Social Media Reunites Injured Soldier, Doctor Who Restored Sight

You didn’t know I helped restore sight to a blinded soldier?  Read on… (Photo credit: Wikipedia)

In January, former Beth Israel Deaconess CEO Paul Levy posted a story on his blog regarding Boaz Weinstein, a then 20-yr old Israeli soldier blinded by shrapnel in 1973.  He was taken to a hospital and operated upon by an English-speaking female surgeon who restored his sight.  He slipped out of the hospital and rejoined the battle, but did not recall the identity of the doctor who had treated him.

The original post is here.

Many readers of Mr. Levy’s blog put forth efforts to aid in the search, sending out tweets and blog posts.  I tried to help as well, passing the story to a senior trauma surgeon and getting input from other specialists.  One theory was the surgeon had been an ophthalmology resident at a northeastern U.S. training program.

In fact, the mystery surgeon was English-speaking Russian doctor Luba Vainshel, who embarked upon a new life in Israel in 1972, as Mr. Levy revealed today.

The story is fascinating and has a happy ending.  Both surgeon and former patient live within 40 miles of one another, and recently met after the story made its way to an Israeli newspaper.

I recommend reading both posts above as the story is engaging.  The doctor in question was allowed to exit Russia in partial exchange for Henry Kissinger arranging to supply the Soviets with food following a bad wheat harvest in 1972.  (Command economies have difficulty feeding their own populations, a topic all its own).

Robotic Surgery: Hospitals Absorb Costs to Gain Market Share

Robotic Heart Surgery Billboard (Photo credit: Marshall Astor – Food Fetishist)

Barron’s recently profiled Intuitive Surgical, maker of the da Vinci Surgical System.  The article was standard high quality work characteristic of the publication.  (Though today’s focus is not on investment quality, the phrase  “120 inch trocar” comes to mind when considering a company trading at twice the market multiple in an environment of slowing growth).

Robotic surgery is an important innovation, but has not yet proven to be a game-changing technology.  Though fascinating and impressive, robotic surgery hasn’t duplicated the impact seen in the laparoscopic revolution.

When laparoscopy emerged, gallbladder removal with a big incision and days in the hospital was replaced with several small cuts and an overnight stay; with a clearly shorter recovery (albeit with an increase in duct injuries until the procedure was mastered).  Other operations were soon improved using laparoscopy, with shorter hospital stays and lower complications.

The benefits of robot-assisted prostatectomies and hysterectomies continue to be debated by researchers.  But the technology is here, and it factors prominently in hospitals’ marketing efforts and clinical programs.

Robotic surgery has higher costs, roughly $2000 per case, but this is not paid by government or private insurers.   The costs are borne by hospitals, which hope to recoup them via capturing additional market share both in the robotic clinical areas as well as additional ones via increased exposure. Institutional reputations may improve with public perception as a high-tech clinical destination.

Right or wrong, the public tends to equate higher-technology care with better care, and it is generally easier to embrace this concept (get the robot) than try and resist and wait for research-proven superiority to be determined.  Residency programs also face a recruiting disadvantage without the latest technology.

Even in freer market areas such as cosmetic surgery, higher-tech is preferred to lower-tech – laser liposuction is a recent example, despite unproven benefits.  So even if patients paid the marginal cost of robotic surgery, it would still be opted for in most cases.

Despite hospitals absorbing the additional cost of robotic surgery, those capturing additional market share have not yet demonstrated lower costs.  And in the distorted healthcare market, such reductions are not likely to be seen unless hospitals are pressured by competitors, patients shoulder more of the cost, or payors take action (with the latter often the least-effective).

In taking on the additional cost of robotic surgery, hospitals assume some degree of risk and participate in another area of technological competition, the so-called ‘medical arms race’.  Should the additional costs not produce the desired results, other clinical programs and staff may bear the fallout.  But with additional clinical areas to be explored, it seems a reasonable risk.  If eventually the robot demonstrates open-to-laparoscopic-gallbladder improvement in some clinical area, it will be well worth it.

Read the Barron’s recent profile here.

