Too Much Knee Surgery? Dirty Details of Medicare Review, and More (Orthopedics This Week)
Dr. Donald Shelbourne, founder of the Shelbourne Knee Center in Indianapolis, tellsOTW, “My partners and I have been discussing the interesting fact that at least half of the people who are told by other orthopedic surgeons that they require a total knee replacement do not need this operation. We are able to treat many of these people nonsurgically. I see patients all the time whose X-rays look bad, but who are not in pain. These are the people who know that you must keep moving your knee or it will get stiff and become painful. But most people just go to an orthopedic surgeon, that doctor says, ‘You need a total knee,’ and they follow that advice. It’s a real waste in so many ways.”
“Let’s say a 60-year-old comes in with an arthritic knee and says that it’s been hurting for about two months. The X-ray he brings, however, is from an entire year ago—and it is problematic. But it’s only now that he is having problems. It’s not right to go back and attribute all his pain to that bad X-ray. Stiffness in the knee is reversible if you have patients work with a physical therapist.”
“I have just hired a total knee specialist and we will be prospectively monitoring how many people can be helped nonsurgically. This has system-wide implications, of course. I’ve been talking to primary care doctors, who say they are striving to help their patients avoid surgery, in part because if we can avoid one knee replacement it saves the equivalent of 150 office visits.”
“But we orthopedists have to put patients first. Now I’m older, and am even more attuned to my older patients. I’m getting patients my age going to total knee surgeons and just—almost randomly—being told, ‘total knee!’ We must be able to provide other appropriate options.”
Ranjan Gupta, M.D. Awarded AOA Traveling Fellowship
Dr. Ranjan Gupta, professor and chair of the University of California, Irvine (UCI) Department of Orthopaedic Surgery, has been selected by the American Orthopaedic Association (AOA) for the 2013 American-British-Canadian [ABC] Traveling Fellowship. ABC Fellows are chosen every two years and travel to various academic institutions in the United Kingdom and South Africa. They present their research and act as international ambassadors for the AOA as they learn about healthcare and research in their host countries. Dr. Gupta, who is the first UCI faculty member to be named an ABC Fellow, has received numerous awards, including the National Institutes of Health’s Career Development Award from the National Institute of Neurological Disorders & Stroke, the Marshall R. Urist Young Investigator Award from the Association of Bone & Joint Surgeons, the Kappa Delta Award from the American Academy of Orthopaedic Surgeons/Orthopaedic Research Society and the Sterling Bunnell Traveling Fellowship from the American Society for Surgery of the Hand.
Osteoporosis Starts in Womb?
Professor Cyrus Cooper is chair of the Committee Scientific Advisors at the International Osteoporosis Foundation. He tells OTW about some promising research in the realm of osteoporosis…and makes a few comments about what we may be missing. “Years ago this condition was considered to be inevitable—like gray hair. Since then we have learned how to accurately assess someone’s fracture risk, not to mention that we now have a great array of treatments that can retard bone resorption and stimulate bone formation. At present, one of the most promising areas of research involves the evolution of the disease throughout the lifespan. We are finding that the first inklings of osteoporosis lie not only in our early years, but may in fact be in the health of the mother as we grow in utero. If in fact these early environmental influences are modulating and establishing the trajectory of skeletal development, that means that we can take preventive measures throughout the course of our lives. Good prenatal nutrition coupled with appropriate physical activity in childhood will lead to a serious reduction in fractures for future generations.”
Dr. Cooper, who is Professor of Rheumatology and Director of the MRC Lifecourse Epidemiology Unit at the University of Southampton, and Chair of Musculoskeletal Science at the University of Oxford, adds, “There is a crucial piece missing in the jigsaw puzzle of fracture management—and that is that those patients who have had a fracture are much more likely to have a subsequent fracture. Orthopedists are great at evaluating and managing fractures, and effectively returning fracture patients to good physical function. But recently we have realized that those individuals who have had a fracture have at least double the risk—and may be up to a fivefold risk—of having a second fracture. A full 20% of those who have experienced a fracture will have another one within the year! We now have the tools to assess these future risks and by targeted treatment we can markedly reduce the risk of subsequent fractures. We also know that secondary prevention strategies such as Capture the Fracture, a system pioneered by the International Osteoporosis Foundation, are cost effective; not only are we paying a small amount, but in some instances we are saving money as well as disability and life years lost.”
