27.3%

27.1%

21.3%

24.3%

27.6%

28.7%

19.4%

24.3%

29.1%

31.6%

15.0%

17.9%

31.2%

33.8%

17.1%

0%10%20%30%40%50%60%70%80%90%

100%

Prop

ortio

n of

Tot

al Pr

actic

e

1988 1992 1994 1996 1998 2000 2002 2004

Time Period

Practice Distribution by Payor, 1988-2004

Private Pay

ManagedCare

Medicare/Medicaid

Other

Professional Compensation

Distribution of Patients by Payor Source The 14-year trend toward movement of patients by payor source into managed care programs and Medicare/Medicaid continued in 2004. However, there was a slight increase in the share of patients reported from private pay sources, and a significant decline in the proportion from other sources, such as workers’ compensation and charity.

Orthopaedic Surgeon Income The proportion of orthopaedic surgeons responding to the member census that reported their gross (72%) and net (76%) incomes in 2004 was significantly higher than in past years. Orthopaedic surgeon incomes reported below represent 63% of all board-certified orthopaedic surgeons in the United States, up from the 42% representation in the 2002 member census report.

In 2004, members were asked their 2003 income at two levels ⎯ 1) total gross collections credited to them personally for medical and professional services, and 2) personal income net of practice-related expenses received from the provision of medical and professional services. In general, the 2004 net income responses correlated closely with the ‘gross personal’ income question of previous years.

The range of incomes reported was very wide. While a few gross income levels reported may show several percentage points of surgeons at that level (primarily numbers ending in 00), the range is a steady continuum, with 97% of respondents reporting between $100,000 and $1 million in gross professional fees collected. For that reason, median incomes are used as the comparison point since these are more representative of actual incomes for the vast majority of orthopaedic surgeons. For example, the mean gross income credited to individual surgeons for their medical and professional services was $3.6 million, while the median was $800,000.

Similarly, 94% of members reported between $100,000 and $1 million in net professional income. Whereas the mean of net income reported was $1.9 million, the median net income was $320,000.


Reported Net Income for Medical and Professional Services

21%

13% 12%

25%

7%

16%

7%

0%

10%

20%

30%

$100,000 orless

$101,000 to$200,000

$201,000 to$300,000

$301,000 to$400,000

$401,000 to$500,000

$501,000 to$750,000

$751,000 andhigher

Net Income Range

% o

f Mem

bers

Reported Gross Income for Medical and Professional Services

24% 24%19%

2%8%

17%

6%

0%

10%

20%

30%

$200,000 orless

$201,000 to$500,000

$501,000 to$750,000

$751,000 to$1,000,000

$1.01 M to$1.50 M

$1.501 M to$1.750 M

$1.751 Mand higher

Gross Income Range

% o

f Mem

bers

2003 Income Compared to 2002 Income While a majority of orthopaedic surgeons (42%) reported they earned less income in 2003 than in 2002, another nearly one-third (30%) reported earning more in 2003. The remaining 28% reported equal income in the two years (24%), or chose not to respond to the question (4%).

Private Facility Income One in four orthopaedic surgeons (24%) reported that a portion of their net income was received as shares or compensation from a private facility, such as a specialty hospital, surgi-center, or radiology center, in which they had ownership.

Income Distribution Nearly one-half (48%) of orthopaedic surgeons report they earned between one-half ($500,000) and $1 million in gross collections for their medical and professional services in 2003.

Overall, 84% reported collections of between $200,000 and $1.5 million.

Nearly one-half (46%) of orthopaedic surgeons reported the earned net income in 2003 of between $200,000 and $400,000.

Overall, 84% earned net income of between $100,000 and $750,000.


