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New total joint government regs.

Started by doctorb, May 07, 2012, 06:01:39 PM

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doctorb

I don't want to bore you guys with inside medical issues.  I don't expect a lot of sympathy from the general public, not that the FF membership falls into that category, because myself and my colleagues are all just filthy rich doctors out for ourselves, as you know ;). But this upcoming scenario is a sign of the future of medicine in this country.  The driving force is cost, and new regulations are crafted to slow the use of medical procedures.  I get that.  It's a form of rationing, and this is just the taste of the pill we will swallow over the next decade.

Medicare is going to deny payment for total joint replacements if there is not documentation of certain signs and attempted treatments prior to the total joint procedure for accepted lengths of time.  You must now have 12 weeks of documented PT before being eligible for a total joint.  You
must now have pre-op bracing ordered.  Creptius (joint creaking and popping) must be documented.  You must document that your activities of daily living are overwhelmingly affected by the arthritis.  You can't just say that the patient now walks infrequently, or uses a cane or walker, it must be worded in a specific manner so that non-medica personnel reviewing the charts can pick-up the buzz words they are looking for.  There's a whole list of hoops to jump through, which may or may not seem like they are appropriate to you.  Let me assure you, my experience in medicine does not contain surgeons doing unnecessary total joint replacements for their own good.  Never seen it.

I've had two total hip replacements.  I had no PT prior to either except splitting and stacking wood, fishing (standing) and trying to keep my place up.  My partner just cancelled 11 total joint replacements for next week as his charts do not meet the new criteria (we just heard about this in the last month).  I am not crying for him.  He'll do fine.  What about the patients?  They have planned for this and inserted this disruption into their lives to try to be more functional and in less pain.  Now they need 3 months of PT?  I am all for cutbacks in medicine.  But delaying patient care is the last place to go, IMO, not the place to start.  BTW, I don't perform total joint so this has little effect on me.  I am just waiting for the other shoe to drop.

Again, not asking for sympathy.  I am asking for empathy and understanding that people in need of help should get it, and not be so encumbered by our government that they can notnreceive it.  Your thoughts?
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

beenthere

I think this was obvious thing to happen, given the introduction of Gov't health care in the very beginning...Clinton et al.
Now we know why Congress and others have exempted themselves from being included in the Gov't plan. More peons making the decision that the Drs. should be making.

Appreciate the heads up.
south central Wisconsin
It may be that my sole purpose in life is simply to serve as a warning to others

Mooseherder

Medicare seems to be cracking down on fraudsters who have been using them as an ATM machine.  They arrested over a 100 people in 7 cities this week who had billed about a half billion.  They'll implement a scale for all procedures before it's over.  Regulators like their regulating.  I wonder how they get and keep their authority?  Seems this stuff doesn't get voted on by Congress.

Norm

Doctorb don't take this wrong for the situation you mentioned but Dr's have been milking the medicare system so bad it was only a matter of time before the gov came down heavy handed on this. I can't tell you how many unneeded tests I've seen ordered because they knew the patient was on medicare. My MIL had a heart skip which could have easily been treated with a blocker. Nope lets order a chemical stress test so we can "adjust the medication". In the end she was given a blocker. Too many examples of this to even mention without boring everyone but medicare and medicaid are just a sign of what's to come.

Supplemental insurance would cover this replacement wouldn't it?

doctorb

Norm-

Points well taken about unnecessary tests.  What's interesting about the new guidlines is that medicare is about to pay for a brace and/or 3 months of PT before they pay for the total joint.  Sure, some patients improve with therapy, but most patients whose degenerative disease has reached the stage of being considered for a total joint do not.  In fact, PT can make an arthritic joint more painful.

I don't take your comments the wrong way.   Those docs that have been caught up in the fraud investigations were billing for tests that were not done, diagnosis the patients didn't have, and office visits that didn't occur.  They deserve to be put away.  Call it fraud, but I'll call it stealing.  Remember that most docs do not profit from tests they order, as most are done at outside facilities.  But it's the money driving these new regs., not the fraud.  The aging baby boomers like myself are requiring more of these procedures, so an attempt to slow their use is beign attempted.  I know I am repeating myself, by I don't see surgical fraud here.  i see well trained docs performing appropriate procedures.  I don't see cost savings either, when you add in the extra therapy, medicines, and office visits this will create.  We need control of medical costs, not control of medical practice, IMO.

