closing disparities and opening markets in orthopedics

8/3/2019 Closing Disparities and Opening Markets in Orthopedics

1/15

November 28, 2011; Malcolm Vivian, Cogency Group

2415 E. Camelback Road, Suite 700Phoenix, Arizona 85016

602.553.1126www.cogencygroup.com

Closing Disparities and Opening Markets in Orthopedics

By Malcolm Vivian, Consultant

A Cogency Group White Paper


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Table of Contents

Introduction ..................................................................................................... 2

Blacks and Total Knee Replacement Disparities.............................................. 3Projecting Medicare TKR Opportunity Among Blacks ...................................... 4

Estimating Total Hip Replacement Disparities.................................................5

Extrapolating Disparities Estimates Among Latinos ........................................ 8

Conclusion...................................................................................................... 12

About Cogency Group.....................................................................................13

References...................................................................................................... 14


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Introduction

The opportunity loss of healthcare disparities can be measured in billions of dollars, and that is just in hipand knee implants. According to a 2002 Institute of Medicine report, blacks comprise one of thirteen

groups of Americans who suffer disparate healthcare despite controlling for insurance status, income,

age, education, and severity of condition.1

In May 2009 Cogency Group produced an internal report estimating the market potential of artificial

knees and hips if racial and ethnic disparities for total knee replacement and total hip replacementprocedures were closed.

We are releasing this report under all of the assumptions made in 2009 but with projection changespertinent to 2011.

The issue of healthcare disparities is as relevant today as it was two years ago, if not more. Although thisstudy is not scientific, these projections provide a compelling business case for the closure of disparities

not only in orthopedics, but in healthcare overall.

Forward thinking healthcare suppliers recognize that efforts to close disparities gaps present

opportunities to identify and penetrate new markets. The Congressional Budget Office and JointCommittee on Taxation assert that the Patient Protection and Affordable Care Act (PPACA) together with

the Health Care Education and Reconciliation Act of 2010 will reduce the number uninsured by

approximately 32 million people.2 In light of increased access to healthcare services through healthcarereform, the need for supplier participation in the dialogue on disparities closure has gained a new level of

urgency.


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Blacks and Total Knee Replacement Disparities

According to a study published by the Centers for Disease Control (CDC) in February 2009, 45% of U.S.

adults might be at risk for developing symptomatic knee osteoarthritis during their lifetimes. While all

Americans are equally at risk for this disabling condition, the percentage of black Medicare enrolleesreceiving hospitalization for total knee replacement (TKR) is significantly lower than the percentage of

blacks enrolled in Medicare (see tables 1 and 2).

The combined population of Medicare enrollees, between whites and blacks, is slightly over 36.6 million.

Whites make up 88.5% of this total. Blacks make up 11.5% (see table 1).

Table 1. Percentage/totals Medicare enrollees between whites/blacks

Race Medicare enrollees

by race white/black only3

Percentage of Medicare enrollees

by race white/black only

White 32,435,218 88.51*

Black 4,211,844 11.49Total 36,647,062 100

Like many other healthcare services, reports indicate that racial disparities in TKR procedures persist even

after adjusting for access to clinical care.4

Table 2 Percentage/totals Medicare TKRs between whites/blacks

Race Medicare TKR

recipients by race in

2006 white/blackonly5

Percentage of Medicare TKR

recipients by race in 2006

white/black only

White 226,829 94.72Black 12,656 5.28**

Total 239,485 100

In an ideal world where racial disparities do not exist in healthcare, specifically in orthopedics, the

percentage of Medicare TKRs between whites and blacks would equal Medicare enrollment percentages.Racial disparities in TKRs have revealed a significant opportunity loss nearly 17,000 new patients for

2006 equivalent to an opportunity loss of over $87 million (see table 3).

