A big (non) decision by the Supreme Court with huge universal health care implications

A nerdy public policy-wonk post today!

Despite a surprisingly brief blurb on the AP wire & broadcast news media, there was a very important move last week by the Supreme Court of the United States (SCOTUS) about the future of health care in this country. The court refused to hear an appeal by the American Association of Retired Peoples (AARP) about a companies ability to terminate health care benefits when a retired former employee becomes eligible for Medicare at 65. The AARP is one of the most powerful political lobbies in the United States, and this is a pretty big defeat for them.
The court's action upholdsa a rule adopted last year by regulators that says the "coordination of retiree health benefits with Medicare" is exempt from the anti-age-bias law.


This case has pitted the interests of younger employees and unions against retirees over the dwindling budget for job-related benefits. In recent years, many employers have pulled back from providing these kind of benefits to their retirees because of the soaring cost obligations. But until Monday it had been unclear whether it was illegal to use a worker's age -- in this instance, 65 -- to trigger a reduction in benefits.

"In some cases, it's become a millstone around their necks," said Jack Kyser, chief economist of the Los Angeles County Economic Development Corp. "Corporations aren't all heartless, but in many cases, you're competing with multinational corporations that don't have quite the obligations that domestic firms have."

This decision not to hear the appeal is interesting because it's going to grease the skids for a large shift of healthcare obligations from the private sector to the feds. As I remained convinced that we're quickly moving towards "Medicare for all" as the eventual American adoption of universal health coverage, the incorporation of more people under it's existing umbrella seems another move in that direction.


Rob

Anesthesia related death during plastic surgery

From the Palm Beach Post comes the tragic death of Florida teen, Stephanie Kuleba, from a rare allergic reaction to inhalation anesthetics called malignant hyperthermia (MH). Wikipedia describes it succinctly as a idiosyncratic reaction that "induces a drastic and uncontrolled increase in skeletal muscle oxidative metabolism which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if untreated."

There's really no way to screen for this process and a patient can die quickly. Most surgeons and anesthesiologists may go their entire career and never see a true case of it. I was talking to one of my colleagues the other day about office based surgery and he said he was unlikely to return to doing that after seen a near fatal MH on a cosmetic surgery case he was doing in an ambulatory surgery center adjacent to a hospital.

I'm not sure what the take home message from this is. It's such a rare event that it's hard to justify having exotic protocols at all times in low risk procedures. Most office surgery suites maintain a supply of Dantrolene, a medicine to treat MH which is almost $2500 per dose and must be restocked often to stay current. There's plenty of adverse events more common then MH, but we don't have aortic balloon pumps or cardiac bypass machines routinely laying around for that. It already sounds like that the family has hired an attorney who is already assuming an aggressive posture in his comments to the media so I'm sure we'll see some legal proceedings even if perfect care for MH was instituted.

Rob

'Tis the season for - Chocolate Bunny Melting

Happy Easter from Plastic Surgery 101!

Courtesy of YouTube, some stylish chocolate bunny immolation. You know, artsy types are just different then the rest of us!





Cheers!
Rob

Do Americans want fee for service medicine?

There's an article on Salon.com about health kiosks in places like Walgreen's and Wal-Mart called "Wal-Mart can be good for your health!".

This is a hot topic in medicine as it gets into a number of hot topics

• Who will own these clinics? (doctors or industry)




• Who will staff & oversee these?




• What affect will this have on continuity of care?




• What affect will this have on the financial sustainability of medical practices when routine patient visits are siphoned off to these clinics?

One theme that jumps out at me, particularly when you read the reader comments section to the article, is that people are schizophrenic when they think about this (ie. Is medicine a business or nonprofit public utility?) and look at this from a completely different perspective than health care providers.

A number of complaints arise which basically boil down to that "the competition these clinics provide against doctor's office visits will be good and result in better service". This pretends that medicine is some true market economy rather then a corporate & federally-rigged game of Jenga. The winner of this "competition" gets the privledge of working much harder for much less money for much more aggrevation.

If you want to send a primary care doctor thru the roof, complain about having to pay a co-pay for and office visit and about not being able to be seen at a moment's notice. There's little understanding (or sympathy) for exactly how much our system is squeezing physicians to achieve savings in our health care system.

