President of Insurance Company to Steve Garfin, M.D.: We Don’t Need Your Help
Steven Garfin, M.D. is professor and chair of the Department of Orthopaedic Surgery at the University of California, San Diego. He is also president of the International Society for the Advancement of Spine Surgery (ISASS). These days, Dr. Garfin is hearing a lot of angst about the fact that doctors are less in charge of patient care. And to top it off, he says, surgeons’ efforts to work with insurers are being rebuffed. Dr. Garfin, who is very involved in spine politics, tells OTW, “I was frustrated with these large, random swaths of denials, and I penned a letter to the president of one of the top five insurers in the country. In it, I offered to help form an advisory panel of ISASS surgeons. In return I received a letter saying, basically, ‘We don’t need your help. We have our own panel.’ I have no idea if there are doctors on that panel. Is it really too much to ask for more transparency and doctor participation?”
Why to Advocate for Orthopedics and How
“But I didn’t go to medical school to become a politico, ” you say. Manish Sethi, M.D., assistant professor of orthopedics and rehabilitation at Vanderbilt University Medical Center, says, ‘Wake up. It’s time we face the fact that patient care is on the line. We must advocate for our patients.’ Dr. Sethi, founder of the Vanderbilt Orthopaedic Institute Center for Health Policy, tells OTW, “I’ve just published a paper entitled, ‘The Evolution of Advocacy and Orthopaedic Surgery.’ In it my colleagues and I define the role of advocacy in medicine, specifically within orthopaedic surgery, explore the history of physician advocacy and its evolution, examine the various avenues of involvement for orthopaedic surgeons interested in advocacy, reflect on the impact of such activities on the future of orthopaedic surgery as it relates to hospital-physician alignment.”
“There have always been disputes of patient care. From the 1500s to the 1800s there was a substantial debate over the role of doctors, and many people felt that physicians should be involved in all spheres of a patient’s life. Political involvement on the part of physicians is not new…a doctor signed the Declaration of Independence, one of the first governors of New Hampshire was doctor, etc. It’s time again for us to reach beyond the bedside and leave our tunnel vision behind.”
“As a society we have come to believe that big government is going to solve our problems, resulting in an ‘I don’t need to get involved’ attitude. For many years we have served patients well at the bedside, but in focusing too narrowly on this we created a vacuum where policy makers who have no idea what they are doing are running the show.”
“What motivated my interest in advocacy? I come from a long generation of doctors. When I was a third year medical student my father was diagnosed with liver cancer. My dad had dedicated his entire life to medicine, often going so far as to go pick patients up and bring them to the hospital. During this horribly difficult time he was hit with a lawsuit. Although the suit was ultimately dismissed, it struck me that if such a thing can happen to my dedicated father, it can happen to anyone. It was then I knew that we had lost control of our profession. For me, advocacy is synonym of being a citizen of this country. Truly, who is going to solve this problem…those of us on the frontlines or the bureaucrats?”
“There are easy ways get involved: join your medical society, get to know your congressman or congresswoman, host or attend events. If possible, make financial donations or even run for office. We can do this! Remember that we have more of the nation’s trust than the lawmakers do. Five years ago when I talking about this people thought I was crazy. Now I think the light has come on and more and more we are realizing that there’s no way around getting involved.”
Green Light: Lumbar Fusion for Low Back Pain
What does the existing research—randomized controlled trials, prospective and retrospective nonrandomized trials, etc.—say about the efficacy of lumbar fusion surgery for chronic low back pain? Frank Phillips, M.D. and colleagues have found out. Dr. Phillips is with Midwest Orthopaedics at Rush, and is Professor of Orthopaedic Surgery and Director of Minimally Invasive Spine Surgery at Rush University Medical Center. He tells OTW, “This work, which was just published yesterday in Spine, was an attempt to provide a transparent and validated review of the literature to determine the value in what we do. We undertook an up to date systematic review of the literature regarding outcomes for spinal fusion for a diagnosis of low back pain with disc degeneration, arguably the most contentious diagnosis in terms of insurance reimbursement. Most previous studies relied on by the insurance industry are dated and include older fusion techniques or exclusively rely on Level 1 studies. Our study included more than 3, 000 patients using strict inclusion/exclusion criteria. Surgical fusion was confirmed as an effective treatment strategy in this patient population.”