The new regs will allow only a 2 day stay for a total knee, 3 days for a total hip.  Also, PCA (push button patient controlled IV pain management) analgesia can no longer be used.  The regs. treat all patients identically, and they are definitely not all the same.  Patients are not going to enjoy this. 
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

pigman

Unlike some medical tests, I am sure not many patients would go through the pain of an unnecessary joint replacement even if it was free.
Things turn out best for people who make the best of how things turn out.

Polly

 :(    i got two total knee replacements ,two total hip replacements ,and one total shoulder replacement ,in each case i ask the dr on a scale of one to ten with ten being the worse how bade was mine in all five cases the rating was eight to ten , i worked over 50 years holding 2 or 3 jobs at a time and i paid way more then my share of taxes ,probly most of the other people having replacments ,did as i did ,i dont think it is rong for uncle sam flip the bill for these operations  ::) ::)

Barney II

DoctoberB,  I am scheduled for shoulder replacement this Feb. at Mayo Clinic. I have read your warning about having intermittant treatment for the shoulder.  The x rays show that joint is bone on bone and has been for some time.  Is it the responsibilitry of the DR to make that this will go through medicare( I am 71) or do I have to do something myself? The x rays were done at Mayo and in talking to the surgeon he stated without doubt it had to be replaced--------what are your thoughts about this.   Thank You, Don
Ya never know
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Busy Beaver Lumber

To be sure, something needs to be done to control medical costs and what others believe are their entitlements. Perhaps this implementation is not 100% correct, but it is a start at an attempt to do something about the ever escalating cost of medical care.

I know of too many people that scam the system and get their medical care for free, while hard working people, like myself, work all their lives and pay for their own medical insurance and get stuck paying for portions not covered by that same insurance. My first wife had a liver transplant and it cost me well over $60,000 out of pocket, on top of what it cost me for my insurance and the $500,000+ the hospital and doctors got paid for 3 weeks of work....thats right $500,000 in three weeks...isnt someone charging a bit too much for their services when there are people that dont make that much in 20 years? Here is the real kicker, while we had to pay the $60,000 in unpaid balances, the welfare people that had the same surgery and same services sat their and bragged how their care was completely free of cost to them.

Then there is the whole separate issue of scammers that  get disability payments every month that are about as dishonest as can be and no more disabled than anyone else in this country that goes to work every day to support their scamming ways. I know of at least 6 people that collect full disability that should be out there working along side you, me, and everyone else instead of sitting home and collecting over $1000 a month for doing nothing. One such person says she cant work because she has occasional siezures, but that does not stop her from driving, playing corn whole, singing karaoke every weekend, drinking alcohol, or zipping around the campground on her golf cart and partying from site to site. She even has her own business that she was smart enough to put in her husbands name so as not to interfere with her disability payments, even though the business actually bears her first name as part of the business name. This type of scamming must stop.


I agree with DoctorB, that is latest set of regulations may not be 100% correct, but i think it is about time that someone try to get control of the runaway cost of medical services and other such abuses way before they even consider raising taxes.

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doctorb

Barney II -

I asked our shoulder replacement experts and, at this time, Medicare does not seem to require certain amounts of documented non-operative care, such as PT, prior to authorizing a shoulder replacement.  So, I think you are good to go with Medicare picking up whatever portion of the costs for which they are responsible.  By the way, I may have mislead you, if Medicare denied payment for the shoulder replacement, or a total hip or knee, you are not the one on the hook for the money.  They can't come back at you and demand payment.  They just deny the payments to the hospital and the surgeon.

Busy Beaver-

Sorry to hear about that big bill you had to pay.  People without insurance are listed as "charity" cases for large, complex cases such as a liver transplant, and may never be sent a bill.  You are right in that those who have worked and have insurance often are stuck with ever increasing copaymnents wherreas those without insurance are not held accountable for the uncovered costs. 

Make no mistake about it, medical costs can and will bankrupt this country in the future.  We are going to have to go to some form of rationing and government control to provide health care to everybody.  I am in the minority of physicians that believes that, in the future, government health care is the only way to control costs, but I also realize it has a tremendous ripple effect.  It will remove the incentive for drug and medical device manufacturers to create new and better advancements, as their profit margins will most certainly shrink.
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

Polly

 :(     the stupid part of our gov. regulations is the fact a fda. approved pill in good ole usa cost anywhere from 40.00 to 100.00 dollars same medication outside usa might cost 1.00  it is a known fact the medical people in other countries are just as intellegent as us and in some cases more so , only thing i can figure out the pill co lobist sust be paying a h--l  ofalot of money to our senator and rep  very sad situation  :( :( 8)

SwampDonkey

Like Polly said pills are a big difference in price. I had an uncle who looked at going over to Maine to get blood pressure pills and they were 4 times as high as here. Same stuff and that was without insurance or government co-payment. At one time, and I don't hear about it now, seniors where coming from Maine by the bus to get their pills.
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rooster 58