*0.885070077 0.114929923 In 2004, 17% of Medicare enrollees were members of managed care organizations they were not included in the CDCs TKR

analysis. Only Medicare enrollees aged 65 are included. Partial knee replacements were not included in the analysis theyrepresent 8% of all knee replacement procedures. 0.947153266** 0.052846734


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Table 3. White/black Medicare TKRs equivalent to Medicare enrollment and associated black

opportunity loss, 2006

Race Ideal percentage of

Medicare TKRs -equal to white/black

Medicare enrollment

- 2006

Ideal Medicare TKR

recipients by race equal to white/black

Medicare enrollment

- 2006

Opportunity

loss inpatients

Opportunity loss in

dollars

White 88.51 226,829 n/a n/a

Black 11.49 29,455 16,799 $87,354,800

Total 100 256,284 16,799 $87,354,800

Projecting Medicare TKR Opportunity Among Blacks

Studies estimate that TKRs will increase 673% by 2030.6 Between whites and blacks, this percentageincrease with disparities unchanged would result in over 1.8 million TKR patients (see table 4).

Table 4. White/black Medicare TKRs projections, 2030

Race Percentage of Medicare

TKRs by race

white/black only - 2006

Medicare TKRs by

race white/black

only - 2006

Projected Medicare

TKRs by race


White 94.72 226,829 1,753,388

Black 5.28 12,656 97,831

Total 100 239,485 1,851,219

With this projected increase in TKR procedures, closed disparities in the year 2030 alone would reveal a

market potential of nearly 130,000 new patients and over $675 million (see table 5).

Table 5. White/black Medicare TKR projections equivalent to Medicare enrollment and

associated black opportunity loss, 2030

Race Percentage of

Medicare TKRs -

equal to white/black

Medicare enrollment

Ideal Projected

Medicare TKRs -

equal to

white/black

Medicareenrollment - 2030

Market

potential

in

patients

Market

potential in

dollars

White 88.51 1,753,388 n/a n/a

Black 11.49 227,685 129,854 $675,240,800

Total 100 1,981,073 129,854 $675,240,800

Average price of knee at $5200 TKR projections are being applied to CDC Medicare TKR figures


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Racial disparities that have persisted since 2006 to the present are estimated to have resulted in anopportunity loss of over 150,000 patients and $804 million (see table 6).

Table 6. - White/black Medicare TKR estimates equivalent to Medicare enrollment andassociated black opportunity loss, 2007 - 2011

TKR Opportunity Loss Since 2006 - Blacks Year Ideal patient estimate

equal to Medicare

enrollment

Actual no.

patients

Opportunity loss

in patients

Opportunity loss

in dollars

2007 37,714 16,205 21,509 $111,846,800

2008 45,974 19,754 26,220 $136,344,000

2009 54,233 23,303 30,930 $160,836,000

2010 62,493 26,852 35,641 $185,333,200

2011 70,753 30,401 40,352 $209,830,400

Total Opportunity Loss 154,652 $804,190,400

If the disparities gap were closed today, a market of nearly 275,000 patients and $1.5 billion could berealized between now and 2016 (see table 7).

Table 7. - White/black Medicare TKR projections equivalent to Medicare enrollment andassociated black market potential, 2012 - 2016

Projected TKR Market Potential Through 2016 - Blacks

Year Ideal patient projection

equal to Medicare

enrollment

Actual

patient

projection

Market potential in

patients

Market potential in

dollars

2012 79,012 33,950 45,062 $234,322,400

2013 87,272 37,499 49,773 $258,819,600

2014 95,531 41,048 54,483 $283,311,600

2015 103,791 44,597 59,194 $307,808,800

2016 112,050 48,146 63,904 $332,300,800

Total Projected Opportunity 272,416 $1,416,563,200

Estimating Total Hip Replacement Disparities

An article published inArthritis and Rheumatismreported that after initial treatment for hip and/or knee

pain, only 3% of blacks ultimately consulted an orthopedic surgeon while 15% of whites did.7 This studyasserts that despite equal access to healthcare services through Medicare, blacks were less likely to have

total hip replacement procedure (THR) due to not knowing others from their social network that have hada THR, resulting in a lower perception of benefit.8

