Hospitals poised to embrace "pay as you go" for patient care

There's a front page story in today's Wall Street Journal, "Hospitals Demand Cash Upfront From Patients" (login required) outlining the increasingly common practice of hospitals demanding pre-payment for services to be rendered.

I've been noticing this locally for awhile as well. As the amount of "bad debt" has been soaring from patients defaulting on their obligations which are the co-pays, deductibles, & any other part of the cost they're responsible for on their insurance. The really disturbing anecdote in the story surrounding a leukemia patient being treated at MD-Anderson Cancer Center in Houston is a painful reminder of the schizophrenic nature of American healthcare where we try to balance patient care and healthcare economics. It's stories like this that just convince me more then ever that we're hearing the death rattle of our traditional system as we move to some universal healthcare system.

Sympathy aside however, patients do need to understand their financial obligations under their insurance plans. One of the least fun things to do in medicine is to start sending collection notices to patients for unpaid charges from office visits or surgery. As you'd predict, it's much harder to get patients to pay after services are rendered then it is prior. There are very common misperceptions among many patients about how, when, and how much we're reimbursed for services.

I can still remember a massive weight loss patient after gastric bypass refusing to pay her co-payment of $1000 to our office for removing her excess abdominal skin (a panniculectomy or tummy tuck) because she felt like the $700 her insurer paid for 4 hours work and half a dozen post-op visits was enough. I'm a softie on many of these cases and we waive charges frequently (particularly on breast cancer reconstruction, which is a passion of mine) but we've had to become much more attentive to this issue as we see more kinds of cases creeping up.

Rob

Sour NOTES - a really, really stupid idea in surgery

At right, a picture of NOTES done "olde school" for a tooth extraction.

I'm not so far out of doing a few thousand abdominal procedures during my general surgery training that I don't still feel fluent in GI surgery. As I'm still boarded in General Surgery in addition to Plastic Surgery, I get a lot of trade journals sent to me on endoscopy, laparoscopy, etc... Occasionally, something I'll read about makes my eyebrow raise as I don't BOTOX yet :) The concept of NOTES surgery is one of those things.

Take an operation that is typically performed safely in less then 30 minutes with minimal pain or morbidity and turn it into one that last 3 hours, introduces unnecessary risk, and has no conceivable advantage. What do they call that at the University of California San Diego (UCSD)? They call it progress (!!!!!)

Welcome to the concept of NOTES "Natural Orifices" surgery (see here for a primer) where intrabdominal surgeries are performed by making a hole thru the stomach, anus, or vagina to work thru versus making several 3-5mm perforations in the abdominal wall with laparoscopic techniques. While ingenuity & creativity is always to be applauded in surgery, at some point you have to do an honest assessment of the risks, benefits, & outcome.

The surgeon in this WebMD article celebrating the first NOTES appendectomy in the United States at UCSD seems to have his intellectual blinders on when discussing this procedure.

Dr. Santiago Horgan, chief of minimally invasive surgery at UCSD, says “We’ve proven this approach works. We’ve seen the impact on patient care and on outcome: less pain, quicker recovery, improved cosmetics.”

So let me get this straight: The absence of three nearly invisible 3-5mm scars, with no advantage in length of stay, with the addition of a hole in your rectum, vagina, or stomach (which all can leak), with significantly prolonged surgery adding cost, increased nausea, and increased risks of deep vein thrombosis (DVT) is somehow supposed to be an improvement? This is a technique that needs to be put back in a holding pattern indefinitely where safe procedures exist until you can come up with some compelling rationale for doing them. If I was sitting on a hospital's Internal Review Board (IRB) looking at this I'm not sure I could give an endorsement for this.

In fairness, some of these same arguments were made when laparoscopic surgery first appeared in the late 1980's and it's now the preferred technique for many procedures. You have my permission to throw this post in my face in 2015 if everything is NOTES and laparoscopic equipment is gathering dust somewhere. I like my odds however!

