Monday, September 22, 2014

The $117,000 surgical assistant's fee

In a post a few months ago, I wondered why Medicare could not control its costs using the investigative power of the federal government instead of releasing physician payment data and relying on journalists to do the work.

Two stories that appeared within days of each other raise a similar question about the private insurance industry's methods.

An article in Modern Healthcare described the impending closure of the proton-beam therapy center at Indiana University, one of only 13 such facilities in the country. Proton-beam therapy, which is very expensive, has never been proven better than other types of treatment for prostate cancer.

Here's what Modern Healthcare had to say:

Blue Shield of California and Aetna last year said they would no longer cover proton therapy as a treatment for localized prostate cancer. Cigna Corp. does not cover proton-beam therapy in the treatment of prostate cancer either.

“I look at this closure as a sign that insurers are finally empowered to say this is a dubious medical technology” in the treatment of patients with prostate cancer, said Amitabh Chandra, director of health policy research at the Harvard Kennedy School of Government.


A couple of days later in the New York Times, a piece by Elisabeth Rosenthal related several anecdotes about patients who were saddled with large and unexpected bills from out-of-network physicians who were involved in their care.

A particularly egregious example was a $117,000 bill from the surgeon who assisted at a 3-hour cervical spine fusion operation. Just to put it in perspective, that's $39,000 per hour or $650 per minute—numbers a professional athlete might envy.

Although the procedure took place at a teaching hospital where residents are usually available to assist, the operative record apparently documented that no qualified resident was available.

The surgeon billed $133,000, but since he was in-network, he received only about $6,200.

Despite some pushback by the patient, the insurance company eventually paid the surgical assistant's $117,000 fee. If he's worth 19 times more than the operating surgeon, maybe he should be doing the operation instead of merely assisting.

Apparently this is not an isolated event. Quoting the Times, "J. Edward Neugebauer, chief litigation officer at Aetna, said the company had ... sued an in-network neurosurgeon on Long Island who always called in an out-of-network partner to assist, resulting in huge charges. The surgeons shared a business address."

The story in the Times related several other instances of insurance companies acquiescing and paying extremely high out-of-network charges.

If insurance companies can decide not to pay for proton-beam therapy, why do they agree to pay an assistant surgeon $650 per minute? I realize they didn't want to leave the patient holding the bag, but have they no recourse other than to pay?

On the home page of the Medical Society of the State of New York, its president responded to the Times piece by pointing out that New York's legislature just passed a law addressing surprise bills, and he correctly noted that some insurance companies do not pay in-network physicians enough to cover their expenses.

But he failed to acknowledge that many of the fees noted in the article are outrageous. Why not at least mention that issue? Doesn't he realize those fees make all doctors look bad?

Wednesday, September 17, 2014

Can Google Glass make you a better surgeon?

Advocates of Google Glass in surgery are apparently desperate to find some use for the device.

An article headlined "Google Glass makes doctors better surgeons, Stanford study shows" concluded that the study offered "compelling preliminary evidence that the head-mounted display can be used in a clinical setting to enhance situational awareness and patient safety."

Using an app capable of displaying vital signs on Google Glass in real time, 7 surgical residents recognized critical desaturation in simulated patients having procedures under conscious sedation 8.8 seconds faster than a control group of 7 residents relying on standard monitors. Glass-wearing residents also became aware of hypotension 10.5 seconds before the control group.

Not mentioned in the article but present in a linked abstract of the paper not yet submitted for peer review was this pearlneither difference was statistically significant.

This evidence is not that convincing. Even if the difference had been statistically significant, it is surely not clinically important.

How seeing vital signs on Google Glass is better than relying on the simple alarms that are built in to every monitor is not clear. Either way, you must stop the operation and look up to see the vital signs.

In a brief video accompanying the article, a surgeon can be seen rather clumsily activating and resetting the app on his Google Glass. The time required to perform these maneuvers apparently was not discussed.

The article, probable written directly from a press release, took a comedic turn with this sentence, "One test demanded that the resident perform a bronchoscopy, in which the surgeon makes an incision in the patient’s throat to access a blocked airway." But bronchoscopy does not involve making an incision in the throat or anywhere else.

If you would like to hear a different side of the Google Glass story, check out this video review from GeekBeatTV entitled "Google Glass is the worst product of all time." You can forward to the 3:45 mark to get past the woes of wearing prescription glasses with Google Glass and hear about the poor battery life, the balky commands, the system crashes, and more.

