March 1st Medicare Cuts

It's not really news that our nation's healthcare system needs a little work. We all may disagree on how much work is needed, but before making your decision, let me help shine a light on one aspect that needs significant work.

As of tomorrow, March 1st, 2010, Medicare will be cutting physician reimbursement by 21%.

The Center for Medicare and Medicaid Services (CMS) relies on a flawed payment system that is based on an outdated formula, called the SGR - the Sustainable Growth Rate. As a result of the reliance on this formula, nearly every year, CMS schedules reimbursement cuts to doctors.

Despite rising costs to run a doctor's office.
Despite increasing malpractice insurance premiums.
Despite more demands on physicians' time.

Many of the cuts are narrowly averted when Congress steps in at the eleventh hour and repeals a cut temporarily to avoid having to deal with the larger issue, the SGR. But no Congress save happened this time... the House of Representatives was able to pass a 30-day extension, but the bill died in the Senate. So the cut looks like it will happen.

To understand why a 21% payment cut is so damaging to the physician workforce, let's put things in a larger perspective. Over the ten years from 1997 to 2007:

Automobile prices have increased 25%.
Home prices have increased 81%.
College Tuition costs have increased 55%.
Reimbursement to a neurosurgeon for performing a laminectomy has decreased by 28%.

Now for the really bad news. Many physicians are saying "enough is enough". While there may not be much an individual physician can do about the SGR, he/she can begin to limit their practice. This translates into many physicians seeing less Medicare patients. In a recent survey conducted by the American Association of Neurological Surgeons (AANS), the Council of State Neurosurgical Societies (CSNS), and the Congress of Neurological Surgeons (CNS), the results indicate a very disturbing trend.

Nearly 40% of respondents indicated that if Medicare payments continue to decline, they will decrease the number of Medicare patients they see, and over 18% will stop seeing Medicare patients altogether.

This is very unfortunate for the nation's elderly, many of whom rely heavily on their physicians on a daily basis.

I, for one, would like to see everyone who needs healthcare have the resources and abilities to obtain it. I became a doctor to help others and I would love to function in a system that facilitates it. But I cannot stand behind a system that squeezes doctors and hospitals to the point that they can no longer uphold their oaths to serve. Let's get rid of the SGR, and let us docs do our jobs without the vise-like reimbursement pressure.

GPS for the Operating Room

I have gotten to the point at which I won't buy a car unless it has a navigation system installed. I am not sure if it is laziness, or an attraction to technology, or simply that I am tired of learning and remembering directions. Whatever it is, I consider the GPS system absolutely essential; to me, it is on the same level as airbags, anti-lock brakes, power steering and at least 6 cupholders.

The same type of navigation technology has been used in neurosurgery for years. We have been using equipment that enables neurosurgeons to triangulate coordinates within patients' brains in much the same way that the satellite system orbiting the earth is able to triangulate coordinates on the surface of the planet. The equipment is so precise that we have been able to achieve sub-millimeter accuracy- this translates to being able to safely and accurately guide our instruments to the region of interest (i.e., a brain tumor) with smaller incisions, and with less damage to the surrounding regions. When you are talking about a 5-millimeter tumor that is 60-millimeters below the surface, it means a tremendous amount that we know exactly where we are going.

Neurosurgeons and their patients have been enjoying the benefits of these navigation systems for years. But there is a catch...


They were terrible when it came to spine surgery.


Inaccurate. Cumbersome. Time-consuming. I tried them several times for complex spinal operations when I was in Florida, and each time that I can remember, I abandoned the use during the case because my own "internal GPS" disagreed with the system and I didn't think it was safe for the patient to continue to use it at the time. I figured, when the time was right, the technology would improve to the point that it would become useful for spinal operations.

Well, the time is now right. When I came to the Bay Area in 2005, I was tasked with helping to build a spine center of excellence in the East Bay. The first piece of equipment that I identified as an essential piece of the puzzle was the "O-arm", a first-of-its-kind device that, for the first time, merged the the cranial navigation technologies with the complexities inherent in the spine.

You can think of it as an intra-operative CT scanner for spine surgeons. In a "real-time" fashion, we can capture 3-dimensional images of the patients spine, showing us unparalleled anatomical details, and use those images with intra-operative navigation. Think of it as the GPS system in your car, except that the system is constantly taking new pictures of the roads from space, allowing you to instantly change direction if needed.

The O-arm is remarkably accurate, and can be used in a variety of different spinal operations. Eden Medical Center purchased one in 2009, and we have been using it for almost 6 months now. Many of the complex degenerative and deformity cases have been dramatically simplified with its use, but its true utility shines in traumatic cases. Spine injuries from falls, accidents, assaults (and a ton of mechanisms that I can't think of right now!) are amongst the toughest to treat. The fractures and soft tissue injuries can be extensive and unpredictable and oftentimes, difficult to characterize for the surgeon. The O-arm allows us to visualize these complex injuries, navigate them with precision, and repair and reconstruct the patients normal anatomy.

I think my patients benefit from the O-arm to degrees that many of them will never know. I don't need it for every spine surgery, but I am definitely grateful to have it when I do need it.

Come to think of it, the GPS in the car is much the same; I don't need it for every drive, but I am definitely grateful that it is there in some neighborhoods...

Welcome!

My intent with starting this blog is to have a place to discuss topics that are of interest to my patients. It will be a casual forum, hopefully informative and thought-provoking at the same time.

I don't intend to use this as a substitute for medical advice between a patient and his/her doctor; most of the posts will likely be experience-based rather than derived from textbooks or the medical literature.

Our website is www.pacbrain.com. You can visit us there until the blog is officially up and running.