2003 Income for Medical and Professional Services by Workstatus (in 000s)

$800

$240

$813

$320

$100

$340

$-

$200

$400

$600

$800

$1,000

Full-time Part-time TotalWork Status

Med

ian

Inco

me

Median Gross Income Median Net Income

2003 Income for Medical and Professional Services by Age (in 000s)

$800

$600

$210

$800

$250

$105

$910$800

$320$325$381

$309

$-

$200

$400

$600

$800

$1,000

Under 40 40 to 49 50 to 59 60 to 69 70 and over Total

Age Group

Medi

an In

com

e


Income by Work Status Income by work status is as expected, with full-time orthopaedic surgeons earning more than 3 times the net income of part-time orthopaedic surgeons.

With the exception of orthopaedic surgeons who are partially retired and work less than 40 hours per week, the number of reported hours a

surgeon works, which ranged from 40 hour weeks to more than 80 hour weeks, has little impact on net income.

Income by Age Both gross and net income form medical and professional services peaked between the ages of 40 and 49 for orthopaedic surgeons in 2003. Surgeons under age 40 and between age 50 and 59 reported similar earnings.

Income by Census Division Orthopaedic surgeons in the East South Central, West North Central and East North Central report the highest median levels of both gross income and net income from their medical and professional services.


2003 Income for Medical and Professional Services by Census Division (in 000s)

$775 $800

$370$300

$390$300

$800$700

$800$800

$700

$900 $900 $900

$320$340

$320$360

$300$300

$-

$200

$400

$600

$800

$1,000

New England MidAtlantic East NorthCentral

West NorthCentral

South Atlantic East SouthCentral

West SouthCentral

Mountain Pacific Total

Census Division

Med

ian

Inco

me


2003 Income for Medical and Professional Services by Primary Focus Area (in

000s)

$400 $360

$180

$320$313

$1,000

$850

$660

$800 $800$868

$275

$330 $350

$-

$200

$400

$600

$800

$1,000

Generalist Adult Hip Adult Knee Adult Spine Arthroscopy Disability/Legal Total

Primary Focus Area

Med

ian

Inco

me

M edian Gross Income

M edian Net Income

Income by Primary Focus Area The highest level of individual orthopaedic surgeon gross and net income in 2003 was reported by surgeons with a primary focus in adult spine, closely followed by specialists in shoulder and elbow. The lowest income levels were reported in the disability/legal area, which is often an area of specialty for doctors near retirement age. The specialty areas of orthopaedic oncology, pediatric spine, and rehabilitation/prosthetics/orthotics did not have sufficient data to include in the analysis.


2003 Income for Medical and Professional Services by Primary Focus Area (in 000s)

$360 $350$300 $320

$900$800$800$817

$692

$1,000

$750

$283$321$350

$-

$200

$400

$600

$800

$1,000

Foot & Ankle Hand PediatricOrthopaedics

Shoulder &Elbow

Sports Medicine Trauma Total

Primary Focus Area

Med

ian

Inco

me

M edian Gross Income

M edian Net Income

2003 Income for Medical and Professional Services by Practice Type (in 000s)

$800

$650

$800$900

$320$275 $328$350

$-

$200

$400

$600

$800

$1,000

Generalist Generalist w/Specialty Specialist Total

Practice Type

Med

ian

Inco

me


Income by Practice Type Orthopaedic surgeons who are specialists report a median income that is 25% higher than that reported by generalist orthopaedic surgeons. Generalists with a specialty area report a median income only 6% below that of specialists.


Income by Practice Setting Orthopaedic surgeons in private practice in a multi-specialty group report the highest gross income as well as the highest net income of all orthopaedic surgeons. While surgeons in private practice in an orthopaedic group report net income that is nearly as high as those in a multi-specialty group, their reported median gross income for medical and professional services is 15% below that of the multi-specialty group doctors.

With the exception of military orthopaedic surgeons or those employed by a public institution or hospital, members report a median income that falls between $280,000 and $357,000. Academic orthopaedic surgeons are slightly below the overall median for all orthopaedic surgeons, as are those in solo private practice.