Tuesday, September 16, 2014

Aortic dissection leads to man's death in the ED: His wife's perspective

A woman wrote to me about the day her husband died. I have edited her email for length and clarity and changed some insignificant details to protect her anonymity as she requested.

Joe passed away outside in the parking lot while they were getting on a helicopter for transport to a hospital equipped to do his surgery.

He had presented to the ED in terrible pain with lots of thrashing and writhing. His right hand was very cold. His right arm tingled to the point of hurting bad. The vision in his right eye was cloudy, and his hearing was muffled on the right. This was in addition to being very pale and diaphoretic upon admission. This is when I felt a dissecting aorta should have been suspected.

I don’t recall the vitals in the beginning, but they were changing and his blood pressure was dropping very fast. As soon as they finished the EKG-in the first 5 minutes of the visit, I asked the doctor about John Ritter's death [the actor died of a dissecting thoracic aneurysm in 2003]. First I asked if he could check for the condition that caused John Ritter's death. I called it an abdominal aortic aneurysm. The doc corrected me and said that it wasn’t an AAA it was a dissected aorta. I said OK, then check for that. This was 1 hour before the CT scan that led to his diagnosis.

Thursday, September 11, 2014

More ratings—this time it's residency programs

Can you really decide which surgical residency program is right for you using Doximity's Residency Navigator?

I don't think so, and here's why.

The rankings of residency programs were obtained by surveying surgeon members of Doximity. They were asked name the five top programs for clinical surgery training. When the survey was announced in June, I predicted that most respondents would probably overlook the word "clinical" and focus on the usual famous academic institutions.

I also pointed out that anyone not intimately familiar with a program would be unable to judge whether it is good or not and suggested that reputation would be the main driver of results.

In fact, that is exactly what happened. Of the top 40 programs listed, all are based at university hospitals, as are 66 of the top 70. Back in June, I speculated about the top five programs and got the first two correct but in the wrong order.

A 2012 survey of surgical residents with over 4200 responders (an 80% response rate) found that community hospital trainees were significantly more satisfied with their operative experience and less likely to worry about practicing independently after graduation. Wouldn't you then expect a few community hospital programs to be among the top 40 hospitals for clinical surgery training?

Proof that the survey's findings are not reliable is that every one of the 253 surgical residency programs in the country was mentioned by one or more of those who responded. This included one program that has been terminated by the Residency Review Committee for Surgery. At least it appears near the bottom of the list.

The number of voters who cited the lower ranking programs must have been very few, meaning the difference between the 200th and 240th program ranks is probably not statistically significant.

Some programs that were rated are so new that very few or no residents have graduated yet. How could anyone know if they are turning out competent clinical surgeons?

Board passage rates for programs, which are available online, were omitted for some and were not clearly identified as the percentage of residents who passed both parts of the boards on the first attempt only.

The percentile rankings of alumni peer-reviewed articles, grants, and clinical trials are displayed prominently. What do those data have to do with the research question—which residency programs "offer the best clinical training"?

So what's the bottom line?

You can put the Doximity Resident Navigator in with the other misleading ratings of hospitals and doctors. Applicants considering surgical residencies should not rely on it for guidance.

It has warmed the hearts of faculty and residents at highly rated programs, but I wonder how the OR lounge discussions are going at places where programs ranked lower than expected.


Tuesday, September 9, 2014

From the trenches: More about grit

The following was compiled from two comments on my recent post about grit written by a doctor who calls himself "Geronimo." It is reproduced with permission.

Grit cannot be assessed by a survey. I wholly agree. As a military physician, my firmly founded opinion is that grit is essential to the practice of medicine. Grit is the elusive characteristic that carries the clinician through the challenges that exceed ordinary capabilities. You cite a paper that argues for surgical training to borrow aspects of SEAL training. I applaud any measure that would allow senior faculty and program directors to unilaterally shape their residents’ training, whether or not it bears any resemblance to the rigors of BUD/S [Basic Underwater Demolition/SEAL training].