Study participants were asked whether they knew of someone who had surgery for hip or knee pain and,

if they did, whether they thought the surgery had helped this person. 25% of blacks reported knowing

someone who had surgery for hip pain, compared with 57% of whites.9

The CDC has not carried out a study on racial disparities among Medicare THR patients. Nevertheless, an

analysis of Medicare beneficiaries showed that whites were more likely than blacks to have this

procedure.10According to findings published by the Center for Health Equity Research and Promotion,black veterans were more likely than white veterans to respond no when asked whether they would be

willing to consider hip replacement surgery if their pain were to worsen and their doctor recommended

it.11


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In developing an estimate for Medicare THR disparities absent a formal study, it was necessary to first

estimate the number of Medicare THRs based on the percentage difference between all TKRs and THRs

performed. In 2006, there were approximately 57% less THRs than TKRs. Applying this percentagedifference to Medicare TKRs specifically, we can arrive at an estimate of Medicare THRs (see table 8).

From there, Medicare TKR disparity rates were applied to the Medicare THR estimate and associated

opportunity loss and market potential were calculated (see tables 8 to 13).

Table 8. - Percentage/totals Medicare THR estimates between whites/blacks

Race Estimated Medicare THR

recipients by race



recipients by race


White 96,674 94.72

Black 5,394 5.28

Total 102,068 100

As with Medicare TKRs, in an ideal world where racial disparities do not exist in healthcare, the

percentage of Medicare THRs between whites and blacks would equal Medicare enrollment percentages.Erasing disparities in THRs reveals significant market potential over 7,000 new patients for 2006

equivalent to an opportunity loss of nearly $40 million (see table 9).

Table 9. - White/black Medicare THR estimates equivalent to Medicare enrollment and associated

black opportunity loss, 2006

Race Ideal percentage

Medicare THRs -

equal to white/black

Medicare enrollment -2006

Ideal Medicare THRs

- equal to

white/black

Medicare enrollment- 2006

Opportunity

loss in

patients

Opportunity

loss in

dollars

White 88.51 96,674 n/a n/a

Black 11.49 12,554 7,160 $39,380,000

Total 100 109,228 7,160 $39,380,000

Studies estimate that THRs will increase by 174% by 2030 resulting in nearly 280,000 patients betweenwhites and blacks12 (see table 10). This data allows us to project future market potential and estimate

current opportunity loss.***

Table 10. - White/black Medicare THR estimate projections, 2030

Race Percentage of TKRs

for Medicare enrolleesby race - white/black

only - 2006

Projected THRs for

Medicare by race white/black only -

2030

White 94.72 264,888Black 5.28 14,779

Total 100 279,667

Average price of hip at $5500*** THR projections are being applied to THR estimates listed.


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Closed THR disparities would reveal a market potential of over 19,000 patients and nearly $108 million in2030 (see table 11).

Table 11. - White/black Medicare THR estimate projections equivalent to Medicare enrollment andassociated black opportunity loss, 2030

Race Ideal percentage ofTKRs equal towhite/black

Medicare enrollment

Projected idealMedicare THRs white/black only -

2030

Marketpotential inpatients

Market potential indollars

White 88.51 264,888 n/a n/a

Black 11.49 34,397 19,618 $107,899,000

Total 100 299,285 19,618 $107,899,000

Racial disparities in Medicare THRs that have persisted since 2006 are estimated to have resulted in a

total opportunity loss of over 43,000 patients and $239 million (see table 12).

Table 12. - White/black Medicare THR estimates equivalent to Medicare

enrollment and associated black opportunity loss, 2007 - 2011

THR Opportunity Loss Since 2006 - Blacks

Year Ideal no.patients

Actual no.patients

Opportunityloss in patients

Opportunity loss indollars

2007 13,464 5,785 7,679 $42,234,500

2008 14,374 6,176 8,198 $45,089,000

2009 15,284 6,567 8,717 $47,943,500

2010 16,194 6,958 9,236 $50,798,000

2011 17,104 7,349 9,755 $53,652,500


If the THR disparities gap were closed for blacks today, a market of over $311 million and 56,000

patients could be realized between now and 2016 (see table 13).