Income by Academic Appointment Full-time salaried academic orthopaedic surgeons reported the lowest median net income in 2004. Orthopaedic surgeons with adjunct academic appointments, where they receive no salary from the institution, reported a median net income 17% over that of the full-time academicians.

2003 Income for Medical and Professional Services by Practice Setting (in 000s)

$700

$800

$300

$170

$300

$132

$600

$850

$650

$1,000

$750

$360 $325 $320

$357$350

$280

$120

$-

$200

$400

$600

$800

$1,000

Priva

te Pr

actic

e-So

lo

Priva

te Pr

actic

e-Or

tho G

roup

Priva

te Pr

actic

e-Mu

lti-Sp

ec G

roup

Acad

emic

Prac

tice

Milita

ry Pr

actic

e

Publi

c Ins

titutio

n

Pre-

paid

Plan

/HMO

Hosp

ital/M

edica

lCe

nter To

tal

Practice Setting

Med

ian

Inco

me


2003 Income for Medical and Professional Services by Academic Appointment (in 000s)

$850 $800

$350

$750$750$788

$320$300$310 $320

$-

$200

$400

$600

$800

$1,000

No appointment Full-time salaried Part-time salaried Adjunct Total

Academic Appointment Status



Appendix A. AAOS 2004 Orthopaedic Physician Census Questionnaire

AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS2004 ORTHOPAEDIC PHYSICIAN CENSUS

If any contact information shown in your cover letter is incorrect (eg, address, phone, fax, email), please go ONLINE toour website: www.aaos.org/myprofile or fax updated contact information to Member Services at (847) 823-8024.

Fax your completed census to (847) 574-7493. Thank you.

4. What is the most recent year in which you were ABOS RE-certified? Not ABOS RE-certified

5. Do you have a CSQ (Certification of Specialty Qualification, formerly CAQ) in hand surgery?6. Do you expect to test for the new CSQ in orthopaedic sports medicine? No Yes

7. Which of the following most closely describes your practice? (Select ONE only)

General orthopaedic surgeon

General orthopaedic surgeon with an area of specialty interest (at least 25% but less than 75%of practice committed to an area of specialty interest)

Specialist within orthopaedic surgery (75% or more of practice committed to an area of specialty interest)

PAGE 1

Do you ever lecture inthis/these language(s)? No Yes

In addition to English, are you fluent in other languages?No Yes (If so, please specify:)

SpanishFrenchGermanItalianPortuguese

ArabicJapaneseChineseOther (please specify)

CaucasianAfrican AmericanHispanic/LatinoAsian American

Native AmericanMulti RacialOther (specify):

Ethnicity (Please choose one)

No Yes (Please specify:)

1. What is your current professional work status? (Select ONE only)Full time Part time Fully retired from professional practice

Age Second career Time for family Bureaucracy & paperwork (govt/ins.) Malpractice concerns/cost Other3. If retired or retiring in the next 2 years, which reasons were VITAL to your decision? (select all that apply)

Fully retire at age:

Fully retire at age:

Partially retire at age:

Partially retire at age:NON-Surgical Practice .......

Surgical Practice .................

2. At what age(s) do you expect to (or did you) partially retire (significantly reduce) and/or fully retire from practice?

Male FemaleGender

In addition to your MD or DO, do you have any ofthe following advanced degrees?

Doctorate in biological sciencesDoctorate in engineeringOther doctorateJDMBAMPH

What percentage of your patientsare limited English proficient?

What is the primary hospital, academic institution,or other institution with which you are associated?

%

Date of Birth

(MM-DD-YY)

American College of SurgeonsAmerican Medical AssociationState Medical SocietyState Orthopaedic Society

Please note if you are a member of the followingorganizations by marking the appropriate box(es).