The 2011 loss of 30-hour call for medical students and interns was a fatal blow to residency training, in my estimation. I count myself fortunate for having a 30 hour call internship before embarking on my operational career. While downrange, it is not at all uncommon to be woken at inconvenient hours of the night to tend to the wounds of war. If you don’t know how you function cognitively, physically, psychologically, and emotionally while sleep deprived, exhausted, hungry, cold, and pissed off, you’re behind the curve. While it isn’t any fun to work in such a state, or to work with people so challenged, it is decidedly less fun to be a patient expiring for want of any medical provider, let alone a tired one. American medicine used to be in such a place in the not so recent past, to hear the story told by my forbearers.

Monday, September 8, 2014

Chance can turn a surgeon into a killer

Risk-adjusted 30- to 90-day outcome data for selected types of operations done by specific surgeons and hospitals are now being publicly posted online by England's National Health Service.

According to the site, "Any hospital or consultant [attending surgeon in the UK] identified as an outlier will be investigated and action taken to improve data quality and/or patient care."

After cardiac surgery outcomes data were made public in New York, some interesting unexpected consequences were noted.

Surgeons and hospitals resorted to "gaming the system" by declining to operate on patients who were high-risk and tinkering with patient charts to make those they did operate on seem sicker. This can be done by scouring the charts for all co-morbidities and making sure none are overlooked when they are coded. An article from New York Magazine explains it in more detail.

Interpreting outcomes data can be tricky.

In a post three years ago about a report that nine Maryland hospitals had higher-than-average complication rates, I pointed out that whenever you have averages, some hospitals are going to be worse than average unless all hospitals perform exactly the same way or, like medical students, are all above average.

A much more sophisticated way of looking at this subject appeared in a fascinating 2010 BBC News piece by Michael Blastland, who is the Nate Silver of England [or maybe Nate Silver is the Michael Blastland of the US], called "Can chance make you a killer?"

Blastland set up a statistical chance calculator for a hypothetical set of 100 hospitals or 100 surgeons performing 100 operations each. The model assumes that every patient has the same chance of dying and that every surgeon is equally competent. The standard is that a mortality rate 60% worse than the norm set by the government for any hospital or surgeon is not acceptable.

You are assigned one hospital. Using a slider, you may choose an operative mortality rate anywhere from 1% to 15%. After you do this a number of times and recalculate for each mortality rate, you will notice that the number of unacceptably performing hospitals or surgeons changes randomly for each percent mortality and your hospital may appear in the underperforming group strictly by chance alone.

The whole concept is explained in more detail on the site. I encourage you to try it for yourself. The link is here.

So it may be difficult for the NHS to separate the true outliers from the unlucky surgeons who happened to fall outside the established norms.

What do you think about this?

Wednesday, September 3, 2014

Health Care and the $20,000 Bruise: A different take

Twitter is buzzing about yet another medical billing horror story. This one appeared in the Wall Street Journal and was written by Eric Michael David who is an MD PhD JD and an officer at a biotech company.

He saw a large, swollen bruise on his three-year-old son's head several days after falling off his scooter. Other than the bruise, no other abnormalities were mentioned. He took the boy to "one of the top pediatric emergency rooms in the country" to have a CT scan done. It showed "a small, 11-day-old bleed inside his head, which was healing, and insignificant."

Dr. David received a bill for $20,000, $17,000 of which had been paid by his insurance company. He was responsible for the remaining $3000.

He noted a $10,000 charge for a trauma team activation which he said never happened. After a lengthy series of exchanges with the hospital's billing department and Dr. David having to prove that a trauma team activation was unwarranted and not permitted by certain regulations, he was able to have the charge rescinded.

The essay went on for some 1200 words listing the steps that he went through. He correctly described what a mess American healthcare delivery is and why as long as overuse and upcoding are rewarded, the Affordable Care Act will not fix it.

Dr. David was right to contest the $10,000 charge for a trauma team activation that wasn't indicated and didn't even occur.

What he didn't address was this.

Why would a doctor who said that he had "served on trauma teams in two of the busiest hospitals in New York City" feel the need to take his apparently asymptomatic son with an 11-day-old injury to an emergency room for a CT scan?

Doesn't this imply overuse of a different type?

Secondary questions:

Did anyone bring up the issue of radiation from the CT scan?
Did the docs in the ED think a CT scan was necessary?
"Inside his head" is a rather odd phrase. Does it mean intracranial? Intracerebral?
Was "one of the top pediatric emergency rooms in the country" the only option or could this asymptomatic boy have been seen in a doctor's office?
Why is the charge for a trauma team activation $10,000?