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A Comparison of Standard and High-Flexion Knees: Are We Getting What We Expected?
The Future of Medicine—Are You Prepared?
The practice of medicine is influenced by so many different factors: technology, economy, politics, sociology, and even theology. Since all of these things change with time, it is no wonder that the practice of medicine is always in a state of flux.
Physicians tend to have risk-adverse personalities. We do not like change. The uncertainty that accompanies change makes us very uncomfortable. Yet, when a new technology is introduced, we often have to change the way we practice. If not, our services will become obsolete. Worse, we would not be providing our patients the best care available. For example, less than 100 years ago, antibiotics were not readily available; now, no clinician would contemplate treating an infection without one. Today, there are very few surgeons (if any) who routinely perform open meniscectomies. Clearly, orthopedic surgeons as a group have demonstrated the ability to change—when there is motivation to do so.
Anticipate and Prepare for the Future
How different is adopting an electronic health record (EHR)? The purpose of an EHR is to provide better documentation and transportability of both the current patient encounter and the patient’s medical history. These are noble goals that we, as physicians, would like to accomplish. Unfortunately, there is often a steep learning curve associated with adopting this new technology. My practice switched to an EHR 18 months ago. Documentation of the patient’s medical history did improve. Unfortunately, my ability to see patients efficiently was significantly compromised, and the actual care my patients received did not improve. But, I suspect 30 years ago, surgeons who switched from an open technique to arthroscopic surgery also faced a steep learning curve. As they began to adopt the new technology, they too, complained of decreased efficiency and no significant improvement in patient outcomes. Thus, I predict that 30 years from now, the paper chart will be as obsolete as the open meniscectomy.
So if medicine is changing, how should physicians, approach the future? I believe the key is to look ahead and try to anticipate and prepare our practices for the inevitable. Practices that adopted EHRs 10 years ago had time to work with software designers to develop systems that both complemented their practices and satisfied meaningful use criteria. If you waited until 2012 to adopt an EHR, you might have had to make a rash—and possibly costly—decision when choosing a platform, and the implementation of the system may have been unnecessarily challenging.
As reimbursements inevitably decrease, we must look for ways to increase our efficiency. This may mean hiring more ancillary staff. One way my practice combated the decreased efficiency created by imputing data into the EHR was to hire a medical assistant whose responsibility was to obtain the medical history from each patient and document the data in the EHR. Another way to increase practice efficiency is to employ physician extenders such as physician assistants and nurse practitioners. Using these employees to see simple follow-up and postoperative patients frees the surgeons’ time to see new consults and grow his or her practice.
Does Pay-for-Performance Provide Appropriate Incentives?
The fee-for-service reimbursement model physicians have grown accustomed to may soon be replaced with a performance- based schedule. In theory, a pay-for-performance (P4P) model makes economic sense—incentivize physicians to obtain good outcomes rather than the fee-for-service model that incentivizes them to increase the number of services and procedures they provide. However, I believe that most orthopedic surgeons are ethical and do not perform unnecessary surgeries. Furthermore, I believe they want their patients to have the best results possible and already do everything in their capacity to ensure good results. Therefore, we, as a group, must question if P4P models truly provide appropriate incentives. Or, does it simply shift a physician’s priority from patient care to documentation?
Regardless of the answer, P4P models have already started to affect our reimbursements. Physicians must not stand by helplessly; rather, we need to take an active role in developing P4P models that make medical and practical sense. The parameters that are employed to define performance need to be verified using evidence-based medicine. Additionally, any P4P system that is implemented must not penalize physicians for treating patients with comorbidities that ultimately affect patient outcomes. Otherwise, patients with obesity, diabetes, cardiac disease, and/or drug addiction—to name just a few comorbidities that are often found in the orthopedic patient—may find it very difficult to obtain care.
Practicing surgeons understand these delicate issues much better than administrators or government agents. We must serve as advocates to make sure that both the patient and the physician are protected from well-intentioned policy that has negative consequences. We need to be actively involved in our national and local professional societies, since it is through these organizations that we have the loudest voice and can invoke the most influence on those who make the policies that directly impact our future.
Yes, medicine is changing. But change is not necessarily a bad thing, especially if we are adaptable and change with the times. Instead of lamenting change, physicians must engage, embrace, and be leaders of change. It is the only way we will control how medicine is best practiced now and in the future. We must stay current, both with new medical techniques as well as with policy and political shifts that may affect our practices. If physicians are not at the forefront of thought-leadership and implementation on these issues, the solutions may be shaped by less-informed actors, and the resulting systems may not provide the best outcomes for patients or society.
