Prevalence, Health Care Expenditures, and Orthopedic Surgery Workforce for Musculoskeletal Conditions

Musculoskeletal conditions account for more disability and more costs to the US health care system than any other condition, and with the aging of the population, this burden to society will increase.¹ Given this reality, it is important to consider the substantial clinical and societal burden of musculoskeletal disease, highlight the importance of research funding for these conditions, and define current issues that will affect the delivery of care for patients with musculoskeletal conditions.

According to the 2008 National Health Interview Survey, an estimated 110 million adults (approximately 50% of the adult population) reported having a disabling musculoskeletal condition.² Estimates of expenditures for musculoskeletal conditions include the costs of preventive care; the costs of direct care; the costs of caring for these conditions by hospitals, physicians, therapists, and secondary caregivers; as well as the indirect costs to society, including the effects on families and loss of productivity.

In 2002-2004, the average annual total direct costs of care for musculoskeletal disease were estimated at $510 billion, whereas indirect costs from lost wages among persons aged 18 to 64 years were estimated to be $330 billion.¹ Accordingly, the total estimated costs to society for the care of such musculoskeletal conditions in 2004 were $840 billion.¹ Among the conditions that account for a substantial proportion of musculoskeletal disease prevalence and health care expenditures are spinal conditions, osteoarthritis, osteoporosis, and musculoskeletal injuries.

Spine problems, including low back and neck pain, are among the leading physical conditions for which patients seek medical care. Low back pain is the most common musculoskeletal condition, reported by nearly 62 million adults. Each year between 12% and 15% of the US population will see a physician for low back pain.² Among adults, 43% to 60% reported neck or low back pain within the previous 3 months and 15% to 20% of these report that the condition was severe enough to preclude work.² The estimated direct costs for spine-related conditions for 2002-2004 were $193.9 billion, with an additional indirect cost of $14 billion due to lost wages.¹

Arthritis is the leading cause of disability and is associated with substantial activity limitation, work disability, reduced quality of life, and high health care costs.³ It is the most common cause of disability in adults and is among the leading causes of work limitations.¹ In the 2003-2005 National Arthritis Data Workgroup survey, an estimated 21.6% of the adult US population (46.4 million persons) had physician-diagnosed arthritis, and 8.3% (17.4 million) had arthritis-attributable activity limitations.⁴ Prevalence is higher among women, older age groups, and white, black, and Hispanic populations. The prevalence of arthritis is projected to increase by 40% to nearly 67 million individuals, or 25% of the population, by 2030.³ Treatment of arthritis includes an expanding list of expensive oral and parenteral medications that add to the overall cost to society.

Osteoarthritis and rheumatoid arthritis are the most common diagnoses requiring total joint replacement. Kurtz et al⁴ estimated that primary total hip arthroplasty will increase from 209 000 cases in 2005 to 572 000 in 2030. Primary total knee arthroplasty is estimated to increase from 450 000 cases in 2004 to 3 481 000 cases in 2030. Revision of total hip arthroplasty is expected to increase from 40 800 cases in 2004 to 95 600 cases in 2030 and revision total knee arthroplasties are likewise expected to increase from 38 300 cases in 2004 to 268 000 cases in 2030.⁴ Baby boomers aged 45 through 54 years are expected to account for the most rapid increase in the rate of hip and knee arthroplasties, accounting for more than 50% of all procedures. The cost for total knee arthroplasty was estimated at $5.36 billion in 1998 and increased to $14.6 billion by 2004.¹

In 2002, an estimated 44 million individuals older than 50 years were at risk for a fracture due to osteoporosis.⁵ Between 1988-1994 and 1999-2004, self-reported prevalence of osteoporosis doubled and is estimated at 19% of individuals older than 65 years.¹ Osteoporosis is a major contributor to low-energy fractures, the most common of which involve the distal radius, hip, spine, and proximal humerus. Hip fractures are especially problematic because of the associated 1-year mortality rate of 20% or greater.⁶ The total costs of treatment for osteoporosis and related fractures was estimated at $19.1 billion in 2004.¹