Table 13. - White/black Medicare THR estimate projections equivalent to Medicareenrollment and associated black market potential, 2012 - 2016

Projected THR Market Potential Through 2016 - Blacks

Year Ideal no.

patients

Actual no.

patients

Market potential

in patients

Market potential in

dollars

2012 18,014 7,740 10,274 $56,507,000

2013 18,924 8,131 10,793 $59,361,500

2014 19,835 8,522 11,313 $62,221,500

2015 20,745 8,914 11,831 $65,070,500

2016 21,655 9,305 12,350 $67,925,000

Total Projected Opportunity 56,561 $311,085,500


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Extrapolating Disparities Estimates Among Latinos

The CDC report on Medicare TKR disparities did not provide data on Latinos because of concerns of

potential underreporting. Nevertheless, the report did provide an overall total of Medicare TKR

procedures, which assists in extrapolating estimate data on Latinos.

The difference between the overall Medicare TKR total and white/black Medicare TKR total was compared

with the difference between the overall Medicare population, where percentages of Latino and otherenrollees are specified, as well as the white/black Medicare total. The percentage of Latino Medicare

enrollees from the total of Latino/other Medicare enrollees was calculated; approximately 61%. This

percentage was then applied to the difference between overall Medicare TKRs and the white/black totalof Medicare TKRs. The resulting calculation provided an estimate of Latino Medicare TKRs - approx. 5,300

in 2006. This estimate unfortunately points to further disparities. With the need for TKRs being equal

across ethnic and racial groups, based on this estimate, Latino Medicare TKRs represent only 2.1% of thetotal while Latinos make up 7.3% of the Medicare population (see tables 14 and 15).

Table 14. - Percentage/totals Medicare enrollees between whites/blacks/Latinos

Ethnicgroup/race

Medicare enrollees byrace

white/black/Latino only13

Percentage of Medicareenrollees by race

white/black/Latino only

Latino(estimate)

2,887,003 7.30

White, black 36,647,062 92.70

Total 39,534,065 100

Table 15. - Percentage/totals Medicare TKR estimates between whites/blacks/Latinos

Ethnic

group/race

Medicare TKR recipients

by race

white/black/Latino only


recipients

Latino 5,364 2.19

White, black 239,485 97.81****

Total 244,849 100

0.0730257060.9269742940.021906891****0.978093109


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Based on the estimated disparity, there was an opportunity loss of over 13,000 patients and $70 millionin 2006 (see table 16).

Table 16. - White/black/Latino Medicare TKR estimates equivalent to Medicare enrollment andassociated Latino opportunity loss, 2006

Ethnicgroup/race Ideal Medicare TKRs equal towhite/black/Latino

Medicare enrollment

Ideal number ofMedicare TKRs byrace

white/black/Latino

- 2006

Opportunityloss inpatients

Opportunityloss indollars

Latino 7.30 18,866 13,502 $70,210,400

White, black 92.70 239,485 n/a n/a

Total 100 258,351 13,502 $70,210,400

Based on the projected increase of TKR procedures of 673% by 2030, the need for these procedures forLatinos would result in a market potential of 104,373 patients and nearly $543 million in 2030 alone (see

table 17).

Table 17. - White/black/Latino Medicare TKR estimate projections equivalent to Medicare enrollment and associated

Latino opportunity loss, 2030

Ethnicgroup/race

Ideal percentage ofTKRs - equal to

white/black/Latino

Medicare

enrollment

Projected idealMedicare TKRs

white/black/Latino

only - 2030

Projected MedicareTKRs

white/black/Latino

only - 2030

Opportunityloss in

patients

Opportunityloss in dollars

Latino 7.30 145,836 41,463 104,373 $542,739,600

White, black 92.70 1,851,219 1,851,219 n/a n/a

Total 100 1,997,055 1,892,682 104,373 $542,739,600

Disparities left unaddressed among Latinos between 2006 and 2011 are estimated to have resulted in anopportunity loss of over 124,000 patients and nearly $647 million (see table 18).