Dirty Details of Medicare Review
A traumatologist tells OTW, “My colleagues and I are becoming increasingly frustrated with the direction of healthcare. Although all of us want to be cost conscious when making healthcare decisions, it’s becoming increasingly difficult to take care of patients without running into roadblocks. I sit on the utilization review committee for my hospital and we recently had to submit nearly 2,000 cases to Medicare Recovery Audit Contractors (RAC’s). These were established by the Affordable Healthcare Act. These companies get paid to find overpayments by CMS [Centers for Medicare and Medicaid Services]. Unfortunately their approach is to cast a large net in hopes of recovering money. These contractors can choose any cases to review that even occurred prior to the establishment of the Affordable Healthcare Act. The criteria used to trigger a review is somewhat vague, which ends up leading to several cases that get sent in which requires a substantial amount of time and energy including the hiring of several people just to handle the processing of these cases that have to be sent. It’s yet another administrative burden that is not something affecting patient care in a good way. It affects how the hospital system uses money for paying employees or improving the facility because we’re not sure if the money is going to be there.”
“The idea is that Medicare may claim that something done was not medically necessary or that they overpaid after the fact, but the cases from our facility have gone through this process…. There’s also a three level appeal process if you don’t agree with their findings…which can take up to two years. So far, in all of the cases that we have appealed, we have gotten 100% of those funds back. But only about 50% of the cases submitted have been reviewed. This whole process ties up valuable resources. If you continue to appeal, these cases can go up to an administrative law judge employed by the state so you are tying up the court process as well. I get that other people have done fraudulent things but punishing everybody instead of addressing it with the individuals is just wrong.”
“Furthermore, another component of the healthcare act is the Surgical Care Improvement Project (SCIP) which is again a good idea to force facilities to be able to address issues that shouldn’t be commonplace. However, it doesn’t allow for things that are going to happen in some instances regardless of how hard you try. For example, if someone gets an infection after surgery, Medicare may not pay for the procedures to address this, which is not financially solvent for the hospital, the healthcare team, or the patient. The fact is that no matter how good of a surgeon you are, some people are going to get an infection. As money gets tighter, I believe that they will start changing the benchmarks so being able to meet them will get even more difficult. As the Affordable Healthcare Act continues to roll out, there will be more surprises. Eventually, the critical decisions that will be made regarding what will happen with government-sponsored healthcare will be left in the hands of 15 people (Independent Payment Advisory Board) that are appointed by the president.”
Humanizing the Orthopedic Surgeon
Michael Schafer, M.D. is chair of the communication committee for the American Academy of Orthopaedic Surgeons (AAOS). Here he gives OTW an update on the AAOS initiative, “A Nation in Motion.” Dr. Schafer: “We are six months into this project, which is an effort to help patients understand how orthopedic surgeons help restore movement and lives. We now have over 600 patient and doctor stories that give testament to the value of orthopedic care.”
“This effort, which is in part meant to humanize orthopedic surgeons, is now expanding to include personal surgeon stories a la, ‘Why did you become an orthopedic surgeon?’, ‘What is the most satisfing part of your work?’ etc. We will also be adding a section entitled ‘Ortho-pinions’ where orthopedic surgeons will write 1,000 word vignettes on different conditions. We will also be promoting Operation WalkUSA, which will take place on December 7 this year. Over 100 orthopedic surgeons throughout country will take part in this effort, something that surely will result in the public seeing orthopedists in a positive light. Next year our major push will be to add information to the site regarding the economic value of orthopedics. It’s yet another way for help patients understand what orthopedics means to their lives.”
Phillip Bauman, M.D. Named Top Doctor in NY
Castle Connolly Medical Ltd. has released the 15th edition of Top Doctors: New York Metro Area and has listed orthopedic surgeon Dr. Phillip Bauman as an honoree. Dr. Bauman performs arthroscopic and reconstructive surgery, and has a special interest in the treatment of sports injuries including the shoulder, knee, foot and ankle. He serves as orthopedic consultant to American Ballet Theatre and New York City Ballet, to their affiliated schools and other dance programs in New York and across the country. He has been recognized by Castle Connolly Medical as a top orthopedic surgeon in the U.S.