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Specialists Under Fire: Health care reform takes aim at the most highly-trained physicians

Posted: Aug-20-2009 8:33 AM ET  |  Add Comment  |  Comments (8)

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The Obama administration and Congress have clearly stated that their priority for healthcare reform is to expand access to care for uninsured Americans.

If they succeed, an additional 15% of the population will receive healthcare coverage, which will surely increase the demand for treatment. Policy initiatives should ensure that patients will have access to the doctors who are best equipped to provide treatment.

Instead, the government has made clear its intention to prioritize prevention over treatment.

Some members of Congress and the Medicare Payment Advisory Commission (MedPAC) have recommended cutting the pay of specialists to fund an increase in reimbursement for primary care physicians.1, 2 This is necessary, they state, to fund the promotion of preventive care in a "budget neutral" fashion. Prevention and wellness are laudable goals; however, the benefits of prevention will be realized only in the long term. For those who need treatment now, prevention is not a solution.

Of particular concern are the most debilitating conditions that often require specialist intervention. Among these, bone and joint disorders stand out as the leading reason why patients visit doctors3, and the leading cause of disability in the United States, affecting 107 million citizens4 and draining approximately $340 billion per year in lost productivity.5

Disturbingly. the government is convinced that specialists are over-paid, and drive up the cost of healthcare with no corresponding improvement in outcomes.6 This conviction is driving healthcare policy recommendations that could affect patients' access to orthopedic surgeons and other specialists. The premises behind these policy recommendations demand scrutiny.

Premise #1: The U.S. has too many specialists and too few primary care physicians

In fact, the U.S. supply of specialists per capita is 18% below the average of countries in the Organization of Economic Co-operation and Development (OECD).7 Conversely, the U.S. has 20% more primary care physicians per capita than the OECD average.7

Country GPs/1000 Specialists/1000
Netherlands 0.5 0.9
Canada 1 1.1
US 1 1.4
Finland 0.7 1.4
UK 0.7 1.6
France 1.6 1.7
Luxembourg 0.7 1.7
OECD average 0.8 1.7
Australia 1.4 2
Iceland 0.8 2
Denmark 0.8 2.3
Hungary 0.7 2.3
Germany 1 2.4
Switzerland 0.5 2.5
Czech Republic 0.7 2.8

 

Further, the supply of primary care physicians per capita grew 12% from 1995-2005, while the supply of specialists grew only 5%.8

The growth of the supply of orthopedic surgeons lags behind that of primary care physicians and other specialists. While the government projects that the supply of orthopedic surgeons must grow 23-54% in order to meet the growing demand for care, the supply is only expected to grow 3%.9

Projected growth in pyhsician supply, 2005-2020

Premise #2: U.S. specialists are paid too much in comparison to primary care physicians

Despite the concerns of some policymakers that specialists are overpaid compared to primary care physicians,1,2,10 the U.S. is not out of line with other countries in its pay ratios.

Ratio of specialist pay to GP pay7
Country Ratio
Netherlands 2.4
Luxembourg 2.0
France 1.7
Austria 1.6
United States 1.6
Canada 1.5
Finland 1.4
UK 1.3
Switzerland 1.1
Iceland 1
Czech Republic 0.8

 

Further, primary care physicians have enjoyed larger increases in collections as compared to specialist physicians. From 2004-2008, median collections for primary care physicians increased 15%, while specialists' median collections decreased 4%.11 From 1992-2007, Medicare reimbursement for the top 25 orthopedic procedures decreased 28%.12

Premise #3: Specialists overutilize services to boost income

The government has made it clear that "controlling volume" and "overutilization" are major concerns.6 The Congressional Budget Office asserted in 2008 that the fee-for-service payment method "creates an incentive to provide "additional or more expensive services."35 The premise is that specialists will maximize volume to the extent possible.

