Medicare Clawing Back Reimbursements!…Key to Happiness for Orthopedists?

Medicare Clawing Back Reimbursements!…Key to Happiness for Orthopedists?…Hospital Success Drives Shoulder Surgery Value…Roy Sanders, M.D. Named Health Care Hero…

Key to Happiness for Orthopedists?

Ray Baker, M.D. is president of the International Spine Intervention Society and a former president of the North American Spine Society. He tells OTW, “Obamacare, the recession, a decline in innovation, and an aging population leaves orthopedists understandably worried. Next month, I will be giving yet another talk on the future of spine care. As I pondered a way to discuss the future and put it into perspective, it occurred to me that what physicians are really concerned with is happiness. I know it sounds ephemeral and ‘soft’, but in reality what people really want is a fulfilling career and a ‘good life’. In researching happiness, I did not look at the self-help section; I went to the scientific literature. And, to my surprise, I found that there is a great deal of hard data on what makes people happy. What I found was a message that might help all of us as we navigate these challenging times.”

“Research clearly shows that increasing income beyond an average wage does not make people happy, and some studies actually show an inverse relationship. Self-image and status are also transient, and do not lead to sustained happiness. What brings sustained happiness? There are several factors, but three stand out in the research: autonomy, mastery, and purpose. Put succinctly, we are happiest when we feel that we have control over our destiny, when we are very good at what we do, and when that mastery is used in the service of something larger that ourselves.”

“None of us know where healthcare is going, who will be elected, and what other changes are headed our way. Truth be told, it might have less effect on us than we think. All of us can probably remember, when we were first entering medicine, being told by a retiring physician that the ‘Golden Age’ of medicine had past. Well, for me, that was 23 years ago and now I hear my colleagues saying that to younger physicians. It appears to me that the ‘Golden Age’ of medicine is defined as the period of medicine ending precisely when you begin practice. But in the end, true satisfaction and happiness comes from people who are meaningfully engaged in their work in helping others. They will continue to work to find solutions and to innovate; they will thrive. I’m not being Mother Teresa here. I’m just saying that we need to keep our eye on the ball and focus on what is truly important. As I said at the conclusion of my NASS presidential address, you can climb the ladder of success to find that it is leaning against the wrong wall.”

Medicare Clawing Back Reimbursements!

There’s at least one joint replacement surgeon who is increasingly shocked by the government’s role in healthcare. He tells OTW, “Just a few months ago there was a study in the Journal of Bone and Joint Surgery looking at the Surgical Care Improvement Project (SCIP) guidelines, which are supported CMS [Centers for Medicare and Medicaid Services] as a measure of quality. The researchers analyzed data from 128 New York state hospitals and measured how well each facility adhered to the CMS antibiotic recommendations. They found that the hospitals that followed those guidelines best had no improvement in their infection rates. To make things worse, they found that increasing adherence to the SCIP guidelines regarding anticoagulant use after surgery actually led to an increase in the infection rate. It is astounding to me that this study was not repeated all over the national media. Adherence to these recommendations doesn’t change care, it actually creates more complications…yet hospitals across the country have spent significant funds in developing programs that adhere to and track their adherence to the guidelines…this doesn’t bode well for government intervention in healthcare.” 

“I’m sorry to say that our future doesn’t look so bright in some ways. CMS is currently having consulting companies decide which patients should qualify for joint replacement surgery. There is a list of requirements regarding what the X-rays must show, a list of requirements regarding what treatments the patients must have already tried, and requirements as to what the surgeon has to find on the physical exam. The problem is that the consulting company’s recommendations look ridiculous to surgeons, as they appear somewhat arbitrary and not evidence based. These decisions made by unmonitored groups will certainly limit access to care, and may even lead to a lower quality of care by taking the decisions out of the physicians’ hands.”

“And to top it off, physicians could be audited and financially penalized years later if we do not adhere to their guidelines. Medicare can ‘claw back’ your reimbursements years after the surgery was done. They can audit our patient decisions and tell the surgeon, ‘Your surgical decisions did not strictly follow our guidelines for who qualifies to have a joint replacement. Therefore we are taking back a percentage of your previous reimbursements as a penalty.’ The problem is that their national guidelines for medical care are not evidence based, are still controversial, and in certain circumstances may lower the quality of care and limit access to care.”

