More Patients, Less Choice, More Anxiety…and More

Mass General: More Patients but Less Choice

They are signs of the times…Massachusetts General Hospital is experiencing an increase in volume and a decrease in control of patient care. Andrew Freiberg, M.D., chief of Hip & Knee Replacement at Massachusetts General Hospital, tells OTW, “We have seen a substantial increase in volume—especially in knee replacement patients. Depending on the surgeon, most patients wait two to three months to see us, and then easily another two to three months to get into the operating room. It’s hard, but we do our best to keep them comfortable with conservative treatment in the meantime. I think we are seeing this increase in part because some  practices in the Northeast (and in Florida) are no longer taking Medicare or limiting them, so many of these patients are finding their way to facilities such as ours, i.e., ones that do accept Medicare. We are just trying to manage the volume as best as we can.”

“As to the other shift we are seeing, namely, a greater focus on preauthorization, we are doing our best to understand what each of the different insurers want. It’s pretty incredible to the patient that their insurer wants them to try physical therapy or require the use of a cane or walker for a month or so before they will approve surgery—even in the face of severe OA [osteoarthritis]. Most insurers, including Medicare, demand a four or six week regimen of physical therapy (PT) to delay or eliminate the need for joint replacement. Patients aren’t happy because they have already waited so long to see us.”

“It’s confusing to us as surgeons to send patients for physical therapy treatments that are costly when we know it will not prevent the need for an arthroplasty (because of severe OA on X-rays and poor functional scores). If someone has a completely destroyed joint it makes no sense to send them to PT. And although when I do call an insurer I am able to speak with a physician, it doesn’t seem to make a difference. A month ago I had a patient who was on one of the Medicare Advantage plans. Her hip joint was totally destroyed yet she was denied surgery because she had not undergone six weeks of PT, something that was not medically indicated in the first place. This woman was nearly wheelchair-bound. This kind of thing is disheartening for all of us.”

Health Exchange Anxiety on the Rise

The mystery surrounding health exchanges is causing some angst and speculation amongst doctors these days. It’s more uncertainty in already uncertain times. James Lubowitz, M.D. is director of the Taos Orthopaedic Institute, Taos Orthopaedic Institute Research Foundation, and Taos Orthopaedic Institute Sports Medicine Fellowship Training Program. He tells OTW, “We are beginning to receive offers from insurers for contracts from health exchanges; interestingly, the rates are close to Medicare and Medicaid. But since the eligibility is substantially above the poverty level, this means that a lot of patients with higher incomes, i.e., many with private insurance, could switch to the federally mandated program. These contracts are going to be effective next January, when ObamaCare mandates that all uninsured Americans are obligated to purchase health coverage, so we have until then to try to work out an equitable fee schedule with the insurance payers. One possible outcome is that if caring for these patients remains marginally profitable, then doctors could accept decreased compensation, and try to make it up in volume. At some point, however, there is a limit when this could become unsustainable or unsafe. And, in the event that treating Health Exchange patients is not profitable, doctors will have to explore whether it is reasonable, or possible, to accept such patients at all.”

“Another option is that a two-tier system will develop, as we have seen in many other nations, where private doctors will only accept well-insured patients, or patients willing to pay on an out of pocket, fee-for-service basis. Then, the burden of the poorly insured may fall upon employed physicians. And, if is an inevitable increase in patient volume when every American is required to carry health insurance, busy doctors will have the option to choose which patients, or payers, they are willing or able to accept. This creates a conflict for physicians, because as doctors, we have a service mission. We are motivated to help and serve all patients in need, and I believe that treating patients, regardless of income, is a moral imperative. The future is uncertain, but I predict that access to healthcare for all Americans may get worse, before it gets better.”

Rothman Institute: Practice-Changing Research on Dens Fractures

Clarity! For those surgeons wondering whether surgery or nonsurgical treatment is better for dens fractures, we have new information. Alexander R. Vaccaro, M.D., Ph.D. is a spine surgeon with the Rothman Institute in Philadelphia. He is also vice chairman of the Department of Orthopaedics at Thomas Jefferson University. Dr. Vaccaro tells OTW, “All major trauma centers frequently encounter elderly patients with C2 dens fracture, so it’s important that we try to settle the controversy surrounding treatment. We have traditionally treated these patients with collars and occasionally Halos, but with that comes a high mortality rate with Halos and complications related specifically to immobilization in a collar. My colleagues and I enrolled 159 patients in a multicenter prospective study; 101 underwent surgery and 58 were treated nonsurgically; they were equal in terms of age and comorbidities.”

“We used the Neck Disability Index (NDI) and found that at 12 months, the NDI had worsened by 14.7 points in the nonsurgical cohort compared with a worsening of 5.7 points in the surgical group. Also, mortality was higher in the nonsurgical group for reasons that may related to issues around collar immobilization. The message to orthopedic and neurosurgeons is not to be afraid to operate on an elderly patient with a dens fracture…it may actually the better option in many patients.”

New Trauma Centers Causing Havoc

A seasoned traumatologist says, “Trauma centers are not McDonald’s restaurants. Skillsets matter!” Why is he exasperated?? Because more and more hospitals are fashioning themselves into trauma centers. He tells OTW, “We are seeing large hospital conglomerates start to apply for level two status and receiving it. The intended effect is to decrease transport time and increase availability of care, but the actual result of this is that most of these community hospitals that were previously covered by general orthopedic group practices are not accustomed to caring for orthopedic trauma and traumatized patients! The flipside is that level one trauma centers have seen a significant decrease in their volume because patients are being ‘held’ by the new level two centers, i.e., they are not transferring patients. The real concern is that patient care will suffer because of the level of sophistication that may be lacking in level two centers. Also, level one centers which are staffed appropriately are no longer seeing the volume necessary for their doctors to maintain their skillsets. This situation could put the entire trauma system at risk.”

“Hospitals now see trauma as very lucrative; in the past trauma was not making money on indigent care but now there is a potential windfall from younger patients coming through the emergency room and having some form of insurance via the new healthcare reform mandates…this will make these patients/trauma profitable.”

“I’m sorry to say that hospitals care more about the economics of the service line than about quality outcomes. The administrators don’t understand medicine so they are managing it as they would a business…they see profit and loss and service lines. They either don’t care or are assuming that quality doesn’t matter, but we know it does. And all of this is so unnecessary. Almost all states have well developed trauma systems complete with helicopters…you don’t need six level two.