Table 18. - White/black/Latino Medicare TKR estimates equivalent to

Medicare enrollment and associated Latino opportunity loss, 2007 - 2011

TKR Opportunity Loss Since 2006 - Latinos

Year Ideal no.patients

Actual nopatients

Opportunityloss in patients

Opportunityloss in dollars

2007 24,157 6,868 17,289 89,902,800

2008 29,447 8,372 21,075 109,590,000

2009 34,738 9,876 24,862 129,282,400

2010 40,028 11,380 28,648 148,969,600

2011 45,318 12,884 32,434 168,656,800Total Opportunity Loss 124,308 $646,401,600

If the TKR disparities gap for Latinos were closed today, the resulting market potential between 2012 and

2016 is estimated to be over $1.1 billion (see table 19).

Does not include previously calculated ideal number of black Medicare TKRs


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Table 19. - White/black/Latino Medicare TKR projections equivalent to

Medicare enrollment and associated Latino market potential, 2012 - 2016

Projected TKR Market Potential Through 2016 - Latinos

Year Ideal no.

patients

Actual no.

patients

Market potential

in patients

Market potential

in dollars

2012 50,609 14,389 36,220 $188,344,000

2013 55,899 15,893 40,006 $208,031,200

2014 61,190 17,397 43,793 $227,723,600

2015 66,480 18,901 47,579 $247,410,800

2016 71,770 20,405 51,365 $267,098,000

Total Projected Opportunity 218,963 $1,138,607,600

A study in the journal Medical Careconcluded that Latinos with Medicare receive THRs at lower rates

than do non-Latinos. Because of the availability of Medicare coverage, the studys authors suggest thatunder utilization of THR by Latinos cannot be attributed to lack of health insurance alone.14

Below are estimates of THR disparities among Latinos along with future projections, associatedopportunity loss, and market potential (see tables 20-24).

Table 20. - Percentage/totals Medicare THR estimates between whites/blacks/Latinos 2006

Ethnicgroup/race

Estimated Medicare THRrecipients

white/black/Latino only- 2006

Estimated percentage of MedicareTKR recipients

white/black/Latino only - 2006

Latino (estimate) 2,286 2.19

White, black 102,068 97.81

Total 104,354 100

The THR disparities gap for Latinos in 2006 reveals an opportunity loss of nearly 6,000 patients and over

$31.5 million (see table 21).

Table 21. - White/black/Latino Medicare THR estimates equivalent to Medicare enrollment andassociated Latino opportunity loss, 2006

Ethnic

group/race

Estimated adjusted

percentage ofMedicare THR

recipients equal

to white/black/

Latino Medicareenrollment

Estimated

adjustednumber of

Medicare

THRs

white/black/Latino only -

2006

Estimated

opportunity lossin patients

Estimated

opportunityloss in dollars

Latino 7.30 8,041 5,755 $31,652,500

White, black 92.70 102,068 n/a n/a

Total 100 110,109 5,755 $31,652,500

Based on projections of THR procedures increasing by 174% by 2030, the disparities gap for Latinos

reveals a market potential of over 15,000 patients and nearly $87 million in 2030 (see table 22).


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Table 22. - White/black/Latino Medicare THR projections equivalent to Medicare enrollment and

associated Latino opportunity loss, 2030

Ethnic

group/race

Adjusted

percentage of THRs- equal to

white/black/Latino

Medicareenrollment

Projected Ideal

Medicare THRs white/black/Latino

- 2030

Projected Medicare

THR recipients byethnic group/race

2030

Opportunity

loss inpatients

Opportunity

loss indollars

Latino 7.30 22,032 6,264 15,768 $86,724,000

White, black 92.70 279,667 279,667 n/a n/a

Total 100 301,699 285,931 15,768 $86,724,000

Based on these estimates, prevailing disparities since 2006 for THR procedures for Latinos have resulted

in an opportunity loss of over 35,000 patients and nearly $193 million (see table 23).