Rob

Looking back to 1983 in Plastic Surgery and Pop Music

As I was leafing thru a recent Rolling Stone magazine, I noticed the list of top ten pop singles from February 1983. It's a diverse collection of songs that I actually know from being a 12 year old then who listened to the radio and watched MTV (when they actually played music). The singles in order were:

Patti Austin "Baby, come to me"
Men at Work "Down Under"
Bob Segar "Shame on the Moon"
Stray Cats "Stray Cat Strut"
Toto "Africa"
Michael Jackson "Billie Jean"
Eddie Rabbit "You and I"
Culture Club "Do You Really Want to Hurt Me?"
Duran Duran "Hungry Like the Wolf"
Phil Collins "You Can't Hurry Love"

Fast forward to Feb 2008 and I haven't heard of a single one of the top ten songs or most of the artists singing them. In fairness, the hipster in me is familiar with most of the music in the Americana Radio top ten, the "retirement home" for alternative music fans in the 1980's and early 1990's. I'll take this opportunity to plug Radio Paradise, the internet's best free streaming radio station.

My nostalgia for 1983 pop music got me to thinking
"What was going on in Plastic Surgery back then?".

Thru the archive online for our major journal, Plastic & Reconstructive Surgery, I was able to scan the "state of the state" of our field 25 years ago.

- One of the first articles on tummy tucks after gastric bypass (GBP) appeared. This was a little surprising to me as that GBP operation was fairly rare and people with experience in the plastic surgery after was uncommon. Interestingly many of the problems and concepts we act like we've just discovered were well described in that 25 year old article.

- A bunch of articles related to refinements in the traditional "open" (coronal) brow lift. The endoscopic brow lift wouldn't show up for almost another decade, whereupon the traditional operation was deemed obsolete, only to make a comeback in recent years as many have decided that "endo brows" do not last and when they do last it's in the least desirable place (the middle brow versus the lateral brow where people are complaining about). Modified open brows, incorporating lessons from the endo-brow experience, have made an impressive come back in recent years.

- The debate about whether immediate breast reconstruction after was either safe or feasible was being written about. At the time it was favorable to say that patients should "appreciate" their mastectomy defect as a rationale to do delayed reconstruction. Ugggggh! Talk about a paternalistic idea that hasn't aged well. We're actually having a related debate on more serious issues. A recent paper suggested that immediate reconstruction with either your own tissue or implants may decrease the beneficial effects of radiation (in patients requiring it) much more then previously suggested. If this hold up under scrutiny (and it may reflect how radiation therapists are failing proper technique more then the reconstruction) it could really decrease the number of women offered immediate reconstruction.

- A number of reconstructive pediatric urologic surgery procedures were still being talked about. This was a field that was really pioneered by early plastic surgeons generations ago. Since 1983 this whole area has really been abandoned by Plastic Surgery and is really almost now exclusively a Urology discipline. The last requirements for familiarity with these operation on our board certification exams were formally removed 2-3 years ago reflecting this

- Most humorously, an editorial by the chairman of an academic program frets about the ability of Plastic Surgery to attract qualified applicants compared to other surgical disciplines like cardiothoracic. That was a real swing and a miss 25 years later! Plastic Surgery is now indisputably the most competitive training pathway in all of medicine in the US while Cardiac Surgery struggles to fill 1/3 of it's training positions with US graduates.

Most striking to me of all changes is the change in editorial tone and professionalism of our flagship journal now versus then. Dr. Rod Rohrich from Dallas has been a tremendous leader in the upgrade in overall quality of articles included. With rare exception, you just don't see really dumb or inane topics thrown in in 2008.

I kid you not, in a Spring 1983 article there's a serious article "Decreased swimming speed following augmentation mammaplasty" and discussion of how breast augmentation theoretically affects the top end speed of a competitive swimmer complete with in depth mathematical hydrodynamic models.

Rob

Silicone-istas going batty over Newsweek breast implant story

If it wasn't so predictable it would be funny.