Particularly offensive to me is a Minnesota internet start up company I read about called CAROL, whose business model is essentially to try and turn medicine into Priceline.com

“We want to let consumers define value,” said Tony Miller, Carol’s founder and chief executive. “We don’t have care competition in the marketplace today.”The free site, which went live in January, generates revenue from health-care providers who become “tenants” on the site. When a consumer sets up an appointment with a clinic or doctor on Carol.com, the provider pays the site a fee.

Great! We were missing one more layer of capitalists strip mining the health care system.

Rob

Dumb laws and smart laws re. plastic surgery

Tragic events have a way of stimulating bad legislation.

Co-conspirator in Plastic Surgery blogging, "Dr. 48307", Tony Youn had a very insightful retort a few weeks backto a bill ("the Donde West law") introduced in the California legislature (read here) to mandate medical clearance on all patients undergoing cosmetic surgery. Something similar is now being mentioned in Illinois. Dr Youn writes:

This is a very interesting bill, considering less than a year ago the California legislature passed a law permitting oral surgeons (DDS dentists) to perform all forms of facial plastic surgery. Instead of forcing surgeons to make their patients undergo preoperative testing (some young, healthy patients may not need it), maybe they should instead make sure that anyone performing plastic surgery is a real, board-certified plastic surgeon?

Keep in mind that California is also the state where a judge ruled in 2006 that a certificate from a non-recognized cosmetic surgery "board" organization was equivalent (or better!) to the American Board of Plastic Surgery for accreditation proposes over the objections of the state medical board for California, the American Medical Association (AMA), the American Society of Plastic Surgeons (ASPS), the American Board of Facial Plastic Surgery, the American Board of Medical Specialties (ABMS), and others. This ruling ignored the existing state law that allowed physicians to advertise board certification only if the certifying board or association is recognized by ABMS or deemed equivalent by the state medical board.

BACK TO THE "DONDE WEST" LAW

Broad non-directed medical screening by 3rd parties would be an extremely inefficient and unnecessarily expensive way to clear patients for surgery. Besides, this process already takes part as part of a patients' surgery evaluation. Now your doctor can be a tool, and adopt the blanket position that "I send all my patients for medical clearance before surgery", but that's just punting the ball and practicing defensive medicine to the extreme.

The scale we commonly use to characterize surgery patients' anesthesia risk, called the ASA system, is a pretty good screening tool. The overwhelming amount of patients undergoing cosmetic surgery are low risk, and ASA class I or II patients should not need "medical clearance". In addition, many primary care doctors have absolutely no idea what "medical clearance" means anyway, and get a little peeved when patients show up for non-reimbursable office visits.

When we talk about medical clearance, it's usually in the context of chronic medical issues or asking whether the patient needs provocative testing for coronary artery disease. Patients who may need to be "tuned up" prior to surgery are those with:

• diabetes - Are there blood sugars under control?


• significant hypertension


• morbid obesity


• sleep apnea


• symptoms of (or strong risk factors for) coronary disease

Many of those conditions might be exclusionary for elective cosmetic surgery in the first place, particularly when combined. Keep in mind that the patient involved in the event triggering this reactionary bill, Donde West's, had undergone coronary testing earlier in the year (which was reportedly normal) and died over 24 hours postop from what sounds like a probable aspiration event. No amount of screening would prevent something like that.

"Smart Laws" relating to cosmetic surgery seem to be a little more difficult to implement. A more practical way to address the whole issue of office based surgery procedures would be to standardize the accreditation of facilities and remove the loopholes in some states that still exist. My state, Alabama, for instance has set a timetable for requiring accreditation for office an ambulatory surgery centers (ASC) over the next 18 months. The ASPS already makes it a requirement for membership that you will pledge to only operate in accredited (or planned accredited) office facilities. A common sense regulatory step would be to require hospital privileges for any surgery you'd propose to do in your office requiring sedation or general anesthesia, which would have the de facto effect of an additional level of credentialing applied by hospital medical staff offices. It's so common sense that it will be violently opposed by many "cosmetic surgeons" who would see their ability to practice cut off at the knees. Something to think about!

Thanks again Tony for your wonderfully entertaining blog!

Rob

The charity business as (un)usual - Operation Smile

There's a nice story on featuring Operation Smile in the New York Time's magazine. Operation Smile is an organization that organizes and performs cleft lip and palate surgery in developing countries. The story is not really about the altruism of Operation Smile, but rather it focuses on how it became an effective organization only after operating more like a business and less like a traditional charity.