No Yes (Indicate year:)

**IF FULLY RETIRED, PLEASE SKIP TO QUESTION 38 on page 5**

Section A - CERTIFICATIONS AND PROFESSIONAL STATUS

VERIFICATION OF CONTACT INFORMATION

(yyyy)

- -

(yyyy)


NoYes - Full time salariedYes -Part time salariedYes -Adjunct (non-salaried)

10. Do you currently have an appointment with a medical school or teaching hospital?

PAGE 2

9. Which setting listed below best describes your practice? (Select ONE only)

11. Do you currently have, or have you ever, completed a fellowship?

13. How many articles have you published in the past five years:

Fellowship Specialty Area(s):ArthritisPediatric orthopaedicsHand surgeryAdult hipJoint replacementOrthopaedic researchScoliosisAdult spineSports medicine

Trauma and fracturesTumorsAdult reconstructionGeneral orthopaedicsShoulder and elbowFoot and ankleAdult kneePediatric spineOther (specify)

Private Practice - Solo (income self-earned)

Private Practice - Orthopaedic Group (income from group)

Private Practice - Multi-spec. group (income from group)

Academic Practice (salary from academic institution)

Military Practice (salary from military)

Public Institution (salary from non-military govt. entity)

Pre-paid Plan/HMO (salary from HMO)

Hospital/Medical Center (salary from hospital/med. center)

12. Have you received basic or clinical research funding in the past 5 years?

14. What was youraverage annual funding(all projects) receivedfrom each of thefollowing sourcesover the past 5 years(in thousands)?

None/GeneralistAdult hipAdult kneeAdult spineArthroscopyDisability/legal orthopaedicFoot and ankleHandOrthopaedic oncologyPediatric orthopaedicPediatric spineRehabilitation/prosthetics/orthoticsShoulder and elbowSports medicineTraumaOther (eg, Total joint)

All focusareas

Specialty/Primary area(check one only)

All8. Please mark all of your focus areas in the left column, selecting all that apply.

Please mark the one area you consider to be your specialty/primary in the right column.

PRACTICE FOCUS

Industry $ ,Foundation $ ,

Federal $ ,

Other $ ,Endowment grants $ ,

Institutional $ ,

⇒

No (Skip to Question 15)

Yes Specify total number of projects funded:

Section B - PRACTICE TYPE AND SETTING

No Yes ...... Number of fellowships:

Total months for all fellowships:

, 000.00, 000.00, 000.00

, 000.00, 000.00, 000.00


23. Do you consider the following to be a problem or major concern in your practice?

PAGE 3

22. During a typical WEEK, estimate the number of patients you see in each of the following categories:

Phys. or Occup. TherapyX-rayMRICT

Ambulatory surgeryEMGPain Management

21. Please indicate the following services you provide within your office: (select all that apply)

16. Average hours worked per week on all activities (exclude on-call time) (note: 7days@16hrs/day = 112 hrs/wk)

15. What proportion of your professional time (hours worked per week, on average across the year) is spent in each of the following activities? (Your total across the eleven categories SHOULD equal 100% of your professional time.)

17. In 2003, how many total WEEKS (cumulative rounded to nearest full week) did you spend away from orthopaedic practice for vacation?

Clinical Care

Teaching/Research

Administration

100%

% Office Time

% Surgery

% Rounds

% Other (i.e., labs, film review, consultations, etc.)

% Classroom/lab teaching

% Teaching rounds

% Research

% Practice-related administration

% Hospital-related administration

% Academic-related administration

% Other

20. In 2003, how many total DAYS did you spend away from orthopaedic practice for:

Orthopaedic business-related meetings,activities, and volunteer work days

Orthopaedic education/training (CME)(include CMEs taken at Annual Meeting) daysweeks

Office Patient Visits Hospital Patient Visits

New Inpatient (incl.consultations)EmergencyRoom

Followup

No Yes

No Yes

No Yes

No Yes

No YesInsurance or CMS reimbursement levels...

Volume of paperwork ................................

Concern about litigation ............................

Increasing regulation (eg, Fraud andAbuse/Stark, HIPAA).................................

