Stuart Weinstein, M.D. Receives OREF Clinical Research Award
For those living with scoliosis, Stuart Weinstein, M.D. has been a godsend. A professor of orthopedics and rehabilitation at the University of Iowa, Dr. Weinstein has now been recognized by the Orthopaedic Research and Education Foundation (OREF) for his decades of work in the field. Dr. Weinstein, who has just been honored with OREF’s Clinical Research Award, tells OTW, “This award recognizes our 40 years of research into scoliosis, and includes information on the natural history of patients with adolescent idiopathic scoliosis (AIS).”
“With this award, OREF also highlights our work on bracing, in particular our efforts to determine if bracing is actually effective. We have been bracing since the 1940s, but it has never been shown to be efficacious. My colleagues and I undertook a multicenter NIH [National Institutes of Health] trial at 25 locations in North America, and we showed that bracing is effective in preventing kids from needing surgery in 90% of cases.”
“When I was a resident, AIS was thought to be a grim prognosis: people would die early, they would not be able to have children, and would become paralyzed. However, the literature that led to those erroneous conclusions was flawed. So this work let parents and doctors know that those with AIS can function well into adulthood and be active older adults; however, if untreated, these patients can experience back pain and significant deformity. Some can even develop pulmonary function symptoms.”
“As for future work, an interesting area of research in AIS is genetics. We know that it is a genetic condition, but we don’t know how it is inherited. The right type of research into this may help us prevent the condition.”
“Scoliosis surgery is extremely expensive, so a major issue is if we can get the same outcomes with fewer implants. My gut reaction is that we can; fortunately, there is a current study that is looking into this.”
“I do think that there is more work to be done on bracing. We need to answer the question, ‘Is there an ideal brace?’ Those 25 centers we worked with used braces of their choice…and no study has yet compared braces. In Europe they are doing studies on combining bracing and exercise; they are also comparing different types of braces.”
“A request for my colleagues, ” adds Dr. Weinstein, “Please support the OREF and advocate for funding through the NIH. We have little hope of bringing about new developments and improving the lives for our patients if we cannot undertake high quality research.”
TJA Readmissions, Length of Stay and Discharge Destination
In the brave new world of bundled payments, there are still many questions to be answered. One is, ‘What is driving total joint readmissions?’ Another is, ‘Should the patient go home directly or go to an aftercare facility?’ Joseph Bosco, M.D., associate professor and Vice Chair for Clinical Affairs in the Department of Orthopaedic Surgery at NYU Langone, tells OTW, “One way to know if you are doing a good job—yes, it’s the buzzword ‘quality’—is via readmission rates. My colleagues and I set out to determine why patients were coming back after total hip and knee arthroplasty procedures. Our ultimate goal was not only to improve quality, but to find ways to decrease hospital costs.”
“All 721 patients in our study were part of the Bundled Payment for Care Initiative from the Centers for Medicare and Medicaid Services (CMS). The participants were all admitted to our facility between January and December 2013 for a total hip arthroplasty (THA) or total knee arthroplasty (TKA). Of those cases, 80 patients, or 11%, had to be re-admitted within 90 days.”
“THA and TKA readmissions due to surgical complications accounted for 54% and 44% of the indications for readmissions, respectively. The average cost of readmission for surgical complications was $36, 038 for THA and $61, 049 for TKA. But we found that many patients were readmitted for things like cancer…things that had nothing to do with the total joint surgery. If you participate in a bundled payment program, you could end up being financially responsible for a readmission that has nothing to do with your surgery. This is important when negotiating bundled payment contracts. If someone is in a motorcycle accident three months after TJA [total joint arthroplasty] you don’t have to pay for that admission.”
“Another quality metric that we have examined is length of stay. We looked at the option of having our patients go home directly from the hospital instead of going to a rehab facility. Rehabilitation facilities receive a per diem rate, an approval saying ‘You are approved to care for person X for 14 days.’ Frankly, it’s to their benefit to keep the patient as long as possible. Among other things, that increases the risk of nosocomial infections. It is very interesting to note that readmission rates are always higher when someone is discharged to a nursing home or a rehab facility. Specifically, the rate of readmission is 25% lower when patients go directly home from the hospital. Some patients are apprehensive about going home directly, but ultimately they are happier because they do want to be home.”
“It costs $1, 000 to have a visiting nurse care for a patient for three weeks; contrast this with the $18, 000 it costs to go to a nursing home facility. We determined that if a patient stays for an extra 3-4 days after total joint surgery the cost to the hospital is not something outrageous like $5, 000 per day. It is $12, 000 the first day and then after that it’s just the cost of food. Even nursing is a fixed cost. Thus it is far better to keep the patient for a few more days and then discharge them to home rather than discharging them to an inpatient facility at an earlier date.”
Patients Surprised by Low Reimbursement Rates
You can get a new water heater for about $1, 500. A rotator cuff repair is cheaper…but patients don’t know that. Sameer Nagda, M.D. an orthopedic sports medicine surgeon at the Anderson Orthopedic Clinic and Joseph A. Abboud, M.D. an orthopedic shoulder surgeon at the Rothman Institute, worked with their colleagues to assess patient perception of physician reimbursement in elective shoulder surgery. Dr. Abboud tells OTW, “This work was initially done in the hip and knee literature; one of our colleagues approached us about extending it to the shoulder arena. We wanted to find out if patients thought that surgeon reimbursement was too much or too little and how close their perceptions were to reality.”
“We administered the survey in our offices, asking questions not only about shoulder surgeries, but also about perceived reimbursement for standard surgeries like heart bypass and appendectomy. The 2011 Medicare data showed that reimbursement for a heart bypass was $2, 250, $660 for an appendectomy, $1, 632 for shoulder replacement, and $1, 175 for rotator cuff repair.”
“Shoulder replacement patients thought that a reasonable reimbursement for their surgery was $16, 832. When asked, however, ‘What do you think Medicare is paying?’ the answer was $8, 500. So they thought that reimbursement for this surgery should be reimbursed at a rate 10x higher than it actually is! As for rotator cuff surgery, patients thought that a reasonable reimbursement rate was $9, 400; they thought that Medicare paid $4, 800.”
“Once the survey was complete and we shared the actual reimbursement numbers with patients, 65% of patients felt that total shoulder replacement reimbursement was ‘much lower’ than they had expected; 58 % thought that it was ‘much lower’ for rotator cuff repair.”
“Interestingly, we didn’t find any correlation between patient income, education, or insurance type as far as the patient’s perception of the reimbursement numbers. In addition, patients felt that if the surgeon had subspecialty shoulder training then their reimbursement should qualify them for higher reimbursement.”
“Our Congressional representatives should find this patient-driven data enlightening given the frequency of misinformation that is out there pertaining to surgeon reimbursement. The next step is to ask patients to compare some of these procedures to everyday things they have done (car repair, etc.). If someone needs a rotator cuff repair then the doctor will be reimbursed $1, 175…you often can’t get a basic home repair done for that price! Given the climate of declining and/ or flat reimbursement rates for many procedures, physicians will need to continue to scrutinize their ability to participate with certain insurance carriers or possibly opt-out given their associated practice overhead and basic fiscal responsibilities.
If a heart bypass costs $2,250, why did I pay >$3,000 for a treadmill test? The perceptions are based on experience.