Too Many Shoulder Replacements?!!…Massachusetts’s Healthcare Reform Flawed…Scope of Practice Controversies Heating Up…Paul Wakim, M.D. Wins Ellis Island Medal of Honor…read the details…
Too Many Shoulder Replacements?
Joseph Abboud, M.D., is an orthopedic surgeon at the Rothman Institute in Philadelphia and associate professor of Orthopaedic Surgery at Thomas Jefferson University Hospital. He tells OTW, “We are seeing a huge increase in the utilization of reverse shoulder replacement. While it is typically done for patients with arthritis and rotator cuff disease, the indications have expanded somewhat. It is interesting to see how much it is being marketed, and in some ways overutilized…and we only have an eight-year track record in the U.S. as far as understanding our salvage options. In particular, it’s not a great option for younger patients; but in some cases it’s being done because it gives so much pain relief and the possibility of return to function. However, the long-term consequences of this is unknown. Patients are in pain and say to the doctor, ‘I’ll do anything to get better function and pain relief.’ The danger is these patients may not fully comprehend the risks. My colleagues at Rothman and I will have some numbers coming out in a year looking at the utilization of standard and reverse shoulder replacement. The issue used to be that the same code had been used for both procedures, so it was hard to decipher which procedure was done. This has now been changed to allow us to track these procedures more accurately. We are hypothesizing that there are more reverse shoulders being done than anyone expects.”
Scope of Practice Controversies Heating Up
Ray Baker, M.D., is president of the International Spine Intervention Society. “Scope of practice is emerging as an increasingly important topic, ” he tells OTW. “At one end are increasing conflicts between spine surgeons, physiatrists, interventional pain specialists, and radiologists as traditional spine treatments evolve from open techniques to minimally invasive techniques, and then to percutaneous techniques, biologic treatments, and even robotics. At the other are clashes between physiatrists, radiologists, interventional pain specialists and advanced practice nurses (CRNAs and ARNPs) over whether the treatment of pain constitutes the practice of medicine, and whether nurses have the training and expertise to perform interventional spine procedures. Both ends involve defining practice parameters and core competencies, and both promise to heat up as technology advances and as we enter the post-healthcare reform era.”
“Two high profile cases typify the surgical turf battle. One case, in New Jersey, involved an anesthesiologist who allegedly overstepped his boundaries in preforming spinal fusions; the other case, in Albuquerque, was an anesthesiologist alleged to have impersonated a neurosurgeon. But, it is not just physicians blurring those lines.”
“Industry is increasingly ‘hedging their bets’ by marketing to interventional pain specialists and radiologists, and they are bringing more ‘cross-over’ products to market that encroach on the traditional domains of orthopedic surgeons and neurosurgeons. Interspinous spacers are a good example of a treatment that was initially marketed exclusively to surgeons, but which has recently been marketed to non-surgeons. The MILD (Minimally Invasive Lumbar Decompression) procedure, which is going head-to-head with open decompression procedures, exemplifies the emergence of ‘cross-over’ products. MILD involves a percutaneous decompression for spinal stenosis. It currently has a category 3 CPT code, but is moving to obtain a category 1 code, which would result in wider insurance coverage.”
“It’s easy to paint things in polarized terms, but this same battle has played out before as technology advanced and new techniques required new (and non-traditional) skill sets. One only need look at the battles that took place between cardiac surgeons and cardiologists over cardiac procedures, or between neurosurgeons, vascular surgeons, and interventional radiologists over extra- and intra-cranial vascular procedures. There are many other examples that could be cited. Spine scope of practice battles are just the latest.”
“From the patient’s standpoint, this presents a real challenge as the best advertised practice is not necessarily the most qualified. In fact, in many instances it is difficult to even determine the specialty of the provider being advertised. Adding to this is the relatively poor state and federal oversight of ambulatory facilities with loose of non-existent credentialing practices. For the sake of our patients, and to preserve our specialties, we must address these issues proactively.”