Related articles

• Serious injuries from the Da Vinci Surgical System(ROBOTIC) (patientharmreportingproject.com)
• Public invited “test drive” da Vinci robotic surgeon at New Bedford hospital (tauntongazette.com)
• Intuitive Surgical Leads The Pack In Robotic Surgery (seekingalpha.com)

Remembering Transplant Pioneer Joseph Murray

At the end of every year, we recall the notable people who have departed our worldly domain.  Naturally, most are entertainers, political figures and other luminaries.  We should also highlight noted personalities in the sciences.  Before the first week of 2013 is past, recall one of the most noted individuals to pass in 2012 – an important figure who hailed from the scientific and medical arena.

Joseph Murray M.D. died on November 26, 2012, and though he may not be a household name, he was one of the most accomplished plastic surgeons in history, and one of the major figures in 20^th century medicine.

Dr. Murray was the first surgeon to perform a solid-organ transplant when on December 23, 1954; he transplanted the kidney of Ronald Herrick into his identical-twin brother Richard, who suffered from end-stage renal disease.  The procedure ushered in the contemporary era of transplantation, and from this accomplishment Dr. Murray shared the 1990 Nobel Prize in physiology or medicine.

Today’s medical world is a bit different from the one in which Dr. Murray came of age and made his mark on medical history.  Laypersons may be surprised to learn that a plastic surgeon performed the first kidney transplant.  But in that era plastic surgery encompassed a wide domain, and surgeons could develop expertise in their areas of interest.  Dr. Murray became interested in transplantation after noting rejection patterns of skin grafts from unrelated donors during his work treating soldiers injured in World War II.

At this time, specialties developed based on advances in physiology allowing work that was previously not feasible.  Advances in anesthesia and critical care allowed bigger and bolder interventions to be attempted and accomplished.  The first kidney transplant was followed by refinements in technique, a better understanding of immunology, and an expansion of acceptable donor and recipient criteria.

Further advances led to success in liver, heart, heart-lung and other types of transplant procedures.  The early kidney procedures involved identical twins, avoiding the problem of organ rejection.  While developing the technical aspects of transplant surgery was critical, wider application came from better understanding of transplant immunology, which Dr. Murray helped lead.

Today transplantation of kidneys and other organs is commonplace.  That is largely due to the efforts of Dr. Murray and others in this developing field.  Science advances one step at a time, and in the field of transplantation many of those steps led to and from the work of Joseph Murray.

Related articles

• Dr. Joseph E. Murray, Transplant Doctor and Nobel Winner, Dies at 93 (nytimes.com)

Preventing Another Sandy Hook

The senseless Newtown massacre has saddened the nation.  The loss of so many children among the victims is even more heartbreaking.  Over the coming weeks, we will hear about possible ways to reduce the risk of future tragedies.  How much security can be reasonably added to schools?  What is the proper amount of gun control and oversight?  Can mental health care be improved enough to reach these troubled people before they become killers?
More restrictive gun access should make it less likely that someone can commit a mass killing with a firearm.  But this does not prevent deranged individuals from causing great harm by other means.

This horrible event was caused by a severely impaired person.   The available information does not suggest he harbored previous violent tendencies.  In a sense, this means we need to detect brain failure with enough accuracy so that intervention can be done in enough time.  Unlike other organs, the brain does not always give early or obvious signs that something is terribly wrong until too late.

Doubtless every move the killer made leading to this event will be scrutinized.  It remains to be seen if any predictive pattern can be found, and if so how such information could be used.  Will it ever be possible to data-mine as a means of discovering these dangerous people, and if so what are the implications for civil liberties and society?

Even more disturbing is that this took place in Connecticut, my native state and a place where nothing much ever seemed to happen, and if it did, it was a big deal.  The “Land of Steady Habits” after all, is the place where liquor stores still close at 8:00 PM thanks to a crime spree in the 1950’s.   Now, the state has found itself in the headlines far too often, with Sandy Hook by far the worst event in recent memory.

Policymakers should engage mental health leaders to help them shape an appropriate response to this tragedy.  Although gun access cannot be ignored, unlocking the mysteries of the diseased mind is more likely to reduce the chances of such future events.

Related articles

• President Obama: ‘These tragedies must end. And to end them, we must change.’ (dailykos.com)
• Does US need gun control or better mental health services? (theweek.co.uk)

USA Today Revisits Medspa Plastic Surgery

USA Today covered cosmetic surgery at medspas, and by non-plastic surgeons.  This is a topic that has been covered before, and bears revisiting with the following points.