“We included patients who had a primary diagnosis of back pain, and we used patient centered outcome measures such as the Oswestry Disability Index and SF-36 and we required at least one year of follow up. Traditionally, payers have considered only Level 1 studies of nonsurgical versus surgical treatments. This is a flawed paradigm as in real world medicine, surgery is generally recommended only in patients that have failed conservative treatment. These should not be viewed as competitive treatments. Comparing these two groups doesn’t make clinical sense and as in other surgical trials using patients as their own controls is a reasonable research approach.”
“After reviewing over 1, 000 papers, we found that 26 met inclusion criteria; we graded them by level of evidence. The clinical outcomes did not vary by level of evidence, confirming that the entire body of literature and not only Level 1 studies add to our evidence base. With this work we have shown that the literature as a whole is in support of fusion surgery as a viable treatment for reducing pain and improving function in selected patients with chronic lower back pain. Now we have to get insurers to pay attention to these results and provide similar levels of evidence and transparency to support their position on spinal fusion to ensure optimal patient care.”
High-Grade Open Fractures Plaguing Developing Countries
There is an ever-increasing problem of serious fractures in some countries…and it is compounded by the fact that delayed care results in high mortality and complication rates. And while the World Health Organization has acknowledged this as one of the most important global priorities there is insufficient data from low and middle-income countries that could help determine the exact level of the problem…and that could help focus research and treatment. Mohit Bhandari, M.D., professor and research chair in Orthopaedic Surgery at McMaster University in Canada, is helping to solve the problem. “My colleagues and I have undertaken a large, prospective cohort study that involves over 4, 500 patients in India (our sample size will increase to 10, 000). We are going with a low cost, fairly low technology, ‘minimal dataset’ approach to decrease the burden of data collection to only those critical questions about factors associated with major outcomes in fractures. Our primary outcome is death and major complications. We aim to determine whether patients who arrived at a hospital with a fracture across several public and private hospitals in India were alive or dead within 30 days (or suffered a major complication such as a reoperation or major infection). Our team presented the preliminary findings at the Orthopaedic Trauma Association meeting this year.”
“The most significant obstacles we have encountered in our ongoing large cohort study are the assurance of accurate data, the lack of existing knowledge and infrastructure about research in many developing nations, and lack of large scale funders for this type of research. But we are progressing, however, and a year from now we expect to be recruiting actively in Nepal, India, Africa and South America towards our sample size goal of 50, 000 patients.”
“Thus far we have found that the number of nonorthopaedic injuries, fractures, open fracture, time to stabilization, and hospital type were significant predictors of mortality, reoperation, and infection; open fractures were the strongest predictor of early mortality. In sum, we must have consistent orthopaedic trauma protocols in order to improve the timing of care for severely injured patients in these countries.”
I have known Dr. garfin for over 8 years.
Eight years ago he told me that I needed to have a five level lumbar fusion.
As many people would, at the time I was not ‘feeling’ much pain associated with my condition and I did the easiest thing to do at the time. I put it off.
Fast Forwad to now,8 years later & I’ve reached the point where I don’t have a CHOICE in the matter.
I can barely walk across the street to allow my dog to take care of business,and at times,wonder ‘IF’ I’ll make it back across the street and home(a total of maybe 50 yds total).
I usually have to sit and rest when I cross the street and tell myself ‘I HAVE’ to cross the street to get back home.
Of course in hindsight,I wished I would have taken Dr. Garfins advice so many years earlier when i was younger and probably better suited to have a better chance of a successful surgical outcome.
Now,I have no choice in the matter.
I simply can’t function in my current condition.I’ll be in a walker soon without the same surgery Dr. Garfin told me I needed 8 yrs earlier.
If there’s 1 good point that I can take away from waiting so long, is that ‘minimally invasive surgery’ has become the norm, instead of in its infancy with Dr.Garfin being a true pioneer of the procedure.
So,I look on the bright side and know that I’ll have several small incisions instead of one long one,running the length of my stomach(and the added pain that would entail).
What’s the saying? “If I only knew then what I know now” I wouldn’t be facing a long battle to be able to walk as a ‘normal’ person again.
Thank you in advance Dr. Garfin
I’m lucky to live in the same city you call home and I’ll be able to be in contact with you,via phone or a short car ride away.
It gives me peace of mind,knowing that you’re ‘just around the corner’