Category Archives: NaBloPoMo

Today, Lisa and I performed surgery . . . right there next to the Macy’s at the mall.

We were there after another of my early morning swim classes—where I learned to kick better—and an 8-mile run after I got home from that. (Hey! Don’t look at me that way. I’m going to be on a plane to Los Angeles tomorrow when I would normally be running, and we all do what we must to get by, right?) We needed to have lunch, get something to organize my exercise clothes—which runneth over—and to get Lisa a coat. We had a bit of time to kill between when we were done shopping and the 2:30 showing of “Wreck It Ralph” (which is fun for all ages) so we decided to look at the two big robotic surgery devices that Brigham and Women’s Hospital had set up.

“Would you like to give it a shot?” Honestly, I wanted to get my hands on the actual device that people were using to place small rubber bands on little spongy rubber mountains that wiggled when you bumped them with the probe the wrong way. (“Well I just botched that poor bastard’s laparoscopic prostate removal. Sorry.”) But the simulator would be just fine . . . for a start.

“You play video games?” It was easier just to say yes than to explain that, while I love playing first-person shooter games, I always have horribly violent dreams afterward. So I don’t actually play them anymore. (We’ll see if I have dreams tonight where I’m beating up terrorists’ innards while performing their bariatric bypass surgeries.) “You know how you eventually don’t have to look at the controller and can just do things by feel and intuition? Well, that’s what this simulator is for. Doctors can spend hours practicing before operating on living patients.”

“Okay, put your thumb and middle finger through the two loops on each handle, look through the goggles, pick up the colored ‘jacks,’ and place them in the ‘dish’ of the same color.” In the viewer I could see a CGI scene of computerized jacks, dishes, and my claws. I took a moment to familiarize myself and then I went to town, moving the misplaced appendix—I mean jacks—to their appropriate place. It reminded me of a miniaturized version of the nuclear fuel handling device I played with at the museum in Arco, Idaho. I did pretty well on my first try (78%) and I got a few pointers for the next time—whenever that might be.

Then Lisa gave me the shopping bags and gave it a whirl. Turns out, she is the one you want doing your surgery. Girlfriend got a 94% on her first go! She was quick and efficient, just like she is in real life. No risk of virtual patients bleeding out while Lisa Mather, MD, is at the controls.

After that, the machine with real-world objects opened up, and I moved little rubber bands onto springy little mountains that had chunks taken out of them by obviously less skilled hands. Lisa didn’t give this one a shot, but I’m sure she would have done it better than I did. (She graciously said that I was better than most of the people we had seen playing earlier.)

It was interesting and fun and very space-agey, yet I couldn’t help wondering whether the $2.5 million dollar machine was worth the cost? Did it give better results? Everything the manufacturer reps said seemed to indicate that it would be—better motion control, less fatigue for doctors, less pain and trauma for patients, the ability for surgical specialists in one country to treat patients in another—but the proof is in the peer-reviewed studies. They assured me that there is published research that says the outcomes are just as good or better using robotic surgery, but (if I were needing surgery) it’s something I would want to check out for myself.

But I had a lot of fun playing around with medical devices. It reminded me of the time several years ago when I went to RSNA, an enormous convention dedicated to radiology. I was killing time before a session when a GE Healthcare rep saw me. “You there! Come try out the new workstation.” I think she assumed that I was a radiologist, and the next thing I knew I was sitting down in front of a very powerful computer performing a virtual colonoscopy next to actual radiologists (who did know what they were doing) with their own displays.

When the device rep told us all to navigate to a particular anatomical structure I felt like I was Chevy Chase in “Spies Like Us.” I might have leaned back in my chair so that I could steal a glance at my neighbor’s workstation. Eventually I gave up any pretext of following along, but I remember thinking, “This is soooo cool! I’m making a movie of flying around in some dude’s colon. Yippie-ki-yay!”

If you need any medical treatment, go see a real doctor. But if you want to play one on TV, hang out with me outside the Macy’s at the Natick Mall.

What if there were a way to reduce the cost of healthcare in the US by $100 million? There is. “What is it?” you ask. Read on.

As a result of some work projects, I subscribe to a couple of e-mail newsletters about radiology. One targets radiologists, while the other aims at the people (like me) who build solutions for those medical professionals. Usually I’m too busy and delete the messages without reading them, but every so often I’ll dig in a little to find out what’s coming down the road that we might need to respond to. There rarely is anything, but I find the behind-the-scenes view of healthcare fascinating.

The two biggest nontechnical issues that keep coming up are (1) shrinking reimbursement rates, and (2) increased utilization of an ever-growing number of expensive scanners. MRI and CT machines can cost in excess of $3 million each, and there’s a desire to push lots of patients through them to recoup the cost. The US federal and state governments (through the Medicare and Medicaid programs) try to rein in the unnecessary use of these devices. And a lot of private insurers follow the federal government’s lead when it comes to the rate that they will reimburse imaging clinics and radiologists. (Remember, only suckers—and the uninsured—pay the full “asking price” of medical care.)