In the U.S., however, musculoskeletal treatments are hardly overutilized. The table below shows that the U.S rate of inpatient hospital discharges for musculoskeletal disorders is below the average of OECD countries.13

Hospital inpatient discharges, musculoskeletal disorders, OECD countries
Country reporting, 2006 data Discharges/100,000
Mexico 106
Portugal 400
Canada 451
Ireland 552
New Zealand 554
Spain 721
Poland 747
United Kingdom 756
Netherlands 796
Italy 826
Denmark 853
Sweden 888
United States 899
Average, OECD 975
Average, non-US OECD 1012
Iceland 1015
Slovak Republic 1049
Australia 1127
Norway 1169
Belgium 1401
Hungary 1407
Czech Republic 1576
Finland 1611
France 1688
Switzerland 1816
Luxembourg 1927
Germany 2357

 

Source: OECD Health database, 2009

Could this relatively lower rate be related to lower disease prevalence? A report by McKinsey Global Institute showed that the U.S. has 14% less prevalence of osteoarthritis and joint disorders than its "peer group" (UK, Italy, Germany, Spain, France) and 9% fewer back problems.14 Thus, it's reasonable to assume that the U.S. inpatient discharge rate for musculoskeletal disorders would be 9-14% lower than that of its peer group. In fact, it's 30% lower.13 This is surprising given the greater waiting times for inpatient procedures in OECD countries.34

The OECD database does not segregate outpatient procedures, which may change the relationship somewhat. In the U.S., an estimated 54% of spine and joint procedures are performed in an outpatient setting33, while in OECD countries outpatient procedures consume 52% of healthcare expenditures.14

Thus, it is hard to argue that the U.S. overutilizes musculoskeletal services. Indeed, in certain orthopedic sub-specialties, evidence indicates that the number of patients who need orthopedic care far exceeds those who actually receive it.15, 16

Utilization decisions are best left to one surgeon and one patient, determining the appropriate treatment in each situation. The consequences of the government miscalculating are severe, including reduced access for patients in need, and ultimately higher costs as treatment is deferred or forgone entirely.

Premise #4: Specialists do not deliver better quality and patient satisfaction

In its June, 2008 report, MedPAC stated:

"Research suggests that reducing reliance on specialty care may improve the efficiency and quality of health care delivery. Areas with higher rates of specialty care per person are associated with higher spending but not improved access, quality, health outcomes, or patient satisfaction."6

The research cited by MedPAC generally concludes that geographies with high concentrations of specialists relative to primary care physicians were characterized by higher Medicare spending and lower quality. Healthcare reformers should exercise caution when basing policy design on this research, for the following reasons:

  • The research generally did not look at the value of individual specialties in treating discrete conditions, where specialists appear to provide better care. Indeed, one published literature review found that the vast majority of studies which compared outcomes for a discrete condition reported superior results from specialty care as compared to generalist care, while noting the limitations of the available research and methodology.17 In an extensive review of literature on the knowledge and outcomes of generalists and specialists, Harrold, et al., reported that "specialists were generally more knowledgeable about their area of expertise and quicker to adopt new and effective treatments than generalists."18

  • MedPAC does not cite, or perhaps dismissed, contrary research that shows that more specialists result in higher quality. Cooper reports that quality is highest in areas with the greatest concentration of specialists and primary care physicians.19

The academic literature on the relationship between the regional supply of physicians, cost and "quality" is extensive, and consistently shows that the high concentration of primary care physicians correlates positively with lower rates of utilization, spending, and mortality.20 This is no surprise; better access to primary care physicians should indeed result in better health.

But does that mean we need fewer specialists to provide treatment for complex disorders? We may indeed have an excess of some types of specialists. In the case of orthopedic surgery, however, evidence indicates underutilization and a future shortage of surgeons.

Premise #5: More primary care physicians will improve the coordination of care

Coordination of care has been shown to improve outcomes and satisfaction, in orthopedics and for surgical patients in general.21, 22 However, the government's view of coordination appears to be decidedly one-way, i.e., pay primary care physicians to coordinate care, at the expense of the providers of specialty care.

Well-educated primary care physicians can facilitate access. Too often, however, this is not the case. For example, Schoenberg, et al., report that only 25% of primary care physicians discussed joint replacement surgery as an option with Medicare-age patients with severe osteoarthritis.23 Further, 83% of primary care physicians underestimated the success rate of total joint arthroplasty.24 Lynch, et al., found that a majority of academic primary care providers "failed to demonstrate adequate musculoskeletal knowledge and confidence."25

Simply paying primary care physicians to coordinate care does not guarantee better outcomes for orthopedic patients. Primary care physicians must also improve their understanding of the value of specialty orthopedic care and refer patients in a timely fashion.