The practice of medicine is influenced by so many different factors: technology, economy, politics, sociology, and even theology. Since all of these things change with time, it is no wonder that the practice of medicine is always in a state of flux.
Physicians tend to have risk-adverse personalities. We do not like change. The uncertainty that accompanies change makes us very uncomfortable. Yet, when a new technology is introduced, we often have to change the way we practice. If not, our services will become obsolete. Worse, we would not be providing our patients the best care available. For example, less than 100 years ago, antibiotics were not readily available; now, no clinician would contemplate treating an infection without one. Today, there are very few surgeons (if any) who routinely perform open meniscectomies. Clearly, orthopedic surgeons as a group have demonstrated the ability to change—when there is motivation to do so.
Anticipate and Prepare for the Future
How different is adopting an electronic health record (EHR)? The purpose of an EHR is to provide better documentation and transportability of both the current patient encounter and the patient’s medical history. These are noble goals that we, as physicians, would like to accomplish. Unfortunately, there is often a steep learning curve associated with adopting this new technology. My practice switched to an EHR 18 months ago. Documentation of the patient’s medical history did improve. Unfortunately, my ability to see patients efficiently was significantly compromised, and the actual care my patients received did not improve. But, I suspect 30 years ago, surgeons who switched from an open technique to arthroscopic surgery also faced a steep learning curve. As they began to adopt the new technology, they too, complained of decreased efficiency and no significant improvement in patient outcomes. Thus, I predict that 30 years from now, the paper chart will be as obsolete as the open meniscectomy.
So if medicine is changing, how should physicians, approach the future? I believe the key is to look ahead and try to anticipate and prepare our practices for the inevitable. Practices that adopted EHRs 10 years ago had time to work with software designers to develop systems that both complemented their practices and satisfied meaningful use criteria. If you waited until 2012 to adopt an EHR, you might have had to make a rash—and possibly costly—decision when choosing a platform, and the implementation of the system may have been unnecessarily challenging.
As reimbursements inevitably decrease, we must look for ways to increase our efficiency. This may mean hiring more ancillary staff. One way my practice combated the decreased efficiency created by imputing data into the EHR was to hire a medical assistant whose responsibility was to obtain the medical history from each patient and document the data in the EHR. Another way to increase practice efficiency is to employ physician extenders such as physician assistants and nurse practitioners. Using these employees to see simple follow-up and postoperative patients frees the surgeons’ time to see new consults and grow his or her practice.
Does Pay-for-Performance Provide Appropriate Incentives?
The fee-for-service reimbursement model physicians have grown accustomed to may soon be replaced with a performance- based schedule. In theory, a pay-for-performance (P4P) model makes economic sense—incentivize physicians to obtain good outcomes rather than the fee-for-service model that incentivizes them to increase the number of services and procedures they provide. However, I believe that most orthopedic surgeons are ethical and do not perform unnecessary surgeries. Furthermore, I believe they want their patients to have the best results possible and already do everything in their capacity to ensure good results. Therefore, we, as a group, must question if P4P models truly provide appropriate incentives. Or, does it simply shift a physician’s priority from patient care to documentation?
Regardless of the answer, P4P models have already started to affect our reimbursements. Physicians must not stand by helplessly; rather, we need to take an active role in developing P4P models that make medical and practical sense. The parameters that are employed to define performance need to be verified using evidence-based medicine. Additionally, any P4P system that is implemented must not penalize physicians for treating patients with comorbidities that ultimately affect patient outcomes. Otherwise, patients with obesity, diabetes, cardiac disease, and/or drug addiction—to name just a few comorbidities that are often found in the orthopedic patient—may find it very difficult to obtain care.
Practicing surgeons understand these delicate issues much better than administrators or government agents. We must serve as advocates to make sure that both the patient and the physician are protected from well-intentioned policy that has negative consequences. We need to be actively involved in our national and local professional societies, since it is through these organizations that we have the loudest voice and can invoke the most influence on those who make the policies that directly impact our future.
Yes, medicine is changing. But change is not necessarily a bad thing, especially if we are adaptable and change with the times. Instead of lamenting change, physicians must engage, embrace, and be leaders of change. It is the only way we will control how medicine is best practiced now and in the future. We must stay current, both with new medical techniques as well as with policy and political shifts that may affect our practices. If physicians are not at the forefront of thought-leadership and implementation on these issues, the solutions may be shaped by less-informed actors, and the resulting systems may not provide the best outcomes for patients or society.