     The American worker has alot of burden to pay for the welfare of people who do not want to work. This includes illegal aliens that, once here, are given free medical attention as well as food and housing, while the cost of our health care steadily rises.
     The politicians in this country are also to blame. they are completely out of touch with the needs of the average American, and what this country needs to turn around. It's about what's good for them and their party. One term in office and their health care is free for life. I wish I could count on that when I retire.
     Lastly, the FDA restricts and impedes proven medical treatments and procedures from other countries that are effective, but not approved here because to do so would eliminate many research grants that would be the death knell for many career researchers. The pharmaceutical  companies are also involved in these practices

Gary_C

Thanks for sharing this with us doctorb.

From what I see, these new regulations have the potential to actually increase overall healthcare costs. As has been noted, these joint problems will not go away and now patients will be forced to go thru expensive PT that will not resolve their issues. So the end result will be the cost for a total joint replacement will increase and the system will find a way to accomodate everyone. Another example of good intentions going the wrong way.

In short, these new regulations sound like the dream of the insurance industry that is keeping one third of our total health care dollars. The Medicare system has just increased the insurance industries take for every total joint replacement surgery.

A person can only hope that technology will come to the rescue in the form of a means to grow cartilage and eliminate the need for total joint replacement. I understand there have been some advances in the research in this area. But there have also been some things like injections of lubricants that have come out that are of dubious benefit.

Things like injections of chicken broth and rooster combs. I've known of many people that have had these injections and still had to have the total joint replacement anyway. But now there are numerous clinics that have sprung up that offer "doctor administered injections" of various lubricants.

There are lots of opportunities in the medical field to make money as well as to actually help relieve suffering. And you are not going to inhibit those opportunities with regulations.

Never take life seriously. Nobody gets out alive anyway.

giant splinter

Doctorb
Thank you for sharing this with us, healthcare is one of the most important things that all Americans must deal with and it is of great importance for everyone involved to protect our healthcare system so that future generations will benefit from it as well. The government could stand a certain degree of improvement on this subject as usual and the freeloaders and non contributing elements involved should be brought under control.
I suspect that what might get the system under control might be a more proactive form of government rather than the reactive approach that is evidently destroying so many important things.
roll with it

doctorb

Here's the next government reg.  I don't know if this is Federal Medicare or just the State of Maryland, but it's a doozy!

From this point on, all re-admissions to hospitals within 30 days of discharge will go uncompensated.  It is perceived that a readmission to a hospital that soon after leaving is a preventable occurrence.  So, for example, let's say you have some chest pain and go to the ER.  They admit you for a cardiac work-up. which turns out to be negative.  You get discharged in a day or so, and are cleared by your doctor to have that total hip replacement that you've been scheduled for for months.  The hospital receives nothing for the costs of he second admission, in this hypothetical, an admission that had absolutely nothing to do with the earlier admission for chest pain.  It's just their way of controling costs.  Tip of the iceberg.....

The bottom line.....if you get discharged from a hospital, you better hope and pray you stay healthy for the next 30 days, because there is now a built in bias against readmitting you for any reason, even if unrelated to the first admission.  WOW!
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

WH_Conley

After 17 years in EMS I can see a lot of problems with that.
Bill

jdonovan

Quote from: doctorb on May 08, 2012, 08:51:10 AM
Points well taken about unnecessary tests.  What's interesting about the new guidlines is that medicare is about to pay for a brace and/or 3 months of PT before they pay for the total joint.  Sure, some patients improve with therapy, but most patients whose degenerative disease has reached the stage of being considered for a total joint do not.  In fact, PT can make an arthritic joint more painful.

so if the PT decides, or for what ever reason, does not participate in the 12 weeks of PT do they continue to be denied the replacement?

If so this might be a tactic of put a barrier in front of people, and not all 'eligible' people will pass the barrier and overall net costs will be lowered.

doctorb

jd-

Medicare has yet to get into the business of denying care before it takes place.  The surgical procedure could be performed.  It's the hospital and surgeon that get their payments denied - after the fact!  So it may well be that your surgeon will cancel your procedure, at least temporarily so he can "work things out" with Medicare, I don't know.  I will tell you that, if a surgeon believes he won't get paid for his work, it's unlikely that the work will get done.  No different than you or anybody else.  Medicare never goes back to the patient for the funds.  It denies them from the providers.

But Medicare is the entity that is going to force thousands of people with arthritis to undergo unnecessary PT, delaying their needed total joint.
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

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