Premise #6: More primary care physicians will result in prevention of disease

While prevention of disease and disorders is certainly a worthy objective, the opportunities to prevent musculoskeletal disorders are limited. The U.S. Preventive Services Task Force (USPSTF) lists only two statements on the prevention of musculoskeletal disorders; one for low back and one for osteoporosis. It recommends regular screening for osteoporosis, but finds no evidence to recommend preventive interventions for low back pain.26 Certainly, reducing obesity may help reduce the burden of musculoskeletal disorders. However it remains an open question whether increasing the supply of primary care physicians and reducing the supply of specialists will reduce obesity among U.S. citizens, particularly when primary care physicians have found obesity treatment to be less effective than treatment of other chronic conditions.27

The government views prevention as strictly the province of primary care physicians. Yet orthopedic care has tremendous preventive value, restoring motion and forestalling the deleterious impact of a sedentary lifestyle. Indeed, chronic conditions are significantly more prevalent among adults with arthritis than among the general population.28 For example, physical inactivity was significantly higher among patients with arthritis and diabetes than among those with diabetes alone.29

Orthopedic surgery can also help patients improve their cardiovascular health. Arthritis and heart disease frequently co-exist; 57.8% of adults with heart disease also suffer from arthritis.30 Patients who receive total hip and knee replacements improve their cardiovascular fitness, while untreated patients show continued deterioration.31,32 If arthritis and other musculoskeletal disorders restrict patients' movement, it stands to reason that prevention of chronic disease, and the effectiveness of therapies required to control existing chronic disease, become significantly more difficult.

Conclusion: Bad premises lead to bad policy

Healthcare reformers are correct to pursue greater coordination and prevention, and to reward primary care physicians appropriately. However, Medicare must recognize that its first priority is to treat sick and injured people, especially given the short-term need to address the impending increase in Medicare beneficiaries. Reformers must ensure that they do not use flawed premises to create policies that restrict patient access to skilled specialists.

Both primary care physicians and specialists practice care coordination and preventive medicine. Indeed, orthopedic care has great preventive value, and orthopedic surgical intervention is highly cost-effective. Rational reimbursement reform cannot emerge from an oversimplified view that ignores the relative value of treatments, and the tremendous economic value of orthopedic care in particular.