It’s a huge problem. The radiologists feel squeezed, being asked to do more work with less money coming in for each case. The hospitals feel like they’re caught up in an arms race with each other to have the “best” equipment and with smaller imaging clinics which use older, less costly equipment and have higher reimbursement rates because they see more patients with private insurance. And patients (god bless us) don’t really know which imaging procedures we need or which imaging providers are the most cost-effective. When we’re feeling sick (or worse) and the doctor says to get a chest X-ray—and BTW here’s where to go to get it—we don’t really call around for the best deal. We just do what’s recommended.

One recurring theme is physician self-referral for radiology services. What’s that? Here’s how a 2002 article in the American Journal of Radiology described it:

Self-referral takes two principal forms. A physician who is not an imaging specialist (or a nonphysician provider, such as a podiatrist or chiropractor) directing patients to his or her own on-site imaging services was the first form of self-referral. Common examples are obstetricians (or their staff) performing sonographic examinations, internists performing and interpreting chest radiography, and orthopedists performing and interpreting musculoskeletal radiography. We include in the concept of self-referral all radiologic imaging done by nonradiologists because the financial incentives are the same regardless of whether a particular type of imaging is predominantly done by nonradiologists, which may affect its quality. The second form of self-referral consists of physicians referring their patients to outside facilities in which the physicians have a financial interest. This second form, which is often called “joint venture” self-referral, has been targeted by federal legislation with respect to services for Medicaid and Medicare patients. Some states, but far from all, have similar legislation applying to non-Medicaid and non-Medicare patients. Because coverage by legislation is incomplete and arrangements exist that attempt to avoid the effects of legislation, we include this form of self-referral in this review.

A host of claims, both positive and negative, have been raised regarding self-referral. The most prominent concern is that inherent conflicts of interest stimulate excessive utilization of health care services and thus generate excessive costs. Quality of patient care, access to services, and patient safety can purportedly be compromised because financial interest might dilute norms of care and quality assurance. Physicians who refer patients to their own services on-site are nonradiologists. Arguments are made that such physicians are generally less qualified because of a lack of relevant training and experience; order more, and more inappropriate, procedures; produce images of poorer technical quality; and are more prone to errors of interpretation than are radiologists. Self-referring physicians’ facilities may have poorer quality control of equipment maintenance, calibration, and film handling. Similar concerns are raised regarding referral to an outside facility in which the physician has a financial interest, with particular focus on higher utilization, poor access to services by underserved populations, and inadequate quality control.

Proponents of self-referral to a physician’s own on-site services argue that such self-referral is convenient for patients and physicians. Proponents maintain that some problems such as a fracture should receive imaging and treatment at a single office. Proponents also say that quality of care can be better in self-referral settings because the treating physicians are better qualified to interpret diagnostic tests relevant to their specialties and have better insight into the specific patient’s problem. Furthermore, physicians may commit diagnostic and related treatment errors as a result of foregoing tests when referral to a radiologist is inconvenient. Access to care for underserved geographic areas might be better with self-referral because of the greater availability of financing for imaging facilities. Finally, economies of scale and the presence of physician owners who are familiar with the patient and his or her financial limitations may help control costs

Okay, that’s what it is. But is it bad? Yes, says the same article:

In short, self-referral constitutes most of nonhospital radiography and sonography and results in utilization and costs usually two or more times as high as in its absence, with overutilization likely; and self-referral generally involves poorer quality.

And this is where the $100 million figure comes into play. The radiologist-focused AuntMinnie.com site reported last week that

A new report from the U.S. Government Accountability Office (GAO) takes a hard line on physician self-referral of imaging services, detailing more than $100 million in annual unnecessary spending in CT and MRI alone. The report recommends steps to curb the practice, including a pay cut for self-referred imaging studies. . . .

The report estimates that in 2010, healthcare providers who self-referred likely made 400,000 more referrals for advanced imaging studies than they would have if they were not self-referring, and these referrals probably cost Medicare $109 million. The referrals are particularly problematic for CT, as they are exposing patients unnecessarily to ionizing radiation.

The report makes several recommendations to help the U.S. Centers for Medicare and Medicaid Services (CMS) identify and rein in self-referred imaging studies:

• The CMS administrator should insert a flag to identify self-referred imaging studies on Medicare Part B claims forms. Providers should be required to indicate whether the services for which they are billing are self-referred.
• CMS should implement a payment reduction for self-referred advanced imaging studies to recognize the efficiencies that occur when the same provider refers and performs a service.
• CMS should develop tools for ensuring the appropriateness of self-referred imaging services.

That $100 million is just what taxpayers kick in for Medicare. The overall impact to the health care system would be much larger if the changes could be applied to people with private insurance, too.