More Anatomic ACL Surgery
David Altchek, M.D.. is an attending orthopedic surgeon and co-chief in the Sports Medicine and Shoulder Service at Hospital for Special Surgery (HSS). He is also the Medical Director for the New York Mets and a medical consultant for the NBA. Dr. Altchek tells OTW, “As a field we are working on making ACL [anterior cruciate ligment] operations more precise and more anatomic. We have documented in great detail the precise anatomic sites of attachment of the ACL on the tibia and the femur. We then place the graft in these exact locations using new instrumentation that was developed for this purpose. By better reproducing the ACL anatomy we are seeing in the short term (first two-five years) that the patients are more easily and rapidly restoring full motion to the knee and returning to aggressive pivoting sports with more confidence than we had seen previously with the prior versions of ACL reconstruction. We are fortunate to have an enormous, detailed registry of ACL reconstructions at HSS; we have data on 1, 700 athletes, more than half of whom are women.”
Massachusetts’s Healthcare Reform Model Flawed
Richard Iorio, M.D., is director of adult reconstruction at the Lahey Clinic Medical Center and Professor of orthopedic surgery at Boston University Medical School. He is discussing his own experience as an example of what is happening to many orthopedic surgeons. “I am leaving soon to join NYU-Hospital for Joint Diseases and run their adult reconstruction program. Like many of us, I was looking for not only clinical excellence in the workplace, but security…I went to the biggest place I could find. If you look at the Massachusetts market, that is a vision of where the national structure is going. But Massachusetts doesn’t work because there’s not enough money in the system to pay for the care—it is totally subsidized by the federal government and that is not sustainable. Boston Medical Center has received $70 million in grants to pay for the Medicaid population reimbursed by Commonwealth Care. Reimbursement is $35 for an office visit that would provide $133 from a private insurance plan. It’s a system built on false assumptions, not facts or data; they will bankrupt the system or physicians will be forced to deny care.”
“We have several years before Manhattan will be affected by health care reform. Several orthopedic societies are partnering to write a health care policy committee white paper on bundled payments. This will show how surgeons and hospitals can partner to ensure good care and maintain revenue. It will help the hospital have predictable costs when they negotiate with insurers. One of the issues being addressed in the white paper is that implant costs need to be controlled; we need a volume related cost structure put in place for companies dealing with hospitals. It’s also necessary to have, for example, standardized length of stay, and in-patient care pathway protocols. This will ensure that doctors within an institution are delivering a unified product that represents the most efficient way of creating a good experience for the patient while minimizing the cost. If you can get 20-30 surgeons doing things the same way—same preop educational experience, etc.—then that’s going to make a huge difference all around. NYU has 168 orthopedic surgeons doing 4, 000 total joints a year; but they are doing a super job of creating a system where if doctors work with the hospital they can get high quality results while minimizing the costs to the health care system.”
Paul Wakim, M.D. Wins Ellis Island Medal of Honor
According to an article in the Orange County Register (Eva Kilgore, “Surgeon honored with Ellis Island humanitarian medal, ” August 14, 2012), Dr. Paul Wakim, is founder and medical director of Pacifica Orthopedics Medical and Surgical Center in Huntington Beach, California. The award is given to men and women who have dedicated their lives to helping others, striving for tolerance and acceptance among ethnic, racial, and religious groups—and to people sharing their personal and professional gifts for the benefit of humanity. Dr. Wakim has performed over 20, 000 orthopedic procedures and is participating in the development of a cultural center for Lebanon and Los Angeles. He is currently the chairman and past president of the American Lebanese Medical Association.
Amer Khalil, M.D. Wins $10, 000 for Spine Project
Dr. Amer Khalil of InVivo Therapeutics Holdings Corporation has been selected as the winner of an MDH Research Award. This grant, given by MDHonors, will further InVivo’s research on spinal cord injury. Dr. Khalil was awarded a grant of $10, 000 for his project titled “Spinal cord repair using biomaterial-based drug-releasing strategies for reducing scarring and promoting regeneration.” Dr. Khalil’s project is important not only for InVivo’s second SCI product but also for the third product in the company’s portfolio, a platform intended for the reduction of fibrosis which has been developed to reduce scarring in both reparative surgical and dermatological applications.
Operation Walk: Mark Your Calendar
Want to help patients in a “concrete” way? Lace up your shoes and get walking! Operation Walk USA, a non-profit medical humanitarian organization that provides free hip or knee replacement surgeries, is announcing that its next walk will take place December 7, 2012. These events, which benefit from a national network of volunteer hospitals, physicians, nurses, physical therapists and others, assist patients who do not qualify for government assistance programs. For more information, please visit www.opwalkusa.com.