References
  1. "Call to Action: Health Reform, 2009," November 12, 2008.
  2. "Report to the Congress: Medicare Payment Policy," Medicare Payment Advisory Committee (MedPAC), March, 2009.
  3. "National Ambulatory Medical Care Survey: 2006 Summary," U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, August 6, 2008.
  4. "National Health Interview Survey, Adult Sample," National Center for Health Statistics, Adult Sample, 2005, available at http://www.cdc.gov/nchs/nhis/reports_2005.htm as referenced in "The Burden of Musculoskeletal Disease in the United States," Bone and Joint Decade, 2008.
  5. "Medical Expenditures Panel Survey," AHRQ, 1996-2004, as referenced in "The Burden of Musculoskeletal Disease in the United States," Bone and Joint Decade, 2008.
  6. "Report to the Congress: Medicare Payment Policy," Medicare Payment Advisory Committee (MedPAC), June, 2008.
  7. Fujisawa R, Lafortune G, "OECD Health Working Papers No. 41: The remuneration of general practitioners and specialists in 14 OECD countries: what are the factors influencing variations across countries?" Organisation for Economic Co-operation and Development, Directorate for Employment, Labour and Social Affairs Health Committee, December 18, 2008.
  8. Steinwald BA, "Primary care professionals: recent supply trends, projections, and valuation of services," GAO, February 12, 2008
  9. "Physician Supply and Demand: Projections to 2020," U.S. Department of Health and Human Services, Health Resources and Services Administration, October, 2006.
  10. Pear, R., "Shortage of doctors proves obstacle to Obama goals," New York Times, April 27, 2009
  11. "Physician Compensation and Production Survey," Medical Group Management Association, 2009 Report Based on 2008 Data.".
  12. Hariri S, et al., "Medicare Physician Reimbursement: Past, Present, and Future," JBJS, November, 2007.
  13. Organisation for Economic Co-operation and Development, Health 2008 Database, available at http://titania.sourceoecd.org/vl=4039643/cl=25/nw=1/rpsv/ij/oecdstats/99991012/v1n1/s1/p1
  14. "Accounting for the cost of U.S. healthcare: a new look at why Americans spend more," McKinsey Global Institute, December, 2008.
  15. National Institutes of Health Office of the Director, "NIH Consensus Statement on Total Knee Replacement," Volume 20, No. 1, December 8-10, 2003.
  16. George LK, et al., "The effects of total hip arthroplasty on physical functioning in the older population," J. Am Geriatr Soc, June, 2008.
  17. Smetana, GW, et al., "A comparison of outcomes resulting from generalist vs. specialist care for a single discrete condition," Arch Intern Med, January 8, 2007.
  18. Harrold LR, et al., "Knowledge, Patterns of Care, and Outcomes of Care for Generalists and Specialists," JGIM, August, 1999.
  19. Cooper RA, "States with more physicians have better-quality health care," Health Affairs Web Exclusive, December 4, 2008.
  20. Starfield, Shi and Macinko: "Contribution of Primary Care to Health Systems and Health," Milbank Quarterly, Vol. 83, No. 3, 2005
  21. Gittell JH, et al., "Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients," Medical Care, August 2000.
  22. Weinberg DB, et al., "Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients," Health Serv Res, February, 2007.
  23. Schoenberg MA, et al., "Perceptions of physician recommendations for joint replacement surgery in older patients with severe hip or knee osteoarthritis," J. Am Geriatr Soc, January, 2009.
  24. Ang DC, et al., "An exploratory study of primary care physician decision making regarding total joint replacement," J. Geg Intern Med, January, 2007.
  25. Lynch JR, et al., "Important demographic variables impact the musculoskeletal knowledge and confidence of academic primary care physicians," JBJS, July, 2006.
  26. U.S. Preventive Services Task Force, available at http://www.ahrq.gov/CLINIC/cps3dix.htm#musculo
  27. Foster GD, et al., "Primary Care Physicians' Attitudes about Obesity and its Treatment," Obesity Research, Vol. 11, 2003.
  28. "Prevalence of chronic conditions among adults with arthritis and related health status," Behavioral Risk Factor Surveillance System, South Carolina, 2005.
  29. Arthritis as a potential barrier to physical activity among adults with diabetes—United States, 2005 and 2007," MMWR Weekly, Centers for Disease Control, May 9, 2008.
  30. "Arthritis as a potential barrier to physical disease among adults with heart disease—United States, 2005 and 2007," MMWR Weekly, Centers for Disease Control, February 27, 2009.
  31. Ries MD, et al., "Effect of total hip arthroplasty on cardiovascular fitness," J. Arthroplasty, January, 1997.
  32. Ries MD, et al., "Improvement in cardiovascular fitness after total knee arthroplasty," Journal of Bone and Joint Surgery (Am), November, 1996.
  33. Watkins-Castillo S, "Orthopaedic Practice in the U.S. 2005-2006," American Academy of Orthopedic Surgeons, Department of Research and Scientific Affairs, June, 2006.
  34. Hurts J and Siciliani L, "Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries," OECD Health Working Paper 6, 2003.
  35. Orszag, PR, "The Overuse Underuse, and Misuse of Healthcare," Congressional Budget Office testimony before the Committee on Finance, United States Senate, July 17, 2008.

8 Comments to Specialists Under Fire: Health care reform takes aim at the most highly-trained physicians


The opinions expressed in the comments section of this blog are solely those of the commenter.
Submitted: Aug-20-2009 1:48 PM ET by Bill Kolter
Submitted: Aug-20-2009 3:58 PM ET by Thomas
Your table on ratio pay....in Premise #2 Let's just assume it's right.... I have one question. We have the 37th ranked healthcare system in the world, and those countries directly below us on your table have much better overall quality of care.

So in all honesty, shouldn't our ratio number be lower still? I think we need to re-evaluate our mission to our patients.