As long as doctors have difficulty earning a reasonable return in their core specialties, they will continue to move into other areas of practice.

Non-surgical doctors don’t really plan to one day pretend to practice cosmetic surgery – at least they didn’t used to.  But faced with non-market determined administered fee schedules and market-based overhead, some have little choice but to attempt to escape their situation, and cash-based cosmetic procedures are one way to do that.

Rules on which type of doctor can do what type of procedure may be helpful, but can be abused.

Some plastic surgeons like to think they should have divine purview over the realm of cosmetic surgery.  Being a plastic surgeon, I would benefit from such an arrangement.  But it is not realistic and it is not ultimately in the best interest of consumers.  Innovation and competition stem from intrusive forces, and as long as practitioners have the appropriate core skills to learn new areas of practice, stopping these does not make sense.  Economic credentialing can be abused in the insurance-based as well as cosmetic areas.

Similarly, regulation of surgery facilities is reasonable for deep sedation, general anesthesia or large-volume liposuction.  Facilities performing straightforward procedures under local anesthesia should be able to adhere to general good-practice standards without complex regulatory burdens.  It is more important that the procedures performed are within the general scope of competence of those performing them.

Patients need to do homework to determine who should be treating them.

Some procedures are easier to learn than others; a cardiac surgeon and an ophthalmologist can both safely inject Botox.  (Do not forget ophthalmologists pioneered it).  But a patient who has a chest surgeon fix his detached retina and an eye doctor replace his aortic valve will likely end up blind and then dead.  To some degree, regulatory boards and the need for hospital privileges can halt such practice drift far outside core areas of training, but they cannot and should not halt any practice migration.  This is not in the best evolutionary interests of medical practice.  There are appropriate and safe methods of expanding one’s practice area.  Regulatory bodies should see to it that they are adhered to with patient safety as the primary concern.

Concerning the patient in the article, it seems fairly obvious that a nine-hour fat transfer is well beyond the typical duration for this surgery.  Compartment syndrome is a known complication of fat transfer surgery, but the risk can be reduced by avoiding over-injection, especially in the lower buttock.  Hopefully she will make a substantial recovery.

Related articles

• Health: MedSpas Explode In Popularity, But Are They Safe? (philadelphia.cbslocal.com)
• Cosmetic surgery laws often aren’t enough (usatoday.com)

EMR-Wars: Attack of the Clones

Cloning (Photo credit: borkweb)

A warning-shot from Medicare has advised healthcare providers that “cloned” medical records notes will result in payment denials, and the Dept. of Health and Human Services stated that billing fraud will be “vigorously prosecuted”.

This is in response to recent news coverage noting that Electronic Medical Records* (EMRs) have made it easier to “upcode”; that is to bill a visit for a higher payment level than might be done without an EMR in use.

Healthcare gurus know that Electronic Medical Records  are one of the latest discussion points.  People cannot believe that something as complex as healthcare can be delivered safely and effectively with dead-tree media products.  It can and it is.    However, the march of technology is and should always be ever upward.  So EMRs will one day become ubiquitous.

But why are visits “upcoded” with an EMR?  It is because mandated documentation requirements – externally imposed on the profession by third party payors- result in long notes simply to check off bullet points required to receive a certain payment level.   Doing this electronically isn’t difficult with an EMR; but the clinical encounter and workflow take longer.  So naturally it makes sense to bill the visit at the highest level justified by the documentation and severity of the clinical problem.  That is not fraud.

The trouble with EMRs has been well-documented by many authors, including myself.  Remember that EMRs were not something the profession needed to make clinical functions smoother or easier.  If it did, the systems would be fast and easy to use and would enhance clinical workflow, much like most electronic systems do in purely commercial settings like restaurants.

Rather, this was an external imposition by those who purport to know how to fix healthcare.  Keep in mind that small, simple practices don’t need fancy electronic record systems, and entities that do such as large integrated institutions or big clinical practices, very often have them.

