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.

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USA Today Revisits Medspa Plastic Surgery

English: Facial Plastic Surgeon Amir Karam, MD...

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.

EMR-Wars: Attack of the Clones

Cloning

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 Clin...

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.

Streptococcal Sepsis: Rare But Dangerous

The tragic story of Rory Staunton received national attention, as well as scrutiny on physician-only discussion boards.  To recap, this otherwise healthy 12 yr-old suffered a seemingly innocent arm scrape playing basketball.  He soon felt ill and was seen the next day by his pediatrician, who referred him to the ED.  There he was rehydrated and discharged.  He did not improve.  When he returned, now gravely ill, he was hospitalized but succumbed to sepsis.

This is a tragic and unsettling story for several reasons.  Simply put, we live in a world of bacteria.  Any time a small injury occurs; there is a very small but real chance of a serious infection developing, should the body’s initial immune-system defenders fail in their job.

The bacteria at issue here were once far more feared.  In the pre-antibiotic era, this infection was very often lethal.  It was staphylococcal sepsis that in 1924 killed Calvin Coolidge Jr., son of the then-President.  Today in otherwise healthy people, it is very treatable, except in unusual circumstances.

As a disclaimer, Monday morning quarterbacking is not science.  Any commentary by those who did not directly participate in the events is speculative and based only upon whatever information is publicly available.

From the coverage and board discussion of the events, it appeared that when the child presented to the pediatrician, he was felt to have dehydration and gastrointestinal distress.  That seems a reasonable initial impression.  After all, hoofbeats usually mean a horse, and not a zebra.  Referral to the ED made sense if he was felt to require significant rehydration.

Diagnosing streptococcal sepsis at this stage would have been hard, and the far more likely diagnosis was presumed.  But, the appearance of the arm was suspicious.  Usually, people with such wounds are covered with antibiotics if the wounds require suturing, or if not sutured, coverage might be prescribed if any redness or surrounding cellulitis is seen.

In cases such as this, it usually takes more than one missed opportunity to have the outcome turn tragic.

At the ED, reports describe difficulty standing and walking, fever, and a pulse of 140.  That sounds fairly ill to me.  On the discussion boards, Emergency specialists sparred with surgeons over whether this is a typical appearance commonly seen with dehydrated kids.  I have to side with my surgeon-colleagues who said that it should have been apparent that something was really wrong with the young man.

The most concerning thing about the ED visit was the discharge without checking the blood work.  Rory had a significantly elevated white count with a major left shift.  That strongly suggests a systemic infection.  It is this point for me that is the most concerning, and one that deserves more scrutiny.  Were the labs forgotten?  Was it presumed that they were probably normal and therefore not an issue? Did someone read the wrong lab report?

The public expects a medical system incapable of error or untoward outcome.   But before blame is assigned, questions need to be answered.

Was this a system problem or an individual problem?  How busy was the pediatrician’s office?  Were they distracted by the non-medical minutiae required to practice medicine today?  Was the ED awash in non-emergent cases and understaffed?  Did the report get lost or mislabeled?

Cases such as this tend to result in calls for more rules, more scripted procedures, and more ways to try to perfect an imperfect system.  But sometimes the answer is not to add complexity to the process of undertaking a clinical encounter, but to simplify it.  In this case, just be sure to take a look at the big picture, and don’t forget to check the labs.

And sometimes the hoofbeats really are from a zebra.

Comments on “10 Cosmetic Procedures You Should Avoid”

English: Facial Plastic Surgeon Amir Karam, MD...

English: Facial Plastic Surgeon Amir Karam, MD harvesting fat from patient’s abdomen for facial fat transfer procedure. (Photo credit: Wikipedia)

ABC ran a quality piece on certain cosmetic procedures to avoid, listing 10 problematic cosmetic procedures.   Most of their discussion is right on target, but there are a few of these that may not be as bad as described.  Here is the complete list with three underlined procedures and a discussion of each and why they may not be as bad as portrayed.