Submitted: Aug-23-2009 9:22 PM ET by Keith m. Maxwell,M.D.
I am president of the Medical Staff at my hospital in N.C. Just last week, I posed a question to my hospital and had their responses recorded in the minutes. I asked each of them if they would consider borrowing 200-300,000 dollars to go to school for 14 yrs for a salary of less than 100,000 dollars a year. Interestingly, not one person in the room said they would embark on such an endeaver. Many of our brightest college students are making the same decision. I fear manpower because of the lack of incentive will ultimately be what controls both access and quality.

Submitted: Aug-26-2009 11:09 AM ET by Bill Kolter
The U.S. ranking of 37th among world health care systems is a widely-quoted statistic from the World Health Organization 2000 report.1,2 The WHO rating is actually a score of "health system performance," and has a tenuous relationship to outcomes.

There are two rankings, "overall performance" and "overall attainment." The "overall performance" ranking is based in part on theoretically constructed variables, whereas the "overall attainment" ranking is based strictly on actual data. The U.S. ranks 37th on the theoretically-adjusted "overall performance" ranking but 15th using the "overall attainment" scale, which we believe is the more valid measure. However, it still is not a true indicator of health outcomes.

The WHO uses an interesting formula that looks at disability-adjusted life expectancy, responsiveness, fairness in financial contribution, and health expenditure per capita. For example, to determine "responsiveness" the WHO establishes a weighted system that prioritizes "quality of amenities" at three times the weight of "choice of provider." It's an open question whether the U.S. population would see it that way. Nonetheless, the U.S. ranks #1 in responsiveness.

The WHO also weights "fairness in financial contribution" equally with "disability-adjusted life expectancy" and "responsiveness." Within the WHO system, countries with the highest percentage of healthcare costs paid by the government rank higher on "financial fairness." As WHO states, "fairness is concerned with the principle of from each according to ability." Many would question whether this is a valid definition of "fair." Nor is there any obvious connection to "fairness" and quality. Indeed, it appears as if the WHO is advocating for government-run healthcare, and has designed its scoring system accordingly.

Additionally, different countries report data differently. For example, the U.S. system is frequently criticized for its low ranking on infant mortality. However, different countries have different definitions of "infant." Several countries place limits on birthweight and gestational period to define a "live birth," whereas the U.S. does not.3 Thus, countries with restrictive definitions would have ostensibly better infant mortality statistics. ("Society at a glance 2009: OECD social indicators," 2009). Moreover, factors that impact health statistics often have nothing to do with the health system: homicides, suicides, auto accidents, etc.2

Perhaps a better way to look at the quality of the health care system is to look at relative survival rates related to certain diseases and disorders.

These data are provided by Organization for Economic Co-Operation and Development, an organization of 30 countries (Health at a Glance, 2007, OECD).

U.S. rankings on various health care measures4
  • Life expectancy at age 65: 14th (females); 9th (males)
  • Perceived health status among adults: 2nd
  • Cancer survivorship rates: 7th
  • Survivorship following stroke: 6th (females); 4th (males).
In all of the above measures, the U.S. ranks above the OECD average. In the area of survivorship following ischemic heart disease, however, the U.S. ranks below average. For reasons cited above, we did not include infant mortality, which we believe to be a flawed measure.

This is not to say that outcomes cannot improve; however, the frequently-used statistic of "37th in quality" is misleading. Even using the highly flawed WHO scoring system, we would argue that the U.S. ranks 15th.

To your point about how the ratio of specialists to primary care physicians relates to quality rankings: We are arguing simply that the U.S. does not now-and is not projected to in the future have a surplus of specialists, and that it is dangerous for reformers to design policies that address a perceived imbalance that simply doesn't exist. If anything, we have too few specialists as compared to OECD nations.