The practice of medicine is influenced by so many different factors: technology, economy, politics, sociology, and even theology. Since all of these things change with time, it is no wonder that the practice of medicine is always in a state of flux.
Physicians tend to have risk-adverse personalities. We do not like change. The uncertainty that accompanies change makes us very uncomfortable. Yet, when a new technology is introduced, we often have to change the way we practice. If not, our services will become obsolete. Worse, we would not be providing our patients the best care available. For example, less than 100 years ago, antibiotics were not readily available; now, no clinician would contemplate treating an infection without one. Today, there are very few surgeons (if any) who routinely perform open meniscectomies. Clearly, orthopedic surgeons as a group have demonstrated the ability to change—when there is motivation to do so.
Anticipate and Prepare for the Future
How different is adopting an electronic health record (EHR)? The purpose of an EHR is to provide better documentation and transportability of both the current patient encounter and the patient’s medical history. These are noble goals that we, as physicians, would like to accomplish. Unfortunately, there is often a steep learning curve associated with adopting this new technology. My practice switched to an EHR 18 months ago. Documentation of the patient’s medical history did improve. Unfortunately, my ability to see patients efficiently was significantly compromised, and the actual care my patients received did not improve. But, I suspect 30 years ago, surgeons who switched from an open technique to arthroscopic surgery also faced a steep learning curve. As they began to adopt the new technology, they too, complained of decreased efficiency and no significant improvement in patient outcomes. Thus, I predict that 30 years from now, the paper chart will be as obsolete as the open meniscectomy.
So if medicine is changing, how should physicians, approach the future? I believe the key is to look ahead and try to anticipate and prepare our practices for the inevitable. Practices that adopted EHRs 10 years ago had time to work with software designers to develop systems that both complemented their practices and satisfied meaningful use criteria. If you waited until 2012 to adopt an EHR, you might have had to make a rash—and possibly costly—decision when choosing a platform, and the implementation of the system may have been unnecessarily challenging.
As reimbursements inevitably decrease, we must look for ways to increase our efficiency. This may mean hiring more ancillary staff. One way my practice combated the decreased efficiency created by imputing data into the EHR was to hire a medical assistant whose responsibility was to obtain the medical history from each patient and document the data in the EHR. Another way to increase practice efficiency is to employ physician extenders such as physician assistants and nurse practitioners. Using these employees to see simple follow-up and postoperative patients frees the surgeons’ time to see new consults and grow his or her practice.
Does Pay-for-Performance Provide Appropriate Incentives?
The fee-for-service reimbursement model physicians have grown accustomed to may soon be replaced with a performance- based schedule. In theory, a pay-for-performance (P4P) model makes economic sense—incentivize physicians to obtain good outcomes rather than the fee-for-service model that incentivizes them to increase the number of services and procedures they provide. However, I believe that most orthopedic surgeons are ethical and do not perform unnecessary surgeries. Furthermore, I believe they want their patients to have the best results possible and already do everything in their capacity to ensure good results. Therefore, we, as a group, must question if P4P models truly provide appropriate incentives. Or, does it simply shift a physician’s priority from patient care to documentation?
Regardless of the answer, P4P models have already started to affect our reimbursements. Physicians must not stand by helplessly; rather, we need to take an active role in developing P4P models that make medical and practical sense. The parameters that are employed to define performance need to be verified using evidence-based medicine. Additionally, any P4P system that is implemented must not penalize physicians for treating patients with comorbidities that ultimately affect patient outcomes. Otherwise, patients with obesity, diabetes, cardiac disease, and/or drug addiction—to name just a few comorbidities that are often found in the orthopedic patient—may find it very difficult to obtain care.
Practicing surgeons understand these delicate issues much better than administrators or government agents. We must serve as advocates to make sure that both the patient and the physician are protected from well-intentioned policy that has negative consequences. We need to be actively involved in our national and local professional societies, since it is through these organizations that we have the loudest voice and can invoke the most influence on those who make the policies that directly impact our future.
Yes, medicine is changing. But change is not necessarily a bad thing, especially if we are adaptable and change with the times. Instead of lamenting change, physicians must engage, embrace, and be leaders of change. It is the only way we will control how medicine is best practiced now and in the future. We must stay current, both with new medical techniques as well as with policy and political shifts that may affect our practices. If physicians are not at the forefront of thought-leadership and implementation on these issues, the solutions may be shaped by less-informed actors, and the resulting systems may not provide the best outcomes for patients or society.