1  Fat dissolving injections

2 Cosmetic foot surgery

3 Permanent filler injections

Injection for breast augmentation 

Cosmetic leg lengthening surgery

6  Buttock implants

7  Tatooed makeup

8  Extreme facial procedures

Combination mastopexy/breast implant

10 Any procedure by untrained hands

Injection for breast augmentation

The concern here is that augmenting the breasts with fat will somehow disguise the diagnosis of breast cancer.  The reality is that nobody really knows this.  It is very possible that calcifications from fat necrosis – possible after transferring fat to the breasts – will look different from the microcalcifications radiologists seek on mammograms.  In selected people with proper anatomy (relatively non-droopy breasts, and enough fat for transfer), fat transfer could be a great alternative for a natural look and feel without the problems associated with implants.  More research is needed.  Due to the risk of lawsuits, most American surgeons will follow the lead from foreign surgeons once they get better at this procedure.

Cosmetic leg lengthening surgery

Admittedly, saying this procedure should not be avoided is a stretch (pun intended).  Major complications, such as amputation and death, are possible.  Though orthopedic surgery is not a cosmetic field, the principles of bone-distraction developed from trauma reconstruction can be applied for cosmetic use.  Few surgeons do this procedure, but one is right here in South Florida.  Dr. Dror Paley was highlighted on ABC’s 20/20 several months ago, and he does hundreds of these procedures per year, some for cosmetic indications.   That being said, anyone considering this should do deep research due to the magnitude of the procedure.

Combination mastopexy/breast implant

The article correctly notes that these two operations somewhat counteract one another.  But that is not a sufficient reason to rule it out entirely.  Surgeons in competitive markets are at a disadvantage if they are not able or willing to do a mastopexy/augmentation.  Many patients do not want to stage the procedure, and will go to other surgeons who can do it in a single stage.

Admittedly, if the breasts are very large or very droopy and the patient wants a large augmentation, staging is preferred and sometimes necessary.  But for more moderate requests, this procedure can be done safely and effectively in the right patient and by the right surgeon.

The Facts About Abdominoplasty Combination Procedures

Abdominoplasty is a cosmetic operation that is...

A recent report discusses the apparent safety of combining abdominoplasty (tummy tuck) with hysterectomy.  The abstract is available on page 30 of the PDF here.

The authors retrospectively studied 65 cases of combined abdominoplasty and hysterectomy (the number of abdominal vs. vaginal hysterectomies is not mentioned, which is an important distinction).

The authors note a 32% overall complication rate, but state there were “no major complications…” they conclude that the combination procedure is safe and effective.  But is this accurate?

It is not a randomized study, though performing such a study is impractical.

Commentary by Dr. Sherrell Aston correctly points out that a transfusion is not a minor complication.

A combination procedure that results in blood loss sufficient to warrant blood replacement is a significant operation.  The specific indications for transfusion are not given, and it is possible more liberal criteria were used in the earlier years over the study’s range (1995-2011).  Even so, it is rare to need a blood transfusion in cosmetic surgery.  Most prudent surgeons would stage procedures that might result in the need for transfusion, such as substantial skin reduction surgeries following massive weight loss.

Below I present a sampling of various studies that have examined the combination of abdominoplasty with other intra-abdominal procedures over the last few decades.   Rather than going through all the details here, I will summarize them  below.  Click here for each full reference.

The data shows that abdominoplasty combined with hysterectomy or other major procedure can be safe and effective.  However, complication rates may be higher than with either procedure alone.  It is difficult to be certain because most studies are retrospective.

Complication rates for combination procedures approach 30%.  The risk of major complications such as transfusion or pulmonary embolism may have decreased in recent years, perhaps due to better preventive methods and tighter indications for transfusion.  Obesity is one of the main risk factors for complications.

Patients interested in undergoing a combination procedure should carefully consider their options as well as the experience of their surgeon(s).

Combination procedures may offer advantages of lower cost and shorter overall recovery time.  The chance of complications may vary between surgeons of differing experience, and patients who are obese or have significant medical problems can have a higher risk of perioperative problems.