Approximately 60% of all injuries involve the musculoskeletal system and falls are the most common cause. In 2004, an estimated 57.2 million musculoskeletal injury visits to physician offices, emergency departments, outpatient clinics, and hospitals were reported.¹ Approximately 3% of patients who sustained a musculoskeletal injury were admitted to a hospital, with those older than 65 years more likely to be admitted.¹ Admitted patients spent an average of 4.7 days in the hospital, accounting for 4.9 million hospital-days at an estimated cost of $26.65 billion. Total estimated costs of care of musculoskeletal injuries in 2004 were $127.4 billion, an increase from $93 billion in 1998.¹

Despite the prevalence and costs of musculoskeletal disease, the National Institutes of Health (NIH) research budget for musculoskeletal conditions is not among the top 10 conditions that receive funding and is decreasing as a proportion of the total NIH budget. In 1987, when the National Institute for Arthritis and Musculoskeletal and Skin Diseases (NIAMS) was established, the total budget for NIH was $6.7 billion and the budget for NIAMS was $138 million (ie, 2.1% of the total NIH budget).⁷ The 2008 NIH budget was $29.3 billion, but the NIAMS budget was $510 million (ie, 1.7% of the total NIH budget).⁸ While the smaller proportion is due in part to the addition of new research institutes and centers at the NIH as well as the creation of the NIH Roadmap/Common Fund, it is concerning that funds available for musculoskeletal conditions are not keeping pace with available research opportunities.

This relative decrease in the share of the research budget may have occurred because musculoskeletal conditions are usually not fatal and as a result do not receive the attention accorded to other conditions, such as cancer and heart disease. However, considering that the costs to care for musculoskeletal conditions represent a major portion of the health care dollar and are predicted to steadily increase, it seems reasonable that funding for musculoskeletal research should keep pace with the projected economic and societal burdens.

As funding has decreased, the supply of orthopedic surgeons has concomitantly declined in many states. In 2004, there were approximately 24 000 residency-trained orthopedic surgeons in the United States, with an unrealistic projected need of nearly 50 000 orthopedic surgeons by 2020.⁹ The supply of orthopedic surgeons has declined in many states; by 2006 there was an overall decline from 7.9 to 5.1 surgeons per 100 000 population.⁹ Approximately 11% of the orthopedic workforce currently works only part-time.

The average age of a practicing orthopedic surgeon is 51.4 years (range, 31-92 years). The proportion of orthopedic surgeons who remain in active practice past age 70 years has maintained a steady increase over the last 20 years, and in 2006 represented approximately 5% of the total orthopedic workforce. The proportion of orthopedic surgeons younger than 40 years comprises less than 15% of the current American Academy of Orthopaedic Surgeons membership.⁹ Frustration with increased litigation costs and the lack of malpractice caps have likewise contributed to an atmosphere in which fewer specialists are available and readily willing to treat the aging US population. It is not coincidental that approximately 24% of currently practicing orthopedic surgeons are in the age group 59 to 69 years; 4% of practicing orthopedic surgeons are aged 40 through 49 years; and 1% of those younger than 40 years report that they plan to retire within the next 2 years.⁹

The inability to enact tort reform and the failure to maintain adequate Medicare reimbursement have contributed to an insufficient recruitment of needed physicians and fostered a sense of uneasiness among graduating medical students entering gerontology, rheumatology, and orthopedics. Despite attempts at increasing medical school class sizes, achieving balance between numbers of men and women physicians, and accepting international medical graduates into residency training programs, there is an ongoing reduction in the required orthopedic surgery workforce. Accordingly, redirection and reassessment may be necessary to develop strategies to enhance physician recruitment and retention and to ensure that the necessary workforce will be available to deliver orthopedic care to the increasing numbers of patients with musculoskeletal conditions. This issue should be one of the prominent concerns within the current debate concerning health care.

In summary, musculoskeletal conditions cost society more in money and disability than any other condition. Allocation of resources for research and for training and retention of musculoskeletal clinicians is necessary, or the ability to provide reasonable, economical, and efficient musculoskeletal care may be lost.