Rising practice expenses (salaries,benefits, overhead) ...................................

19. During a typical MONTH, estimate the number of each of the following procedures you perform:

Inpatient Outpatient ICD-9 -CM (Vol. 3) Procedures Code

18. During a typical MONTH, estimate the number of TOTAL surgical procedures you perform:

Section C - PRACTICE AND PROFESSIONAL ACTIVITIES

80.26 - Arthroscopy of knee

04.43 - Release of Carpal Tunnel

80.51 - Excision of intervertebral disc

--------- 81.0x - Spinal fusion (all regions/techniques)81.45 - Other repair of cruciate ligament (ACL)

--------- 81.51 - Total hip replacement

81.52 - Partial hip replacement------------------ 81.53 - Revision of hip replacement

81.54 - Total knee replacement---------

--------- 81.54 - Partial knee replacement (unicompartmental)

81.55 - Revision of knee replacement---------

83.63 - Rotator cuff repair


PAGE 4

29. What type of Internet access do you have on the computer you most frequently use when seeking orthopaedic related research or educational information? (select one)

Dial-up (phone line)High speed (DSL, cable, or T1)Do not have Internet accessDon't know

32. Do you send your patients to the AAOS website for information?

Yes No (please explain below)

34. In 2003, approximately how many orthopaedic-related education purchases did you make from any source that were:

CME Courses

Video/CD/DVDs

Books and Journals (paper)

Books and Journals (electronic)

33. Do you use a personal digital assistant (PDA)?No Yes Which type?

Palm PilotPocket PCOther

30. Please rate your comfort level with using the Internet for research and educational information:

28. Was any of your personal medical and professional income received as shares or compensation from a private facility, such as a specialty hospital, surgi-center or radiology center, in which you have ownership? No Yes

27. Was your personal income from your medical and professional services in 2003 more or less than your personal income in 2002? More Same Less Choose not to respond

CONFIDENTIALITY NOTE: All income data will be held strictly confidentialby the Research and Scientific Affairs Department. All personal identifierswill be removed from the data, and data will be analyzed solely in aggregateform.

Collection of income data is important to AAOS Fellows. Frequentquestions arise from members related to practice management settingsand average salaries. Without member input, we are unable to providethis information.

Self Assessment Materials

31. Which services on the AAOS website do you regularly or frequently use? (select all that apply)

Do not access AAOS website

Continuing EducationPublic/Patient InformationAnnual MeetingAcademy JournalsEducational Resources CatalogLibrary and Archives (reference area)Member Services Area

Health PolicyResearchPublic & Media InformationOKOPatient SafetyPractice Management CenterOrthopaedic Yellow pages

Not at allcomfortable

Extremelycomfortable

Section E - TECHNOLOGY USE

24. Within your practice, what was the approximate distribution of patients by payor source in 2003? (Total SHOULD equal 100%)

⇒

Section D - PROFESSIONAL COMPENSATION

Total: 100%

% Private Pay (self or insurance)% HMO/Capitation

% HMO/PPO/IPA (discounted fee for service)

% Medicare (including Medicare managed care)

% Medicaid (including Medicaid managed care)

% Other (Workers' Comp., Charity, etc.)

25. For the year 2003, what were the total gross collections (in thousands) credited to you personally for your medical and professional services?

$ , ,000.00

26. For the year 2003, what was your personal income net of practice-related expenses that you received from the provision of your medical and professional services?

$ , ,000.00Do not include income you may have received from third parties forpatents and/or royalties, expert testimony, for workers compensationevaluations, or IMEs.


PAGE 5

39. Which of the following types of professional liability insurance coverage does your policy include? (Select ALL that apply)

Claims made

Occurrence

Nose

Tail

Other:

Don't know

40. Which of the following does your policy include? (Select ALL that apply)

Don't knowSurcharges based on number of malpractice claimsDiscounts based on number of malpractice claimsDiscounts for attending risk mgt course/obtaining risk mgt materialsSpecial provisions for providing care to the indigent"Co-payment" provisionsProvisions for (non-medical care) managed care dutiesNone of the above

36. Please rank your preferred provider for Orthopaedic CME courses in the boxes below. Mark a '1' as your top choice, '2' as your second choice, etc.

