Death of Spine Surgery Research?, Residency Program Overhaul, Bypass Hospitals and Go Straight to the Insurer

Death of Spine Surgery Research?

A disheartened spine surgeon tells OTW, “Just this week my department held a research meeting, an event which turned out to be terribly disappointing. The upshot is that nobody wants to do Investigational Device Exemption trials anymore because of the cost involved. Here we hold an official spine research meeting to try and determine what kind of research we are going to undertake, only to find out that people are tired of fighting the funding issue. Virtually no one wants to sponsor these major studies, but how will we improve the science of medicine if we don’t do them? Our group meets quarterly and the last two quarters there has been this dawning realization that our best intentions aren’t going to get the work done. We are at a standstill—and I suspect that this is across the board in all of medicine. We Americans are no longer the world leaders in the medical realm. The country is grappling with a myriad of other problems and I don’t think that lawmakers realize the long term consequences of the research funding issue.”

Overhaul of Residency Programs Continues

Laura Robbins, Ph.D., is senior vice president for education and academic affairs at Hospital for Special Surgery (HSS) in New York. She has been in the thick of the issue of accreditation, and now sheds some new light on the situation for OTW. “The revamping of orthopedic residency programs remains a nationwide work in progress. Program administrators are in the process of trying to understand how to implement the newest Accreditation Council for Graduate Medical Education (ACGME) guidelines. In the past, ACGME required a significant amount of paperwork, followed by a site visit. Now, the paperwork is being phased out and the focus will be on ‘real time’ program evaluation. The goal is to turn people’s attention away from completing documentation and toward detailed consideration of what and how they are teaching—and to ensure that the teaching and academic components are integrated into the rest of the hospital.”

“One of the challenges is that the former ACGME system was not well integrated into hospital systems. The Next Accreditation System tries to better integrate teaching with clinical and administrative initiatives such as including senior managers like CEOs in site visits. This will require ongoing communication and ways to further integrate training. An example of how this will unfold: during site visits the ACGME representative will also speak to other health-care providers like nurses to understand the role of residents in keeping patients safe.”

“At HSS our residents and fellows are very motivated to make this happen, and in fact about eight months ago started a house staff quality council that meets monthly. It has been very successful, and they have identified 10 quality initiative projects that they want to take on. To my knowledge, we may be the only orthopedic facility that has such a council.”

Time for Surgeons to Negotiate Directly With Insurers?

Roy W. Sanders, M.D. is president and cofounder of the Florida Orthopaedic Institute in Tampa (OTA). Dr. Sanders is a past president of the OTA and is currently serving as director of the Orthopaedic Trauma Service, and chief of the department of orthopedics at Tampa General Hospital. He has found some positive things to say about the much-maligned Patient Protection and Affordable Care Act (PPACA). Dr. Sanders tells OTW, “PPACA has received a lot of negative press, but the overarching positive is that the goal is to improve quality. Best practices will continue to thrive, so the emphasis will be on quality, not quantity. I also think that because one of the goals is to save money and at the same time improve patient care, more and more outpatient orthopedic surgery will be performed. This is typically promoted by insurance companies, which are looking for bundled payment plans, as a way to decrease costs. This is because people can get sicker in hospitals, they may have pain management issues, and it’s all really expensive because you are paying for the bricks and mortar of a hospital as opposed to just providing quality services. If you work in a surgical center therefore, you may be able to negotiate directly with the insurer and bypass the hospital altogether. ”

“This is a new trend, and because these are bundled payments, doctors are rewarded for quality and efficiency as opposed to not being a participant in hospital facility fees. Over the next three-five years I believe this will be the standard for everyone except very sick or infected patients, or patients requiring blood transfusions, and long hospitals stays. I would say that of the surgeries being done in a hospital at this time, perhaps a full 50% could be done on an outpatient basis, especially in states where they are allowed a 23 hour stay. I would advise my colleagues to get involved in the direct negotiation of bundled payment with insurers. As of now surgeons negotiate fees for procedures, but they leave the rest to the hospital, physical therapy, and anesthesia providers. We need to understand how to handle these negotiations. To date hospitals have tried to squeeze doctors by convincing them that it is better to work for a hospital. Going forward however, it will be the hospitals that are getting squeezed by the elephant in the room: the insurance companies. They are going to demand lower prices from the hospitals…and who, in turn, will be stuck because they have fixed costs. This will afford doctors the opportunity to negotiate directly with the insurance companies. Hopefully they won’t all be working for hospitals by then!”

Atul F. Kamath, M.D. Wins OREF Award

The Orthopaedic Research and Education Foundation (OREF) congratulates Atul F. Kamath, M.D., recipient of the Winter 2012 OREF/Current Concepts in Joint Replacement (CCJR) Clinical Practice Award. Dr. Kamath is being recognized for his prospective study on unplanned admissions to the intensive care unit after total hip arthroplasty (THA). Dr. Kamath and his research team investigated whether assessing patients preoperatively to determine if they should be placed directly in intensive care or a regular hospital room after surgery would reduce the incidence of unplanned admissions to the ICU. Independent risk factors included advanced age, revision surgery, creatinine clearance, prior myocardial infarction and Body Mass Index. Dr. Kamath found that determining pre-operatively whether a patient should be placed in the ICU after surgery not only reduced the number of unplanned admissions to the ICU, but also resulted in fewer major complications after THA.

Dr. Kamath graduated from Harvard University with a bachelor’s degree in the history of science. He received his medical degree from Harvard Medical School in 2007 and completed an internship and orthopedic residency at the University of Pennsylvania. Dr. Kamath was a 2010 Orthopaedic Research Society-OREF-American Academy of Orthopaedic Surgeons (AAOS) Clinician Scientist Program participant and also has served as a resident liaison for the AAOS. Dr. Kamath is the current American Association of Hip and Knee Surgeons Health Policy Fellow.

New Microvascular Flap From Penn L.

Scott Levin M.D., FACS is chair of Orthopaedic Surgery at the University of Pennsylvania. Dr. Levin, Professor of Surgery (Plastic Surgery), recently told OTW about his latest work in the microvascular world. “I’ve adapted a microvascular flap—called a medial geniculate artery microvascular transfer—that is being used for complex nonunions and problems around the foot and ankle. It is a bone flap that solves very complex problems related to infection, avascular necrosis, and tarsal bone nonunion. It is suited for small bone defects that require vascularized bone graft. We have done 15 cases thus far, and we have patients who are two to three years out who have done well (no secondary surgery).”

“Most institutions aren’t prepared to undertake such a procedure because people don’t have the appropriate training…and most orthopedic surgeons don’t do reconstructive microsurgery. But the results speak for themselves, and so I suspect that this will evolve in the literature and that orthopedic surgeons will become familiar with the technique and demand it. It is extremely effective, relatively straightforward, and has low morbidity. Our team will soon have several review papers coming out in Techniques in Foot and Ankle Surgery.”