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Tuesday, June 2, 2015
Not Runnning a Hospital
Paul Levy is one of my favorite reads....and he loves alpacas His most recent post deserves some commentary, and for what it is worth..my history pre-dates his somewhat and all I can observe is that nothing seems to change...at all.
Robert Pear at the New York Times offers an excellent summary of findings by the General Accountability Office that the procedure used by the Medicare agency (CMS) to determine the relative weightings for $70 billion physician payments has major flaws. That CMS weighting is also used by most private insurance companies as the basis for physician payments. This is a topic that has received coverage over the years, but little has changed.
(A pause here to ask and refer back to a previous post: When was the last time you heard one of the Triple Aim advocates—inside or outside of CMS--take on this issue, which has a direct result in how much primary care doctors and other cognitive specialists get paid?)
But, there is an important reminder in this story. Pear notes (with my emphasis added):
“Under federal law, Medicare fees are supposed to reflect the time required to perform a service and the intensity of the work.”
Uh oh. Let’s consider how the pervasive use of robotic surgery will factor into this calculation. For example, in the past, most prostatectomies would have been done as open procedures or using a manual laparoscopic approach.
Now, due to a highly successful marketing campaign by Intuitive Surgical and by doctors and hospitals that have showcased their robotic surgery program, the vast majority of these cases are performed robotically. This has increased the required time in the operating rooms.
The same applies to other procedures in which Intuitive has made and will make inroads—gall bladder removal, hysterectomies, hernia repairs, and so on.
Is this a back-door way for surgeons to receive more money for the same procedures?
Medical Device companies repeatedly create this type of disruptive innovation, created by an innovative medical bioengineer, and quietly pass along the problem to the MD who becomes the evil-doer. In this case the increase in time due to the complexity of the surgery requiring significant expense purchasing the equipment retraining and other hidden costs should be adjusted upward.
A newer approach is to do the laparoscopic surgery using a robotic interface (called the da Vinci system), which is known as robotic-assisted laparoscopic radical prostatectomy (RALRP). The surgeon sits at a panel near the operating table and controls robotic arms to do the operation through several small incisions in the patient’s abdomen.
Like direct LRP, RALRP has advantages over the open approach in terms of pain, blood loss, and recovery time. So far though, there seems to be little difference between robotic and direct LRP for the patient.
In terms of the side effects men are most concerned about, such as urinary or erection problems (described below), there does not seem to be a difference between robotic-assisted LRP and other approaches to prostatectomy.
For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard LRP. Still, the most important factor in the success of either type of LRP is the surgeon’s experience and skill.
If you are thinking about treatment with either type of LRP, it’s important to understand what is known and what is not yet known about this approach. Again, the most important factors are likely to be the skill and experience of your surgeon. If you decide that either type of LRP is the treatment for you, be sure to find a surgeon with a lot of experience.”
In another specialty such as ophthalmology, cataract removal underwent many changes requiring more expensive equipment, such as phacoemulsifiers, femtosecond lasers, yag lasers and more. These changes resulted in a shift to an ASC for a fifteen minute surgery, vs a three day in patient procedure taking one hour. Medicare slashed the allowed amount from $1300 for the physician fee to about $ 500.00. The overall change improved outcomes greatly, reduced hospital stay (eliminating it completely in most cases)
One must not forget that the reimbursement includes time for post-operative care, up to 90 days in the case of cataract surgery, which is truly neglected in the case of cataract removal and most likely also LRP or RALRP.
The truth is that CMS is bloated with bureaucracy and needs to be investigated by an inspector general. We have too many parastic entities feeding off the chaos of CMS , the Affordable Care Act and burgeoning health reform.