Table 23. - White/black/Latino Medicare THR estimates equivalent to

Medicare enrollment and associated Latino opportunity loss, 2007 - 2011

THR Opportunity Loss Since 2006 - Latinos Year Ideal no.

patients

Actual no.

patients

Opportunity

loss in patients

Opportunity loss

in dollars

2007 8,624 2,452 6,172 $33,946,000

2008 9,207 2,618 6,589 $36,239,500

2009 9,790 2,783 7,007 $38,538,500

2010 10,373 2,949 7,424 $40,832,000

2011 10,956 3,115 7,841 $43,125,500


The market potential for Latino THR procedures are estimated to exceed 45,000 patients and $250million through 2016 if the disparities gap were closed (see table 24).

Table 24. - White/black/Latino Medicare THR projections equivalent toMedicare enrollment and associated Latino market potential, 2012 - 2016

Projected THR Market Potential Through 2016 - Latinos

Year Ideal no.

patients

Actual no.

patients

Market potential

in patients

Market potential

in dollars

2012 11,539 3,281 8,258 $45,419,000

2013 12,122 3,446 8,676 $47,718,000

2014 12,704 3,612 9,092 $50,006,000

2015 13,287 3,778 9,509 $52,299,500

2016 13,870 3,943 9,927 $54,598,500

Total Projected Opportunity 45,462 $250,041,000


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Conclusion

Racial and ethnic minorities accounted for 90% of the growth in the U.S. population over the past

decade.15 Minorities are expected to become the majority in 2042, with the nation projected to be 54%minority in 2050. By 2023, minorities will comprise more than half of all children.16

The total market potential for TKR and THR procedures for blacks and Latinos with disparities gaps closedbetween 2012 and 2016 exceeds $3 billion (see table 25). This market potential, coupled with the reality

of minority population trends, calls for healthcare suppliers to develop strategies to confront the

healthcare disparities issue head on.

Table 25. Market potential summary for black and Latino TKR/THR procedures

Disparities in Orthopedics Market Potential Summary, 2012-2016

TKR Blacks $1,416,563,200

THR Blacks $311,085,500

TKR Latinos $1,138,607,600

THR Latinos $250,041,000

Total $3,116,297,300


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About Cogency Group

Cogency Group, Inc. is a professional development company specializing in an integrative approach to

leadership development, strategic capabilities, and sales training, driving breakthrough performance forcorporations and individuals through education, coaching, and consulting.

In the area ofsalesforce training and development, we enable companies to build sales capabilitiesthrough leadership development, executive coaching, and sales force training and development. We work with

clients to identify critical sales issues, recommend and develop solutions, and execute solutions. Utilizing an

intense process, role plays and practice sessions, we enable participants to improve skills and change their

behaviors and practices.

We provide solutions to address your organizational effectiveness capabilities. Whether you need

assistance with strategic thinking skills, annual or long-term strategic planning, change management, orimproving performance by building needed capabilities, we can help.

The extensive background and experience of our Principals equips Cogency Group to successfully deliver

outstanding results to our clients. Our CEO leads the firm as a Principal Consultant and is responsible for all

sales-related projects. He has over 30 years experience in sales and has been a Vice President of Sales with a

Fortune 500 company. He has also held VP positions for start-ups seeking to go public and turn-around

situations.

Our COO has responsibility for operational matters and is a Principal Consultant on strategy and strategic

thinking projects and issues. She has a Masters degree from Stanford and over 20 years business experience,

much of that in consulting and organizational effectiveness with major companies including The Coca-Cola Co.,McDonalds Corp. and McKinsey & Company. She has consulted internally and externally with CEOs, Vice

Presidents, and Business Unit Leaders to develop strategic solutions and build skills in dynamic and competitive

environments.

Cogency Group belongs to a network of independent sales consulting organizations and experts which enables

us to scale appropriately for each job. We have the experience, expertise and expandability to meet theindividual needs of our clients.

The Cogency Group ApproachWe strive to understand our clients from the inside out. We have a passion for what we do and how we do it.