⇒ 36a. What is the PRIMARY reason for selecting your #1 choice? (Select one)

Quality

Cost

Relevance of topics

Cutting edge topics

Convenience

Other (Specify below)

35. In 2003, approximately how much money did you personally spend on orthopaedic education (CME course registration fees, subscriptions/books, electronic media, examination program fees, etc.)

(Do not include travel, hotel, and meal costs.)

Nothing Under $500$501 - $1,000$1,001 - $2,000$2,001 - $3,000Over $3,000

37. Select your preferences for the Setting, Length, and Content of CME Courses:

Setting preference (select one) Preference for length of course you travel to (select one)

Content Preference (select one)

Private, commercial carrierPhysician-owned carrierPhysician cooperativeHospital-based coverageOther (If so, please specify:)Retired, no longer carry insurance (Skip to Question 45)

38. What type of medical liability insurance carrier do you use? (Select one only)

AAOS

Industry

Private Hospital orInstitution

Orthopaedic SpecialtySociety

Other source

Home study programsTravel for a course or study programOnline CME

I prefer 1-2 day CME programs.I prefer 3-4 day CME programs.

Narrowly-focused CME topicsComprehensive CME topics

Section F - EDUCATION PREFERENCES

Section G - LIABILITY ISSUES


47. Have you ever conducted independent medical examinations? No (Skip to Question 50) Yes

PAGE 6

46. If you were the defendant in a medical malpractice case and another doctor testified against you, to the best of your knowledge, what was his/her background?

50a. In how many malpractice cases have you testified?

50b. On average, how many days per year do you spend testifying in malpractice cases?

No (Thank you for completing this census.)

Yes ...If yes, for whom have you testified?

50. Have you ever served as an orthopaedic expert witness in a medical malpractice case?

Plaintiffs (continue to question 50a)Defendant-physicians (continue to question 50a)Both of above (continue to question 50a)

45. Have you EVER been named in a medical malpractice action?

DismissedPendingSettled

ArbitratedTrial

45a. What is the status of this action? (select one) ⇒

Not Applicable (skip to Question 47)

No changeSee fewer patientsRefuse to see potentially litigious patientsLimit/eliminate emergency room callsRefer complex cases to orthopaedic subspecialistOrder more diagnostic testsTake more extensive histories, keep more detailed recordsSchedule more follow-up visitsSpend more time w/patients discussing patient education and informed consentPractice "medical orthopaedics" - no surgery or limit practice to 2nd opinions, etc.Retired from all medical practice Changed careers or specialtyApply a system for patients who fail to show up for follow-ups or make future apptsReduce or eliminate care provided through managed care contracts

Taken a loss prevention seminar

44. Which of the following changes have you made to your practice to minimize the risk of professional liability suits? (Mark all that apply)

42. How much did you individually pay for professional liability insurance coverage in 2003 (in thousands)?

43. How does this compare to your cost in 2002?Decrease No change Increase

Professional liability insurance is usually identified with peroccurrence/aggregate limits (eg, $1M/$3M indicates there isinsurance of up to $1M per occurrence and $3M aggregateeach year).

41. Which of the following is the closest to your individual insurance level?

$250k / $750k$500k / $1.5 Million$1 Million / $3 Million$2 Million / $6 MillionOther

Per Occurrence / Aggregate

If the action resulted in ajudgement against you, indicatethe amount below (in thousands).

