Sunday, January 24, 2010
The bane of existence for plastic surgeons who treat breast cancer is the deliverence of external beam radiation (XRT) after surgery. It creates a hostile environment in the tissue exacerbating stiffening of the skin and scar formation. Above all else, it is the most disruptive factor for getting good results from breast reconstruction surgery.
The negative experiences of plastic surgeons with XRT in this setting has produced the interesting survey results among us, that we would overwhelmingly suggest our spouse (or self in the case of women plastic surgeons) get a mastectomy instead of lumpectomy and XRT. Most women recieving mastectomy would not be suggested XRT except in rare instance involving more aggressive tumors, innvolvement of the chest wall, or extensive spread to the armpit (axillary) lymph nodes. In contrast, European physicians are much more likely to perscribe XRT to the chest and axillae. The practice patterns have to do with how the different countries interpret the same literature regarding this practice. IMO, the rationale Europeans emply to justify XRT is pretty sketchy and is hard to show much difference in outcomes.
On the front page of the New York Times today (click here) is an absolutely horrifying story on the frequent misdosing of patients recieving XRT in the NYC metro area entitled, "Radiation Offers New Cures, and Ways to Do Harm ". Some of the stories are jaw-dropping in how the series of events led to serious adverse events. It is absolutely incovievable that the delivery of XRT, a largely computer driven process, should be doing this. The number of radiation therapists, nurses, and techs who had to drop the ball or ignore clear warnings for these events to happen is staggering. Heads will roll in the Big Apple hospitals for this!
Monday, January 04, 2010
Since I last wrote, the Senate voted their version of the health care reform bill to consensus conference with the house. Even for Washington, the "sausage making" of this bill was pretty ugly. The naked bribes required to get Sen. Ben Nelson (D-NE) & Mary Landrieu's (D-LA) votes were particularly offensive, and quite possibly illegal (see here).
One story that is very symbolic but did not get much play in the media was the announcement that one of the Mayo Clinic satellites in Arizona would no longer see Medicare patients. Mayo is doing this because it lost $840 million last year on Medicare patients, and specifically it's Arizona hospital and four primary-care clinics lost over $120 million. No matter how efficient you are, that is unsustainable. It must be particularly embarrassing to Pres. Obama to see his "model" franchise for health care telling him to his face that he does not understand the effects of the legislation both he and his party are foisting on America.
To doctors in practice, it was always amusing to see the Mayo clinic proposed as a replicable model for our health care system. For starters they operate in a coccon on a largely wealthy, educated, and homogenous patient group. Even more ironic is the fact that the Mayo clinic doesn't even really take Medicare, but exists as a "non participant (non-par)" where they reserve the right to balance bill the patient for what they think their services are worth. From the Mayo website
"Mayo Clinic is a non-participating provider in the Medicare Program. We do not accept assignment on claims submitted to Part B Medicare except:
•where the law requires us to;
•in the case of documented financial hardship;
•when the supplemental insurance is a contract payer;
•when the patient resides in the state of Minnesota.
When claims are sent to Medicare on a non-assigned basis, the benefits for the services are sent directly to the patient. Mayo Clinic is entitled to bill the patient for the difference between our billed amount and Medicare's approved amount. We do not have to accept Medicare's approved amount as payment in full. Mayo Clinic limits its charges according to the limits set forth by HCFA for the Medicare program. Mayo hospital claims are sent assigned."
Expect to see real push back from providers at other places who treat these patients.