Cogency Group takes an individualized and tailored approach to addressing the needs of our clients. There are

no cookie cutter solutions to sales or organizational challenges. If you have purchased off the shelf training

seminars you realize that they seldom address your specific requirements. We know that every client has

issues that are peculiar to their specific environment. Our customized approach addresses this critical factor.

The obvious is often not so obvious

We can assemble in-depth cause analyses to identify skill gaps that may hold the key to your success. We

have a thorough understanding of the complexity of large sales organizations as well as the focused pressures

on smaller organization leadership. Through detailed Needs Analyses, we identify key competencies necessaryfor sales leadership. Utilizing interviews, field visits, and detailed analysis, Cogency Group will develop a

customized approach that delivers training and skill development solutions for your specific issues and problem

areas.

Personal involvement

We will be with you through every phase of the engagement as a confidant and guide. Our goal is for yourorganization to emerge stronger and more effective. Our role is supportive and includes the appropriate level

of hands-on involvement balanced with behind the scenes support. You are in charge while we turn limits intoleverage.


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References

1 Dykes, Daryll C. MD, PhD, et al. Communication for All of Your Patients, ICL #307 Handout. American Academy of OrthopaedicSurgeons, 2009. 19 Mar. 2009.2

Health Care Estimates for March 2010 Health Care Legislation. Congressional Budget Office Health Care. 15 Sep. 2011.3 Distribution of Medicare Enrollees by Race/Ethnicity, states (2006-2007), U.S. (2007). State Health Facts.org Kaiser FamilyFoundation. 18 Mar. 2009 .4 Cisternas, M.G. MA, et al. Racial Disparities in Total Knee Replacement Among Medicare Enrollees--United States, 2000-2006.

Morbidity and Mortality Weekly Report - Centers for Disease Control and Prevention. 58(06); 133-138. 20 Feb. 2009 18 Mar. 20095 Ibid.6 Kurtz, Steven PhD, et al. Projections of Primary Revision Hip and Knee Arthroplasty in the United States from 2005 to 2030. TheJournal of Bone and Joint Surgery. 89; 780-785 1 Apr. 2007 22 Apr. 2009.7 Blake, Valerie, et al. Racial Differences in Social Network Experience and Perceptions of Benefit of Arthritis Treatments AmongNew York City Medicare Beneficiaries With Self Reported Hip and Knee Pain. Arthritis and Rheumatism (Arthritis Care andResearch) - American College of Rheumatology. 47.4; 366-371. 15 Aug. 2002 21 Mar. 2009.8 Ibid.9Ibid.

10 Baron, John A., et al. Total Hip Arthroplasty: Use and Select Complications in the U.S. Medicare Population. American Journal ofPublic Health. 86.1; 70-72. Jan. 1996 22 Mar. 2009.

11 Ibrahim, Said A. MD, MPH and Kwoh, C. Kent MD. Opportunities for Understanding Disparities in Joint Replacement Surgery.Center for Health Equity Research and Promotion Policy Brief - VA HSR&D Center of Excellence. 1.2 Dec. 2003 22 Mar. 2009.12Kurtz, Steven PhD, et al. Projections of Primary Revision Hip and Knee Arthroplasty in the United States from 2005 to 2030. The

Journal of Bone and Joint Surgery. 89; 780-785 1 Apr. 2007 22 Apr. 2009.13 Distribution of Medicare Enrollees by Race/Ethnicity, states (2006-2007), U.S. (2007). 2007. State Health Facts.org Kaiser

Family Foundation. 18 Mar. 2009 .14 Escalante, Agustin MD, et al. Disparity in Total Hip Replacement Affecting Hispanic Medicare Beneficiaries. Medical Care. 40.6;451-460. Jun. 2002 23 Mar. 2009.15 Census Data Show Hispanic Boom; Blacks Leave Cities for South, Suburbs. PBS Newshour (transcript). 24 Mar. 2011 15 Sep.

2011 .16 Bernstein, Robert, et. al. An Older and More Diverse Nation by Midcentury. U.S. Census Bureau News. 14 Aug. 2008 15 Sep.2011 .

closing disparities and opening markets in orthopedics

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