To The Editor:
Kudos to Forte and colleagues for their excellent study, "Provider Factors Associated with Intramedullary Nail Use for Intertrochanteric Hip Fractures" (2010;92:1105-14). Yet it would be wrong to emphasize the higher Medicare payment for inserting a nail. The national payment by Medicare for CPT Code 27244 differs from that for CPT Code 27245 by only $17.68. For the average surgeon in this study, the difference in payment, about $60 per year, is trivial. (By contrast, the difference between accepting $5 million from an implant manufacturer and accepting $10,001 is not trivial, although both trigger the same "conflict of interest" disclosure.) Quantitative differences impose qualitative ones.
Furthermore, the added cost to the hospital for the nail is not a true social cost, but rather it is a transfer payment from the hospital to the surgeon: the third-party payer doesn't pay a penny more when the nail is used. The loss to the hospital is no more a cost to society than it is a benefit to society when the hospital saves money and hassles its surgeons by hiring only one operating-room team on nights and weekends.
Last, there is no particular reason why the various nails should cost more than plates. Indeed, we predict that, as this device becomes more prevalent, the differences in cost will disappear.
In short, this was an enlightening study, one that should lay to rest the fiction that orthopaedic surgeons are somehow exempt from the influences of marketing: clearly, the growing popularity of nails is not due to a profusion of studies demonstrating their superiority. We hope that this study is one of many to come that examine the forces outside of medical care influencing medical decision-making.