High-Pressure Paint Gun Injection Injury to the Palm
Comparative Effectiveness of Joint Reconstruction and Fixation for Femoral Neck Fracture: Inpatient and 30-Day Mortality
RE: The Affordable Care Act: Politics Over Policy
I was interested to read Dr. JP Tasto’s remarks on the Affordable Care Act (ACA) and his characterization of providing health coverage for the uninsured as “idealistic”.1 It is an ideal that most of the developed world has achieved. Are its 2000 pages too many? Considering that it attempts to reform a $2.8 trillion-dollar segment of our economy, roughly equal to the gross domestic product of France, one should expect it to be long. Campbell’s Operative Orthopaedics is longer.
Tasto’s second paragraph on Medicaid fails to note the important point that reimbursement for family practice, internal medicine, and pediatrics will be increased to 100% of Medicare. It seems unlikely that these newly insured individuals would flood the emergency rooms (ERs) because it is more likely that their insurance companies would be directing them to primary care providers to keep them out of the expensive ERs. In regards to the comments on the uninsured, if the uninsured have money, they have plenty of access to medical care. The uninsured who have little money don’t have access to health care because they cannot afford it and now end up in the ER when their illnesses become intolerable or the paramedics bring them in with their injuries.
On the subject of health exchanges, who would Dr. Tasto have run the health exchanges? The federal government runs Medicare, and 80% of seniors are happy with their Medicare program. No one has to buy insurance on the exchange, but if you cannot get it elsewhere or you are looking for a subsidy, then the exchange is where you will need to go. If the
taxpayer is going to pay your subsidy, it seems reasonable that your financial information be required and the government be involved.
I am at a total loss to find data to support Dr. Tasto’s fourth paragraph comments on the relation of small business health coverage and providers. The Congressional Budget Office has made estimates that some small business employees could lose coverage because their employer would rather pay the penalties. But that has not been the case in Massachusetts, where employer coverage has actually increased. In regards to finding primary care providers and specialists, again it is likely that the insurance companies will be arranging this as they have in the past with their state regulators spurring them on.
Few people with individual income over $40,000 or family income over $90,000 do not have insurance. The typical uninsured is a young person with a low paying job. If he is a male, I would speculate that his entrance into the healthcare system would be by arriving in the ER with a broken femur. If he has waited until this moment to buy coverage, he will find there is no mandate on how quickly the company company he chooses will pick him up and his uncovered bills would likely be considerable. It is like buying fire insurance after the house has burned down.
Finally, and again, who would Dr. Tasto have regulate one of the “largest and most complex industries in the world”? Remember the 2000 pages; maybe it is reasonable. His examples of 3 poorly run government programs are Medicare, which our seniors like, Medicaid—I bet if they increased their reimbursement to orthopedists, Dr. Tasto would like it—and The Department of Veteran’s Affairs—but nothing remotely like the United States Department of Veteran Affairs is in the ACA.
So is the ACA unaffordable? What we have now is certainly not affordable. The cost of rising insurance premiums is being passed on at even higher levels to employees from their employers. The total health care costs are taking a bigger share of our country’s gross domestic product each year, with no evidence of improved health for the population for that extra cost. A median family income in the United States, stagnant at about $55,000, makes it hard to afford the average insurance premium for that family of about $13,000, which is increasing yearly. In the insurance exchanges, subsidies would reduce that family’s costs to around $4000 per year. The ACA was probably not anyone’s first choice for health reform in this country, but it is the one, after 100 years of trying, our political system finally passed.
Craig Stevenson, MD
1. Tasto JP. The Affordable Care Act: politics over policy. Am J Orthop. 2013;42(4):158.
Commentary
James P. Tasto, MD
I would like to thank Dr. Stevenson for his thoughtful rebuttal to my recent editorial. Our views are quite different. My comments are based on over 48 years in the practice of medicine, including 40 years in private practice. I have dealt with, and continue to deal with MediCal, Medicare, TriCare, Medicaid Health Maintenance Organizations, Accountable Care Organizations, academia, and the United States Department of Veterans Affairs Hospital.
Dr. Stevenson is currently employed by the Kaiser health-care system, and his views are driven, I suspect, by ideology, but certainly not by practical experience. I have the utmost respect for Kaiser Permanente and their physicians, but they are not exposed to the weakness of many of these government systems. The medical healthcare delivery system is indeed broken, but the Affordable Care Act (ACA) does little to address the real issues.