Newsweek magazine ran a vanilla story about breast implants called "Chest Right" which was an overview safety/educational guide for laypeople on some issues re. breast augmentation surgery. It's a very conservative piece and touches on a few important factors like choosing a qualified surgeon, complications, follow up, silicone vs. saline devices, etc.... It quotes the presidents of the two major Plastic Surgery organizations and one of the more well-known female Plastic Surgeons, all of whom are reputable and all of whom have extensive track records of championing patient safety issues. In summary, a very mainstream and respectful treatment of the issue.

Skip to the reader comments however, and you see breathless condemnation of the story by a number of the crusaders that populate the handful of web bulletin boards promoting the idea that a giant medical-industrial conspiracy exists to hide the truth from unsuspecting women about links of implants to every known medical condition and psychiatric disorder known to man. Readers of Plastic Surgery 101 know that there is pretty overwhelming international consensus that breast implants have been vindicated over and over in this regard in the medical literature (read here).

Now implants have their own issues, namely capsular contracture and surveillance for rupture, but we appear poised to make signifigant progress on these issues with the 5th generation form stable silicone implants seemingly poised for approval. Both the major manufacturers, Allergan & Mentor, have arranged for inservices this spring for their product reps on these devices. To me this suggests they've already heard thru the back channels that FDA approval is imminent and are getting ready for a new marketing push. You'd think with the improved performance data on these devices, the people upset over existing implants would be encouraging the FDA to act. On the contrary they're determined to push the FDA to rescind access to all breast implant devices (silicone and saline).

Rob

Does an Accolate a day keep the capsular contracture away?

Capsular contracture, an exaggerated hardening of the tissue around a foreign body, continues to be one of the most stubborn issues to stomp out with breast augmentation and reconstruction surgery. It's also been one of the most difficult things to study in a way that's useful because of a relative lack of a clear understanding of why it happens.

Forming a capsule is a normal physiologic process. It happens around everything your body doesn't recognize as "self" when it's implanted and is mediated by a well established interaction among signaling proteins on cell surfaces and your bodies immune system cells. When this process goes haywire, you get thickening and shortening of the capsule which can become painful and distort the shape of the breast.

There's a couple things we know clearly cause high rates of hard capsules with breast implants:

• post-operative hematoma


• infection around an implant


• a history of breast irradiation


• older silicone devices (1970's-19080's) with high rates of "gel bleed"


• rupture of silicone implants

What's more complex is trying to "reverse engineer" how to prevent capsules. Suggestions to reduce high grade capsule rates have included:

• textured implant surfaces


• placement of the implant underneath the pectoralis muscle


• polyurethane-coated implants


• antibiotic irrigation of the implants during insertion


• the use of contemporary "4th generation" implants with thicker "low bleed" shells and more cohesive fillers


• saline implants

The data on textured implants and position of the implant relative to the muscle have been somewhat mixed. At this point it's hard to definitively say that either make much difference long-term. Polyurethane foam works very well, but it's use in the US is likely DOA in the long-term due to liability issues over a (now debunked)risk of breast cancer. Antibiotic irrigation works well in the short-term, but it's not clear that it could affect capsular contracture years out from surgery.

It's been very interesting to see the performance of the "5th generation" silicone devices in published studies. These are the "gummy bear" implants which are semi-rigid and textured. Whether it's a synergistic effect or what is not clear, but these implants have dramatically lower rates of capsular issues almost a decade out. These devices appear to offer an improved solution to capsular (and rupture) issues and hopefully the FDA will give the green light sometime in 2008 for their US debut.

So what else do we have to offer?

There's a class of drugs used to treat asthma called leukotriene inhibitors (LTI) that has shown some promise in prevention or treatment. The two most common LTI's are Accolate and Singulair. Accolate has a small potential for liver problems and has mostly been avoided in favor of Singulair. Singulair was in the news as it's been alleged to cause suicidal ideation by people suing Merck. (How you prove a negative here is anyone's guess, but call me the skeptic.)