3rd world missions by plastic surgeons, where a team flys in for a few days, does a lot of pediatric plastic surgery (cleft lip/palate) and leaves would seem like a hard thing to be criticized, but it has been increasingly done. The appropriateness of these kinds of surgeries performed by surgeons who didn't do them in their state side practice and by loosely-supervised residents (as was often the case on these trips) has been questioned for years. Groups like operation smile have addressed this, and require active practices in pediatric plastic surgery among volunteers. More importantly IMO has been the change in philosophy to where we're now increasingly training local physicians in these countries to do simple and reproducible operations to correct these defects recognizing the limitations of resources they may face in terms of speech therapy and orthodontics post operatively.


Rob

Wall Street Journal on SmartLipo - I scooped 'em!

A visitor to the site pointed out to me that today's Wall Street Journal also featured a profile of Cynosure's SmartLipo platform highlighting some of the same thoughts I had in my post yesterday.

If you're interested, you can read it here.

Plastic Surgery 101 - Iceland's most popular plastic surgery blog :)

I'm constantly amazed at the ability of the internet to put like minded people in touch from around the world. I can still remember the thrill I got from Napster's heyday where I was able to communicate in real time with fans of artists I liked (Richard Thompson, Bruce Cockburn, Chris Whitley, among others) around the world.

While I may only be the 281st most popular health care blog this week according to Healthcare100.com (I demand a recount!) , like many under appreciated rock bands I'm now "big in Europe". I'd like to give a shout out to American ex-pat, Ms. Erika Wolfe, who took the time to send some beautiful postcards from her adopted home in Kopavogur, Iceland telling me how much she enjoys Plastic Surgery 101. I wish I had some "PS 101 brand" swag I could mail you back! My Icelandic is kind of "rusty" but via the magic of web-translator programs - Ericka, þakka þú fyrir the póstkort

Ericka sent me stunning images from:

Waterfall Dettifoss, north Iceland

Iceland's famous "Blue Lagoon"

Rob

Is SmartLipo a smart choice for you liposuction? I'm sticking with "dumb lipo" (for now)

I had the chance to go to an educational event last month put on by Cynosure, manufacturers of the "SmartLipo" platform for body-contouring. Cynosure is a well respected company and has manufactured generally well designed laser platforms. SmartLipo's gimmick is to place a pulsed laser (a 1064nm Nd:YAG for tech geeks in the audience) on a fiber optic cable which is used like a liposuction cannula. The theory is that the laser's energy disrupts and emulsifies fat cells, thereby eliminating or reducing the need for conventional suction assisted lipectomy (SAL). Also promoted is enhanced skin contracture from the thermal energy adjacent to the skin.

I've got to say I was a little unimpressed with the results shown from this device with body contouring procedures. It just didn't produce dramatic results. The presenting doctor in this instance was an ENT surgeon, which I think may have something to do with this. Much like many pictures shown by Dermatologists who do liposuction, there sometimes seem to be an ignorance or indifference to the skin quality and underlying anatomy of patients. (in fairness, many plastic surgeons are guilty of this too.) So picture after picture gets shown of people with undercorrection of significantly fatty areas and lots of residual loose skin in patients who were poor candidates for SAL, SmartLipo, Ultrasonic Liposuction, VASER, etc.... in the first place.

When you read industry publications quoting paid investigators & consultants who are "hanging crepe" about patient selection and expectations, that's usually a code word to me it works best on people who arguably need surgery the least. That's what the expectations had been dumbed down to with the "thread lift" fiasco in 2005-2007 (see here for one of my first blog entries on it).

To get results with SmartLipo, you're still going to have to do traditional liposuction afterwards, begging the question of whether a $100K-120K laser platform that can't be used for other indications makes any sense. It may also be effective for small touch up liposuction cases, but that's an awfully flawed business plan for a doctor assuming that much overhead.

I did see some nice results with SmartLipo when used in the neck/face, and it makes sense that it would work better in those area. If you've got thin fatty layers (like in the neck/face), you may indeed be able to treat that and get skin improvement. Complicating my assessment was the fact that many of those patients had face or neck life surgery simultaneous, which makes it hard to sort the skill of the surgeon's techniques from any effect of the laser. Facial and neck procedures might be the better group for this, but blindly applying high thermal energy to tissue adjacent to nerves and the carotid artery could potentially result in catastrophic complications.

In a nutshell, there may be some applications for this technology but presently I still feel it's more of a marketing tool then revolutionary device.

Rob