So what is a cloned note and how is it fraud?  Cloned notes are copies of earlier notes used on subsequent visits.  Is that really a big deal?  Most of the notes for a traditional medical practice that bills insurance contain a lot of information to satisfy billing points as noted above.    Most of it never changes from visit to visit, such as family history, past surgeries, etc.  So a simple solution is to have the patient check their prior information at each new visit and add anything new or changed.  The clinician then reviews this and makes alternations to the old note before finalizing the new note.  Why re-create all that material?

Fraud is something different.  That involves billing for things that were not done, or making up information.

The larger issue here is the inherent conflicts in third-party payor healthcare.   The clinician needs to satisfy the documentation requirements in order to receive any payment.  The required documentation is often more than what is really needed.  So clinicians look for ways to make this process easier.

As long as cloned notes are updated and reviewed before being finalized, they should be considered acceptable   Cloning is a good example of an unintended but predictable consequence of mandated use of cumbersome EMRs.

But confusing this with fraud is a different matter, and should not be allowed to lead to unwarranted disciplinary actions.

And I’ve never seen anyone clone a note with pen and paper

*-For simplicity the differences between Electronic Health Records (EHR) and EMR is ignored in this post.

Fingertip Injury Points Out Emergency Care Billing Conundrum

The emergency department entrance at Mayo Clinic’s Saint Marys Hospital. (Photo credit: Wikipedia)

A recent case from Dayton, OH highlights the tangled mess of emergency department specialty coverage, federal law, and out-of-network insurance benefits.  When these interact, patients, doctors, insurers and hospitals can be left frustrated and perplexed.

Here’s a brief summary:

A 6 yr old boy suffered a fingertip injury and the emergency staff called the covering plastic surgeon, who repaired the injury.  The surgeon, who does not participate with insurance, submitted a bill for approximately $8000.  The insurance company paid 80% of what it determined to be usual and customary charges, leaving the family the remainder, approximately $6000.  They were unaware the surgeon was out-of-network.  The hospital later changed call coverage, contracting with another group that accepts all insurances.

This case illustrates how current on-call realities can fail all four parties:  patients, hospitals, insurers, and on-call doctors.

First, a few preliminary facts:

• The Emergency Medical Treatment and Active Labor Act (EMTALA) applies to hospitals accepting federal funds.  It does not allow for a discussion of financial considerations prior to rendering care.  (It is less clear whether this applies to independent physicians or just the hospital).
• Doctors in private practice are not required to participate with insurance, and do not work for the hospital.
• Hospitals often do not pay for on-call coverage.  Some hospitals may have other sources of funding for serving the uninsured, but such arrangements may not apply to the covering doctors.
• Insurers may send payment directly to patients for out-of-network care.  When this happens, doctors try to recover from the patient, often receiving nothing.
• On-call doctors summoned by the Emergency Department cannot refuse, and as noted above can’t discuss financial considerations, such as their insurance participation status.
• In specialties such as plastic surgery, on-call doctors are sometimes called in for non-emergencies.

When these factors intersect as in this case, there can be confusion and finger-pointing.  The doctor may be upset at being inappropriately called (not so in this case), or not paid.  Patients may be surprised by a large bill despite having insurance.  Hospitals risk a public-relations problem if patients complain.  Insurers limit their out-of-network liabilities or risk being overcharged.  All of these positions have some validity.

The essence of the problem is not the Emergency Department’s behavior, the out-of-network status of the doctor, or the insurance company’s payment policy.

The problem is that under EMTALA, care is mandated but payment is not, and no cost discussions are permitted.  Hospitals and doctors know this, but all too often nothing is done to plan for the inevitable misunderstandings.

The solution lies with hospital executives meeting with each specialty, and figuring out how get patients the emergency care they need, that specialists are available and billing surprises do not occur.  There are many options, such as paying for call, providing for payment if patients are uninsured, or an agreement that there will be a limiting charge in emergency situations.  Some hospitals may decide that hiring specialists meets their needs.   Plenty of options are possible though they need vetting for legal correctness.

As the healthcare delivery system evolves, creative on-call solutions may be required.  What works in one community may not be optimal for another.  But with an open approach, and all stakeholders working together, collaborative solutions are possible.

Related articles

• ER overcrowding hurts minorities in California (eurekalert.org)
• Children’s Hospital Boston testing three innovative telemedicine pilots (medcitynews.com)
• Health Insurance Definitions: What the Terms Mean (health.usnews.com)