The New York Times recently noted that approximately one-half of the “poorest of the poor” with yearly incomes below $15,000 per year will not be eligible for subsidized healthcare because their states have refused to expand Medicaid.1 The Supreme Court has upheld this decision of State rights. Yes, the 2000 or more pages of legislation are quite lengthy to say the least, and certainly can be equated to an orthopedics textbook. My bigger issue than the number of pages is the fact that there is an estimated 22,000 pages of supportive regulation that has yet to be defined. Medicare patients are indeed generally happy with their insurance today, but benefits are beginning to unravel.
One needs to spend some time analyzing the explanation of benefits on services rendered, and he/she will be shocked by the discounted value of the physician’s care. I am sure everyone that is familiar with ACA has heard that 14,000 to 16,000 new Internal Revenue Service agents will be employed to enforce the mandates of this law. How comfortable is everyone with this little publicized element of the law in light of the recent scandal at the Internal Revenue Service? This agency that has access to our financial records will now have access to our health records, as well as taxing potential for those that do not comply.
Admittedly, our healthcare system is broken, but the administration missed a golden opportunity to fashion meaningful bipartisan legislation to solve many of these problems.
1. Pear R. States’ policies on health care exclude poorest. The New York Times. May 25, 2013: A1.
Dr. Tasto is Department Editor for Socioeconomics and Practice Management of this journal; Managing Partner, San Diego Sports Medicine & Orthopaedic Center, California.
I was interested to read Dr. JP Tasto’s remarks on the Affordable Care Act (ACA) and his characterization of providing health coverage for the uninsured as “idealistic”.1 It is an ideal that most of the developed world has achieved. Are its 2000 pages too many? Considering that it attempts to reform a $2.8 trillion-dollar segment of our economy, roughly equal to the gross domestic product of France, one should expect it to be long. Campbell’s Operative Orthopaedics is longer.
Tasto’s second paragraph on Medicaid fails to note the important point that reimbursement for family practice, internal medicine, and pediatrics will be increased to 100% of Medicare. It seems unlikely that these newly insured individuals would flood the emergency rooms (ERs) because it is more likely that their insurance companies would be directing them to primary care providers to keep them out of the expensive ERs. In regards to the comments on the uninsured, if the uninsured have money, they have plenty of access to medical care. The uninsured who have little money don’t have access to health care because they cannot afford it and now end up in the ER when their illnesses become intolerable or the paramedics bring them in with their injuries.
On the subject of health exchanges, who would Dr. Tasto have run the health exchanges? The federal government runs Medicare, and 80% of seniors are happy with their Medicare program. No one has to buy insurance on the exchange, but if you cannot get it elsewhere or you are looking for a subsidy, then the exchange is where you will need to go. If the
taxpayer is going to pay your subsidy, it seems reasonable that your financial information be required and the government be involved.
I am at a total loss to find data to support Dr. Tasto’s fourth paragraph comments on the relation of small business health coverage and providers. The Congressional Budget Office has made estimates that some small business employees could lose coverage because their employer would rather pay the penalties. But that has not been the case in Massachusetts, where employer coverage has actually increased. In regards to finding primary care providers and specialists, again it is likely that the insurance companies will be arranging this as they have in the past with their state regulators spurring them on.
Few people with individual income over $40,000 or family income over $90,000 do not have insurance. The typical uninsured is a young person with a low paying job. If he is a male, I would speculate that his entrance into the healthcare system would be by arriving in the ER with a broken femur. If he has waited until this moment to buy coverage, he will find there is no mandate on how quickly the company company he chooses will pick him up and his uncovered bills would likely be considerable. It is like buying fire insurance after the house has burned down.
Finally, and again, who would Dr. Tasto have regulate one of the “largest and most complex industries in the world”? Remember the 2000 pages; maybe it is reasonable. His examples of 3 poorly run government programs are Medicare, which our seniors like, Medicaid—I bet if they increased their reimbursement to orthopedists, Dr. Tasto would like it—and The Department of Veteran’s Affairs—but nothing remotely like the United States Department of Veteran Affairs is in the ACA.
