Scrambling to Get Ready for ACA
It’s hard to say which party is sweating the impending insurance changes most. Some are doing their best to plan. Ted Miclau, M.D. is an an orthopedic surgeon with San Francisco General Hospital. Dr. Miclau, who is also past president of the Orthopaedic Research Society, tells OTW, “I work in a public hospital, and my vantage point in looking at the changes emanating from the Affordable Care Act is one that is shared by many of my colleagues in similar systems. Like many of our ‘sister’ public hospitals in the U.S., our hospital is scrambling to figure out how our facility will fit in to the bigger picture. Part of the problem is that we are having to make assumptions; while the rules are clear, how they will play out are not.”
“For example, in San Francisco we have roughly 60, 000 uninsured patients enrolled in a city-supported system. Two-thirds of these patients will be eligible for some type of coverage. Some of these patients will elect not to have coverage, and we are estimating that about half of these patients will continue to be uninsured. The question is, ‘Will those who have a choice stay in the system or sign up for coverage with another organization?’ Further, will those from other systems in other counties choose to migrate to our system. So, the planning and budgeting in this era of new health care changes is extremely challenging.”
“In our system and others, one of the deciding factors that will likely influence individuals’ choices will be whether they have a primary care provider in their system. In San Francisco, for example, nearly 20, 000 of our uninsured patients currently have a medical home, and it is quite likely that they will remain in the system. However, for those who do not have a medical home with the Department of Public Health, they will likely be more motivated to look for other options. We therefore have to be ready to adapt and compete.”
Asked what advice he might give to his colleagues in other public hospitals, Dr. Miclau told OTW, “I recommend that physicians and their public health departments make a strong effort to work together, and this includes the specialists. Complete health care systems, which include primary and subspecialty care, are more likely to provide the kind of network that would be attractive to individuals who become covered in these new insurance exchanges. For those who are not engaged in a system, such as sole practitioners, the challenge for them will be to become integrated into a system. You can see where these new changes would be anxiety-provoking for those in the health care industry at many levels.”
Treating the Marathon Bombing Victims: What It Was Like
Trauma is what John Kwon, M.D. is used to. What was unusual about that April day in Boston was how much trauma there was. Dr. Kwon, a foot and ankle and orthopedic trauma surgeon at Massachusetts General Hospital, was there when the patients began to appear in the wake of the recent bombing. He tells OTW, “First of all, the outcome would have been very different if the bomb had gone off at the starting point. Because it was at the finish line, there were substantial medical providers in the area, as is typically the case with such an event. It was also helpful that the square is centrally located amongst all of the level one trauma centers; patients went to many of these facilities, namely Massachusetts General, Boston Medical Center, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, and Boston Children’s Hospital.”
“From the time the bombs went off the first injuries arrived at our facility within 20 minutes. While these are the type of injuries we see on a daily basis, it was the volume of injuries that made it unique. There was quite a lot of careful triaging between the orthopedic trauma team and the other surgical services such as general surgery, vascular, burns and plastic surgery. We had the first patient in the OR within 40 minutes of the first bomb blast; by approximately 11:00 pm on the first day we were done operating. Afterwards, we dealt with smaller lacerations and shrapnel injuries that came in over next couple days…then the burn service and plastic surgery took over. It was amazingly seamless—as it should be.”
“Any level one trauma center must be prepared for this type of disaster—a concrete disaster plan is required. Here at Mass General we called up extra nurses, and were fortunate that most surgeons were available. Everyone knew his or her role; we activated the disaster plan, and used the algorithms in place (who is in charge, what do they do, who’s next in line, what do they do, etc.).”
Finally…A Way to Measure Arthroscopy Proficiency
How do we know that surgeons are doing arthroscopy well? Gregg Nicandri, M.D., assistant professor in the Department of Orthopaedics and Rehabilitation at the University of Rochester Medical Center, set out to learn more. He told OTW, “In the world of surgical training it’s been the ‘see one, do one, teach one’ model for years and in general, orthopaedic residents that complete a five-year program and are deemed competent to perform the core surgical procedures of that specialty. Clearly, there must a better way to educate and evaluate the skills of our residents. It has been recognized that not all training needs to take place in the presence of patients and newer curricula which incorporate simulated surgery are being developed.”
“Currently there is no objective way of evaluating a resident’s proficiency with arthroscopy, and as a result it is difficult to determine whether your curriculum is appropriate or whether arthroscopic surgical skills labs are achieving their purpose. The Arthroscopic Surgery Skill Evaluation Tool (ASSET) allows for the assessment of a surgeons arthroscopic skill level. As a result we will be able to determine whether a certain curriculum or method of training (virtual reality simulation for instance) actually improves a surgeons arthroscopic proficiency and to what extent. Hopefully this will result in more effective and efficient training.”
“The tool is valid for construct; we had residents perform diagnostic knee arthroscopy and found that the ASSET score did correlate with experience (novices achieved lower scores than those with intermediate experience and individuals with intermediate experience recieved lower scores than those with advanced experience). The tool also demonstrates quite a high level of intraobserver reliability when compared to other similar evaluations; we had two raters review videos of residents performing diagnostic knee arthroscopy and then assign a score and the level of agreement was very high between the two scores. The next step is seeing how we might apply the ASSET to other procedures such as ACL reconstruction, shoulder arthroscopy, and menisectomy. We also want to see if residents can perform as well in a live environment as they do in the lab and use the tool to assess skill transfer from one environment to the other. There is a lot of promise here. There is increasing pressure on residency programs and certifying bodies to more rigorously evaluate procedural competency and the ASSET is one tool which may help to satisfy that need.”
Reverse Shoulder Arthroplasty: How Many? Who Is Doing Them?
Orthopedic surgeons are using reverse shoulder arthroplasty for complex fractures and cuff arthropathy with increasing frequency these days. A team at the Rothman Institute, including Joseph Abboud, M.D., wanted clarification on this very statement and hence they have been studying these questions. The team looked at how many reverse shoulder arthroplasties are being performed yearly and who is performing these procedures. Dr. Abboud told OTW, “In our first study we used the Medicare database to examine the volume of arthroplasty (total shoulders versus reverse shoulder arthroplasty). What we have found was that the volume of arthroplasty being performed is nearly evenly split between a standard arthroplasty and a reverse shoulder arthroplasty. We also looked at volume by surgeon and found that there was indeed a fairly significant percentage of reverses being done by lower volume surgeons. This is somewhat surprising since this is an advanced procedure with a relatively high complication rate even in the hands of high volume surgeons.”
“Our second study involved new graduates performing reverse shoulder arthroplasty for fractures during their boards collection period. While hemi arthroplasty is still a more common procedure there is definitely an uptick in those surgeons taking step two of the boards who are utilizing reverse shoulder arthroplasty for these fractures. While in many instances this is the best option for the patient, we have to continue to emphasize the indications and technique to continue to optimize outcomes and minimize complications.”