Anyway the genesis of this post was a study I saw in a European journal showing dramatic inhibition of capsule thickening in an animal model using zafirlukast (aka Accolate) which you can see view here). This is the first basic science model I've seen actually showing this idea of LTI's can work. This information gives us another option to discuss in the high risk capsule former which is good!

Rob

VA Voodoo Economics - Krugman wrong on John McCain

A few months ago I introduced some of the audience to the idea of "VA (Veteran's Administration System)logic". VA logic is the bizarre culture that has crept into the bureaucracy of the VA system that lead doctors who have trained or work in the VAMC system to shake their head when the system is held up as some paragon of universal health care.

While the VA system has America's only comprehensive electronic medical record system (which is a great thing), it has the world's most effective system of "nurses with clipboards" (NWC), non-clinical personal who walk around nagging everyone and serving little utility. Ironically, it's many VA employee's goal to be promoted to NWC/supervisor status because they get pay raises for doing less work then actually taking care of patients.

The VA system is much better benefits then no insurance at all or medicaid, but offers much less choice of providers or locations then a federal program like medicare. Veterans' reactions to the VA are very polarized in my experience. Some are very emotionally attached to the system, while others are resentful of the inconvenience of having to travel great distances and then having to suffer thru puzzling bureaucracy for appointments, consults, and surgery. My grandfather-in-law, a multiple purple heart & bronze star veteran from Iwo Jima & Guadalcanal in WW II, refuses to set foot in the VA even for free prescription benefits he'd be eligible for.

It is puzzling to imagine how building some parallel healthcare universe like the VA system is either cost-effective or sustainable. There already exists enough capacity in the "civilian" system to accommodate veterans without having to federally subsidize each and every VA hospital, clinic, & pharmacy. The federal benefits we're also covering for VA employees are also often much more generous then regular health systems.

I got thinking about this after reading the world's worst syndicated columnist, New York Times liberal Paul Krugman's column on "Voodoo Health Economics". Reading Paul Krugman columns regularly is like subjecting yourself to the cesspool of the Daily Kos (which I used to like BTW). Both have become so hyper-polarized with ideology they've ceased to be relevant.

He writes

As I’ve mentioned in past columns, the Veterans Health Administration is one of the few clear American success stories in the struggle to contain health care costs. Since it was reformed during the Clinton years, the V.A. has used the fact that it’s an integrated system — a system that takes long-term responsibility for its clients’ health — to deliver an impressive combination of high-quality care and low costs. It has also taken the lead in the use of information technology, which has both saved money and reduced medical errors.

Sure enough, Mr. McCain wants to privatize and, in effect, dismantle the V.A. Naturally, this destructive agenda comes wrapped in the flag: “America’s veterans have fought for our freedom,” says the McCain Web site. “We should give them freedom to choose to carry their V.A. dollars to a provider that gives them the timely care at high quality and in the best location.”

That’s a recipe for having healthy veterans drop out of the system, undermining its integrated nature and draining away resources.

I'd first like to offer a squid like Mr. Krugman the middle finger for disrespecting a man like John McCain.

On substance I could not agree more with Sen. McCain. We should be offering vets more flexibility rather then herding them into the VA system. How do you do that? You simply make them preferred Medicare enrollees which instantly give them access to any hospital (and potentially 90-95% of providers) they want. How do you guarantee the vets access? You sweeten the payment for this class of beneficiaries 3-5% above medicare rates or offer tax rebates for their care. Even that slim margin would start tremendous competition to serve that group. If vets are as happy with the VA as Krugman suggests, he should have to little to fear from offering them choice in the private sector, he's supposed to be an economist for chrizsake!

If Mr. Krugman was as savvy as he thought, he'd be encouraging something like this because Medicare is the front & back door towards the Universal Health Care system he's always ranting about. The more people enrolled, the greater the momentum it gets.

Rob