So is the ACA unaffordable? What we have now is certainly not affordable. The cost of rising insurance premiums is being passed on at even higher levels to employees from their employers. The total health care costs are taking a bigger share of our country’s gross domestic product each year, with no evidence of improved health for the population for that extra cost. A median family income in the United States, stagnant at about $55,000, makes it hard to afford the average insurance premium for that family of about $13,000, which is increasing yearly. In the insurance exchanges, subsidies would reduce that family’s costs to around $4000 per year. The ACA was probably not anyone’s first choice for health reform in this country, but it is the one, after 100 years of trying, our political system finally passed.
Craig Stevenson, MD
1. Tasto JP. The Affordable Care Act: politics over policy. Am J Orthop. 2013;42(4):158.
Commentary
James P. Tasto, MD
I would like to thank Dr. Stevenson for his thoughtful rebuttal to my recent editorial. Our views are quite different. My comments are based on over 48 years in the practice of medicine, including 40 years in private practice. I have dealt with, and continue to deal with MediCal, Medicare, TriCare, Medicaid Health Maintenance Organizations, Accountable Care Organizations, academia, and the United States Department of Veterans Affairs Hospital.
Dr. Stevenson is currently employed by the Kaiser health-care system, and his views are driven, I suspect, by ideology, but certainly not by practical experience. I have the utmost respect for Kaiser Permanente and their physicians, but they are not exposed to the weakness of many of these government systems. The medical healthcare delivery system is indeed broken, but the Affordable Care Act (ACA) does little to address the real issues.
The New York Times recently noted that approximately one-half of the “poorest of the poor” with yearly incomes below $15,000 per year will not be eligible for subsidized healthcare because their states have refused to expand Medicaid.1 The Supreme Court has upheld this decision of State rights. Yes, the 2000 or more pages of legislation are quite lengthy to say the least, and certainly can be equated to an orthopedics textbook. My bigger issue than the number of pages is the fact that there is an estimated 22,000 pages of supportive regulation that has yet to be defined. Medicare patients are indeed generally happy with their insurance today, but benefits are beginning to unravel.
One needs to spend some time analyzing the explanation of benefits on services rendered, and he/she will be shocked by the discounted value of the physician’s care. I am sure everyone that is familiar with ACA has heard that 14,000 to 16,000 new Internal Revenue Service agents will be employed to enforce the mandates of this law. How comfortable is everyone with this little publicized element of the law in light of the recent scandal at the Internal Revenue Service? This agency that has access to our financial records will now have access to our health records, as well as taxing potential for those that do not comply.
Admittedly, our healthcare system is broken, but the administration missed a golden opportunity to fashion meaningful bipartisan legislation to solve many of these problems.
1. Pear R. States’ policies on health care exclude poorest. The New York Times. May 25, 2013: A1.
Dr. Tasto is Department Editor for Socioeconomics and Practice Management of this journal; Managing Partner, San Diego Sports Medicine & Orthopaedic Center, California.
I was interested to read Dr. JP Tasto’s remarks on the Affordable Care Act (ACA) and his characterization of providing health coverage for the uninsured as “idealistic”.1 It is an ideal that most of the developed world has achieved. Are its 2000 pages too many? Considering that it attempts to reform a $2.8 trillion-dollar segment of our economy, roughly equal to the gross domestic product of France, one should expect it to be long. Campbell’s Operative Orthopaedics is longer.
Tasto’s second paragraph on Medicaid fails to note the important point that reimbursement for family practice, internal medicine, and pediatrics will be increased to 100% of Medicare. It seems unlikely that these newly insured individuals would flood the emergency rooms (ERs) because it is more likely that their insurance companies would be directing them to primary care providers to keep them out of the expensive ERs. In regards to the comments on the uninsured, if the uninsured have money, they have plenty of access to medical care. The uninsured who have little money don’t have access to health care because they cannot afford it and now end up in the ER when their illnesses become intolerable or the paramedics bring them in with their injuries.
On the subject of health exchanges, who would Dr. Tasto have run the health exchanges? The federal government runs Medicare, and 80% of seniors are happy with their Medicare program. No one has to buy insurance on the exchange, but if you cannot get it elsewhere or you are looking for a subsidy, then the exchange is where you will need to go. If the
taxpayer is going to pay your subsidy, it seems reasonable that your financial information be required and the government be involved.
I am at a total loss to find data to support Dr. Tasto’s fourth paragraph comments on the relation of small business health coverage and providers. The Congressional Budget Office has made estimates that some small business employees could lose coverage because their employer would rather pay the penalties. But that has not been the case in Massachusetts, where employer coverage has actually increased. In regards to finding primary care providers and specialists, again it is likely that the insurance companies will be arranging this as they have in the past with their state regulators spurring them on.