$ , ,000.00

48. Did you conduct independent medical examinations in 2003? No (Skip to Question 50) Yes

Workers' Comp. Defendant-Physicians Plaintiffs

49. Indicate the number of examinations you provided in 2003 for the following parties:

General Orthopaedics Specialty Area(If more than 1 action, pleaseanswer for the most recent action)

The action involved:⇒ Number of actions named in:

No (Skip to Question 47) Yes (If yes, please specify)

$ ,000.00

Finished. Thank you for your participation. Return tothe AAOS via mail or fax all pages to 847-574-7493.

Orthopaedic surgeonOther physician

Local to site of actionNot local

RetiredPracticing

University-affiliatedSurgeon with CAQ

Profession Region Retirement status Other


Appendix B. Practicing Orthopaedic Surgeon Density and Member Census Response Rate by State

\State Abbrev

State Number of Orthopaedic Surgeons1

US Population 20002

Density3 State resp rate4

AL Alabama 282 4,447,100 6.34 52% AK Alaska 64 626,932 10.21 69% AZ Arizona 287 5,130,632 5.59 65% AR Arkansas 146 2,673,400 5.46 61% CA California 2067 33,871,648 6.10 60% CO Colorado 346 4,301,261 8.04 66% CT Connecticut 280 3,405,565 8.22 60% DE Delaware 64 783,600 8.17 61% DC District of Columbia 57 572,059 9.96 63% FL Florida 1002 15,982,378 6.27 56% GA Georgia 490 8,186,453 5.99 56% HI Hawaii 72 1,211,537 5.94 69% ID Idaho 109 1,293,953 8.42 59% IL Illinois 697 12,419,293 5.61 57% IN Indiana 347 6,080,485 5.71 59% IA Iowa 163 2,926,324 5.57 71% KS Kansas 154 2,688,418 5.73 70% KY Kentucky 220 4,041,769 5.44 60% LA Louisiana 266 4,468,976 5.95 51% ME Maine 95 1,274,923 7.45 73% MD Maryland 428 5,296,486 8.08 62% MA Massachusetts 471 6,349,097 7.42 64% MI Michigan 415 9,938,444 4.18 66% MN Minnesota 339 4,919,479 6.89 65% MS Mississippi 127 2,844,658 4.46 57% MO Missouri 323 5,595,211 5.77 58% MT Montana 98 902,195 10.86 66% NE Nebraska 126 1,711,263 7.36 61% NV Nevada 122 1,998,257 6.11 52% NH New Hampshire 108 1,235,786 8.74 59% NJ New Jersey 542 8,414,350 6.44 59% NM New Mexico 98 1,819,046 5.39 65% NY New York 1139 18,976,457 6.00 61% NC North Carolina 551 8,049,313 6.85 57% ND North Dakota 38 642,200 5.92 58% OH Ohio 616 11,353,140 5.43 64% OK Oklahoma 178 3,450,654 5.16 59% OR Oregon 259 3,421,399 7.57 65% PA Pennsylvania 743 12,281,054 6.05 61% RI Rhode Island 84 1,048,319 8.01 63% SC South Carolina 265 4,012,012 6.61 60% SD South Dakota 59 754,844 7.82 53% TN Tennessee 400 5,689,283 7.03 60% TX Texas 1089 20,851,820 5.22 62% UT Utah 149 2,233,169 6.67 68% VT Vermont 52 608,827 8.54 79% VA Virginia 502 7,078,515 7.09 59% WA Washington 429 5,894,121 7.28 63% WV West Virginia 81 1,808,344 4.48 67% WI Wisconsin 393 5,363,675 7.33 66% WY Wyoming 54 493,782 10.94 69%

Total USA 17,486 281,421,906 6.21 61%

1 Number of Active Fellows and Candidate Member Orthopaedic Surgeons from membership records, 3-17-04 2 US Population from US Census Bureau, 2000 3 Density equals the number of Orthopaedic Surgeons per 100,000 population. 4 For board certified members in active practice membership categories