1 "The World Health Report 2000-Health Systems: Improving Performance," available at http://www.who.int/whr/2000/en/index.html
2 Whitman G., "WHO's Folling Who? The World Health Organization's Problematic Ranking of Health Care Systems," Cato Institute Briefing Paper No. 101, February 28, 2008, available at http://www.cato.org/pub_display.php?pub_id=9236
3 "Society at a glance 2009: OECD social indicators," 2009, available at http://www.sourceoecd.org/pdf/societyataglance2009/812009011e-07-03.pdf
4 "Health at a Glance, 2007," OECD, available at http://oberon.sourceoecd.org/vl=16194778/cl=17/nw=1/rpsv/health2007/index.htm

Submitted: Aug-27-2009 5:24 PM ET by Mark D Brown, MD Miami Florida
What differentiates us from the 36 other countries that outrank us for "health system performance" for less than we spend is the enormous cost of liability, bureaucracy , fraud and abuse, unproven treatments and excessive technologies. If our government would depoliticize the health care reform and correct these issues we could easily afford high quality health care for all. The VA system has solved most of these issues so the government can do it.

Submitted: Aug-29-2009 1:51 PM ET by Stuart Miller, M.D.
Great forum, excellent data analysis, thanks for the contribution! I think we must also analyze the roles of the specialists. As a foot and ankle subspecialist, I am often in the role of primary care physician to my patients as their sole active medical contact. I limit my practice to orthopaedic concerns, but am very efficient and effective at doing so. Most of my peers are finding similar roles as patients see no need to see their primary physician for a treatment they know will best be served by the specialist. These issues will be tough to analyze but surely play a role in the effective delivery of healthcare.

Submitted: Oct-1-2009 11:59 PM ET by Tom Doerr
Many experts in this subject matter area do not agree with your thesis, or with most of the posts on this thread.

Let me recommend that you read this brief interview of Barbara Starfield, who has spent her career analyzing and consulting on health care system design in many different countries.

http://bostonreview.net/BR30.6/starfield.php

Then, if needed, please google her credentials and read some of her studies that have been published in peer reviewed medical journals. A couple of her books are also available at amazon.com. This has been her life's work. You can also validate her credibility by appreciating that NCVHS invited her testimony about the Medical Home. http://www.ncvhs.hhs.gov/080520tr.htm#performance

Also review the 2008 Dartmouth Atlas Project. Fischer and Wennberg have unequivocably demonstrated that 50% of Medicare spending is supply sensitive, and half of this has no demonstrable value and is associated with worse outcomes. This is not controversial. They have found similar results for decades.

Dartmouth Atlas was independentaly validated by Katherine Baicker and Amitda Chandra (Kennedy School of Governement and Harvard School of Public Health).

It is difficult for people who are not experts in a very narrow discipline such as this to correctly interpret primary data--there are so many confounding variables, asterixes, footnotes etc. There are some paradoxes involving primary care statistics. http://www.annfammed.org/cgi/reprint/7/4/293

This is all the more difficult when we admit to ourselves that we all (including myself) may have personal agendas.

Regards, Tom

Submitted: Oct-6-2009 5:52 PM ET by Bill Kolter
Thank you very much for your comment on the blog post, “Specialists Under Fire.” I am responding on behalf of Jeff, as I helped him research the blog post.

The blog acknowledges the work of Starfield, Baicker and Chandra, the Dartmouth group, and numerous others who have evaluated the relationship between physician supply, spending, and quality.

While the blog does not reference each of the numerous papers that have reached this conclusion, it did reference Starfield’s 2005 report, which we believe to be a well-reasoned overview.

The blog also references the work of Richard Cooper, who has reached conclusions that are contrary to those of Baicker and Chandra.

Clearly, the blog presents a point of view that is in contrast to the conclusions of most academicians. However, it does not put forth an alternative interpretation of their data. Rather, we are simply pointing out that, for the most part, these studies have not looked at the true outcomes of specialists treating discrete disorders within their specialty.

What is undisputed is the projected surge in demand for musculoskeletal care and the projected shortage of specialists to provide it. Policies that discourage specialty care may squeeze out some overutilization, but will those savings compensate for creating waiting lines and extending the disability of patients in need?

Appropriate reform measures will encourage coordination and appropriately timed intervention, without constraining access to needed care. Research to date on the impact of specialists and primary care physicians are useful to the dialog, but ultimately not sufficiently conclusive to inform policy design.

As Philip Musgrove wrote in Health Affairs: “Perhaps it is time to get beyond such relatively simple analyses.” (1)

Reference 1. Musgrove P., “Primary/Specialty Care: An Author Responds,” Health Affairs, March/April, 2009.


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