Few people with individual income over $40,000 or family income over $90,000 do not have insurance. The typical uninsured is a young person with a low paying job. If he is a male, I would speculate that his entrance into the healthcare system would be by arriving in the ER with a broken femur. If he has waited until this moment to buy coverage, he will find there is no mandate on how quickly the company company he chooses will pick him up and his uncovered bills would likely be considerable. It is like buying fire insurance after the house has burned down.
Finally, and again, who would Dr. Tasto have regulate one of the “largest and most complex industries in the world”? Remember the 2000 pages; maybe it is reasonable. His examples of 3 poorly run government programs are Medicare, which our seniors like, Medicaid—I bet if they increased their reimbursement to orthopedists, Dr. Tasto would like it—and The Department of Veteran’s Affairs—but nothing remotely like the United States Department of Veteran Affairs is in the ACA.
So is the ACA unaffordable? What we have now is certainly not affordable. The cost of rising insurance premiums is being passed on at even higher levels to employees from their employers. The total health care costs are taking a bigger share of our country’s gross domestic product each year, with no evidence of improved health for the population for that extra cost. A median family income in the United States, stagnant at about $55,000, makes it hard to afford the average insurance premium for that family of about $13,000, which is increasing yearly. In the insurance exchanges, subsidies would reduce that family’s costs to around $4000 per year. The ACA was probably not anyone’s first choice for health reform in this country, but it is the one, after 100 years of trying, our political system finally passed.
Craig Stevenson, MD
1. Tasto JP. The Affordable Care Act: politics over policy. Am J Orthop. 2013;42(4):158.
Commentary
James P. Tasto, MD
I would like to thank Dr. Stevenson for his thoughtful rebuttal to my recent editorial. Our views are quite different. My comments are based on over 48 years in the practice of medicine, including 40 years in private practice. I have dealt with, and continue to deal with MediCal, Medicare, TriCare, Medicaid Health Maintenance Organizations, Accountable Care Organizations, academia, and the United States Department of Veterans Affairs Hospital.
Dr. Stevenson is currently employed by the Kaiser health-care system, and his views are driven, I suspect, by ideology, but certainly not by practical experience. I have the utmost respect for Kaiser Permanente and their physicians, but they are not exposed to the weakness of many of these government systems. The medical healthcare delivery system is indeed broken, but the Affordable Care Act (ACA) does little to address the real issues.
The New York Times recently noted that approximately one-half of the “poorest of the poor” with yearly incomes below $15,000 per year will not be eligible for subsidized healthcare because their states have refused to expand Medicaid.1 The Supreme Court has upheld this decision of State rights. Yes, the 2000 or more pages of legislation are quite lengthy to say the least, and certainly can be equated to an orthopedics textbook. My bigger issue than the number of pages is the fact that there is an estimated 22,000 pages of supportive regulation that has yet to be defined. Medicare patients are indeed generally happy with their insurance today, but benefits are beginning to unravel.
One needs to spend some time analyzing the explanation of benefits on services rendered, and he/she will be shocked by the discounted value of the physician’s care. I am sure everyone that is familiar with ACA has heard that 14,000 to 16,000 new Internal Revenue Service agents will be employed to enforce the mandates of this law. How comfortable is everyone with this little publicized element of the law in light of the recent scandal at the Internal Revenue Service? This agency that has access to our financial records will now have access to our health records, as well as taxing potential for those that do not comply.
Admittedly, our healthcare system is broken, but the administration missed a golden opportunity to fashion meaningful bipartisan legislation to solve many of these problems.
1. Pear R. States’ policies on health care exclude poorest. The New York Times. May 25, 2013: A1.
Dr. Tasto is Department Editor for Socioeconomics and Practice Management of this journal; Managing Partner, San Diego Sports Medicine & Orthopaedic Center, California.
Try Before You Buy: Simulate, Then Operate
Type of Helmet May Not Lower Concussion Risk
“According to our research, lower risks of sustaining a sports-related concussion (SRC) and its severity were not improved based on a specific manufacturer. In addition, the SRC rates were similar for players wearing new helmets, as compared to those wearing older ones,” commented McGuine. There is limited data detailing how specific types of football helmets and mouth guards affect the incidence and severity of SRC in players participating on high school football football teams. “It is also interesting to note, that players who wore a generic mouth guard provided by the school had a lower rate of SRC compared to players with more expensive mouth guards,” added McGuine.