Orthopaedic Surgeon Density by US Census Division

Division Total Pop Orthopaedic

Surgeons Density

New England1 13,922,517 1090 7.8

Mid Atlantic2 39,671,861 2424 6.1

East North Central3 45,155,037 2468 5.5

West North Central4 19,237,739 1202 6.2

South Atlantic5 51,769,160 3440 6.6

East South Central6 17,022,810 1029 6.0

West South Central7 31,444,850 1679 5.3

Mountain8 18,172,295 1263 7.03

Pacific9 45,025,637 2891 6.4

Total US 281,421,906 17486 6.2

1 New England: Connecticut, Main, Massachusetts, New Hampshire, Rhode Island, Vermont 2 Mid-Atlantic: New Jersey, New York, Pennsylvania 3 East North Central: Illinois, Indiana, Michigan, Ohio, Wisconsin 4 West North Central: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota 5 South Atlantic: Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina,

Virginia, West Virginia 6 East South Central: Alabama, Kentucky, Mississippi, Tennessee 7 West South Central: Arkansas, Louisiana, Oklahoma, Texas 8 Mountain: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming 9 Pacific: Alaska, California, Hawaii, Oregon, Washington


Appendix C. Open-Ended Responses : Other Language Fluency

Other Language Fluency Identified

Language N

reporting

%speaking language (n=2104)

AFRICAANS 11 0.5%ARMENIAN 15 0.7%AZARY 1 0.0%BASQUE 1 0.0%BENGALI 2 0.1%BOSNIAN 1 0.0%BURMESE 1 0.0%CAMBODIAN 1 0.0%CANTONESE 3 0.1%CHAMORRO (ISLAND OFF GUAM) 1 0.0%CROATIAN 2 0.1%CZECH 6 0.3%DANISH 3 0.1%DUTCH 20 1.0%ESTONIAN 2 0.1%FARSI 43 2.0%FILIPINO 7 0.3%FINNISH 2 0.1%FLEMISH 1 0.0%FRENCH 2 0.1%GAELIC 1 0.0%GERMAN 1 0.0%GERMAN (SWISS) 2 0.1%GREEK 51 2.4%GUJARATI (Indian language) 16 0.8%HEBREW 60 2.9%HINDI 62 2.9%HUNGARIAN 6 0.3%IGBO (NIGERIAN LANGUAGE) 2 0.1%INDIAN LANGUAGES (MULTI) 5 0.2%IRISH 1 0.0%ITALIAN 1 0.0%KANNADA (Indian language) 3 0.1%

Language N

reporting

% speaking language (n=2104)

KOREAN 44 2.1%LATVIAN 9 0.4%LITHUANIAN 2 0.1%MACEDONIAN 1 0.0%MAGYAR 1 0.0%MALAYAN 7 0.3%MARATHI (Indiana language) 4 0.2%NORWEGIAN 5 0.2%PEPIAMERTH 1 0.0%PERSIAN 11 0.5%PHILIPPINO 1 0.0%POLISH 13 0.6%PUNJABI (Indian language) 15 0.7%QUECHUA 1 0.0%ROMANIAN 1 0.0%RUSSIAN 15 0.7%SANSKRIT 1 0.0%SERBIAN 3 0.1%SIGN LANGUAGE 5 0.2%SINGALESE 1 0.0%SLOVAK 2 0.1%SPANISH 5 0.2%SWAHILI 4 0.2%SWEDISH 9 0.4%TAGOLOG 6 0.3%TAIWANESE 1 0.0%TAMIL (Indian language) 13 0.6%TELUGO (Indian language) 13 0.6%THAI 9 0.4%TURKISH 4 0.2%UKRAINIAN 11 0.5%URDU (Indian language) 17 0.8%VIETNAMESE 7 0.3%YIDDISH 14 0.7%

Documents

American Academy of Orthopaedic Surgeons - Strykerimaging.stryker.com/imaging2006/media/OrthoPad_2004 opus report.pdf · American Academy of Orthopaedic Surgeons Orthopaedic Practice