Hospital Success Drives Shoulder Surgery Value

Mark Frankle, M.D. is a shoulder specialist at the Florida Orthopaedic Institute and researcher with the Foundation for Orthopaedic Research and Education (FORE). Awhile back he started wondering, ‘What is the value of shoulder arthroplasty?’ Here he tells OTW about his study, a four-year look at the value of shoulder replacement, which was recently presented at the October 2012 Closed Meeting of the American Shoulder and Elbow Society. “We wanted the costs to be measurable and readily apparent to the patient and payers…how much did the entire episode of care cost and what were the benefits? We wanted to limit the subjectivity of the ‘benefits’ so we used objective range of motion measurements and strength measured by an independent therapist pre- and postop. We included 83 primary total shoulder arthroplasty (TSA) patients and 55 reverse shoulder arthroplasty (RSA) patients.”

“As for cost data we sought out experts, who broke costs down as follows: we started the cost meter going at the pre-op visit, we included hospitalization, and then the follow-up care post-hospitalization. It was helpful that our hospital had standard methods of calculating costs. For each of the 83 TSA patients and each of the 55 RSA patients we captured every cost that occurred—and we did so using in-hospital costs given to us by the hospital. For home health therapy and surgeon fee, we used Medicare reimbursement. If the patient was readmitted we looked at that cost and we then recognized some variation in patient cost so we wanted to sort out the drivers of cost in these groups.”

“The cost drivers: in TSA patients, it turned out that the number of comorbidities didn’t make a difference but in RSA it did. The most surprising finding was that the surgeon fee was only 8% of the total cost for the TSA group and only 6% for the RSA group. This would probably surprise those in the media that assume surgeons are responsible for a large portion of the costs of care.

Also, the fact is that the federal government wants to make one bundled payment for the entire episode of care. So with shoulder arthroplasty, they don’t want to pay a fee to the anesthesiologist, a fee to the surgeon and a fee to the hospital, etc. They want to write one check to one entity. We sought to discover what these costs were ourselves so that we can be a part of the process. I was also hoping that in doing this that other centers would start to measure their costs and outcomes the way we did.”

Irreparable Fractures No More!

Anand Murthi, M.D. is chief of the Shoulder and Elbow Service and Director of Shoulder and Elbow Research at Medstar Union Memorial Hospital in Baltimore, Maryland. He has just completed an interesting study on irreparable coronoid fractures. Dr. Murthi tells OTW, “There are many patients with severe elbow trauma who, to date, have not been able to get much assistance. This is especially true if they have a comminuted coronoid fracture. In some of these cases they are unreconstructable because the bones are fragmented and the only the option is to do an anterior capsulodesis where you repair the anterior capsule to the coronoid fracture bed of the elbow, and leaving patients with a stable, but stiffer elbow. So my colleagues and I began experimenting with cadaveric elbows and when we were reviewing their anatomy we wondered, ‘What if we take the tip of the olecranon a part of the bone that is unused and has no issues with being removed and transfer it as an autograft. It ended up that it was a near perfect anatomic replica of the coronoid (we flipped it around and put it where the coronoid used to be). Our biomechanical research shows that this renders the elbow very stable and doesn’t increase contact pressures in the elbow—which is excellent because these pressures make someone more prone to arthritis. We are submitting our manuscript for publication now, and will soon begin using this treatment on patients.”

Roy Sanders, M.D. Named Health Care Hero

The Tampa Bay Business Journal has honored Dr. Roy Sanders, president and chief medical officer at Florida Orthopaedic Institute, with a Health Care Heroes Physician Award for 2012. Chosen by an independent panel of judges, Dr. Sanders was selected from more than 200 nominees. Dr. Sanders has more than 27 years’ experience as an orthopedic surgeon specializing in acute trauma, post-traumatic reconstruction and foot and ankle surgery. He is one of the original founders of Florida Orthopedic Institute, and has served as president and board chair for more than 15 years. Since 1991, Dr. Sanders has worked as chief of department of orthopedics at Tampa General Hospital and has authored more than 100 articles and abstracts on orthopedic trauma as well as developed approximately 20 patents that are issued and used locally and internationally.