Researchers collected data by Licensed Athletic Trainers (ATCs) at 36 public and private high schools in Wisconsin during the 2012 high school football season. A sample of 1,332 players were enrolled in the study with 251 (19%) individuals having reported at least 1 SRC within the last 6 years, and 171 (13%) players reporting 1 SRC within the previous 12 months. At each school the licensed athletic trainers recorded the brand, model, and purchase year of the helmets. They also recorded the type of mouth guard utilized (eg, generic, specialized or custom fit). Licensed athletic trainers also recorded the number and type of exposure (practice vs game) and the number of SRCs sustained. There were 115 (8.6%) players of the 1,332 that sustained 116 SRCs.
“Increased risk of concussions in our study was not associated with age, body mass index (BMI), grade in school, level of competition, or years of football experience. However, players with a history of SRC were twice as likely to sustain another one compared to players without a history. Additional screening to identify those players with increased concussion risk is a key to prevention and hopefully will help reduce rates in the future,” noted McGuine.
“According to our research, lower risks of sustaining a sports-related concussion (SRC) and its severity were not improved based on a specific manufacturer. In addition, the SRC rates were similar for players wearing new helmets, as compared to those wearing older ones,” commented McGuine. There is limited data detailing how specific types of football helmets and mouth guards affect the incidence and severity of SRC in players participating on high school football football teams. “It is also interesting to note, that players who wore a generic mouth guard provided by the school had a lower rate of SRC compared to players with more expensive mouth guards,” added McGuine.
Researchers collected data by Licensed Athletic Trainers (ATCs) at 36 public and private high schools in Wisconsin during the 2012 high school football season. A sample of 1,332 players were enrolled in the study with 251 (19%) individuals having reported at least 1 SRC within the last 6 years, and 171 (13%) players reporting 1 SRC within the previous 12 months. At each school the licensed athletic trainers recorded the brand, model, and purchase year of the helmets. They also recorded the type of mouth guard utilized (eg, generic, specialized or custom fit). Licensed athletic trainers also recorded the number and type of exposure (practice vs game) and the number of SRCs sustained. There were 115 (8.6%) players of the 1,332 that sustained 116 SRCs.
“Increased risk of concussions in our study was not associated with age, body mass index (BMI), grade in school, level of competition, or years of football experience. However, players with a history of SRC were twice as likely to sustain another one compared to players without a history. Additional screening to identify those players with increased concussion risk is a key to prevention and hopefully will help reduce rates in the future,” noted McGuine.
“According to our research, lower risks of sustaining a sports-related concussion (SRC) and its severity were not improved based on a specific manufacturer. In addition, the SRC rates were similar for players wearing new helmets, as compared to those wearing older ones,” commented McGuine. There is limited data detailing how specific types of football helmets and mouth guards affect the incidence and severity of SRC in players participating on high school football football teams. “It is also interesting to note, that players who wore a generic mouth guard provided by the school had a lower rate of SRC compared to players with more expensive mouth guards,” added McGuine.
Researchers collected data by Licensed Athletic Trainers (ATCs) at 36 public and private high schools in Wisconsin during the 2012 high school football season. A sample of 1,332 players were enrolled in the study with 251 (19%) individuals having reported at least 1 SRC within the last 6 years, and 171 (13%) players reporting 1 SRC within the previous 12 months. At each school the licensed athletic trainers recorded the brand, model, and purchase year of the helmets. They also recorded the type of mouth guard utilized (eg, generic, specialized or custom fit). Licensed athletic trainers also recorded the number and type of exposure (practice vs game) and the number of SRCs sustained. There were 115 (8.6%) players of the 1,332 that sustained 116 SRCs.
“Increased risk of concussions in our study was not associated with age, body mass index (BMI), grade in school, level of competition, or years of football experience. However, players with a history of SRC were twice as likely to sustain another one compared to players without a history. Additional screening to identify those players with increased concussion risk is a key to prevention and hopefully will help reduce rates in the future,” noted McGuine.
Caring for the Polytrauma Patient: Is Your System Surviving or Thriving?
When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.
Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.
At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.
Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.
A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.
All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.
We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
See Dr. Guillamondegui's commentary here.
When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.
Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.
At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.
Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.
A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.
All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.
We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
See Dr. Guillamondegui's commentary here.
When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.
Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.
At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.
Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.
A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.
All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.
We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
See Dr. Guillamondegui's commentary here.
