Wednesday, April 25, 2012

Wednesday Editorial

TSB spent some time looking at the Agenda and the topics for discussion for the upcoming 9th Annual STEGO meeting that will be held in beautiful Carlsbad, California.  Interestingly, the most obvious topics that jump out at the casual observer are entitled, "Can Future Coverage of Lumbar Cases Be Secured, The Changing Economics of Spine, The Value of Spine, How Can the Industry Participate in the Value Debate, and Venture Capitals Perspective."

Whether one agrees with the old adage, one must admit, Einstein's definition of insanity continues to rule the medical device industry.  Failure in the American Healthcare System is not some aberrant occurrence, because in reality we don't have a healthcare system, we have a system that is built on taking care of the sick.  The word "system" is defined as an assemblage of things or combination of things forming a complex or unitary whole. The word denotes organization.  So the question must be asked; is the industry really concerned about helping the patient and improving the outcomes?  Far too often, economic incentives dictate how the patient is managed with the goal of maximizing everyone's cut in the food chain, especially when it comes to medical devices. Don't believe it?  Would a topic like "The Changing Economics of Spine" have been on the Agenda ten years ago? How about "The Value of Spine?"  TSB is sure that our favorite commentators will surface to call out our socialistic opinion, yet TSB must admit that every time someone states that the United States has the greatest healthcare system in the world, I must admit, I laugh. There is a fundamental difference between arguing that we have the greatest system at inventing emerging technologies, some would dissent with that opinion, and that we have the greatest healthcare system in the world. Sometimes there are people that are out of touch with reality, or, enjoy lying to themselves.  The fact remains that America is the greatest place to get medical care if you have the ability to pay for it, it's not a great place if you are uninsured or for that matter, poor.  So TSB did a bit of research using publicly available information from the CIA, yes fellow bloggers that CIA,  and found the following information incredibly educational;

The average life expectancy for Americans is 78 years of age, this ranks us 50th among the world.  This information takes into account murder, accident rates as compared to other first world countries.  Our infant mortality rate ranks us at No. 44.  The U.S. per capita health care spending is the highest in the world.  We spend two and a half times more on healthcare than we do on food.  By the year 2019 our cost of delivering healthcare will roughly be $4.5 million dollars, accounting for 19.3% of our GDP.  It is argued that by the year 2025 healthcare will account for 25% of our total economy.  The truth of the matter is that our "System" fails to stop expensive, unnecessary, and frequently harmful intervention even when proven that these interventions are wrong.  Essentially, when one reviews the Agenda and the aforementioned topics, one can immediately sense that the industry and its surgeons are concerned at sustaining a system whereby the participants can continue to suck out as much money out of a broken  system, before everyone is forced to make change.  And whether you agree with it or not, you will be forced to make a change,  and change will be an unwelcome guest at the party.

The recent debates and scare tactics surrounding reforming healthcare is political theater at its best. Those that argue about rationing healthcare fail to comprehend that rationing already exists, don't believe it?  Ask the spine surgeons at this meeting how many or them or their staff spend their day arguing with insurance companies that want to reduce their cost by telling them that they cannot perform a specific procedure?  Haven't we heard that before? Don't believe it?  Why would there be a topic like, "Can Future Coverage of Lumbar Cases Be Secured?" Why do topics like this exist? Because the medical community has proven over and over again that rather than using medical intervention rationally to benefit patients, many have a propensity to use technology to maximize revenue. Why can't there be a discussion at providing medical care at a lower price? Has anyone seen that topic on the Agenda? Isn't it possible to have innovation at lower costs? Do we have to choose?

When one looks at the scope of the Agenda, it is evident that financial incentives play an important role in medicine and they should, but decision making based purely on profits have a effected a devastating impact on the system.  It's been proven that doctors that have ownership in MRI's or labs are been shown to order more tests.  So doesn't anyone doubt that doctors that are paid consultants have a propensity to use more hardware? Or doctors that have ownership in POD's or POC's use more product? How many start-up or early growth stage companies would exist if they didn't have their physician investors using their products? Have we ever seen a meeting where the spine community talks about the methodology that can be utilized to police their own profession? No! Because collegiality takes precedence over the well being to the patient. Based on the surgeons that continually are invited to these meetings, the who's who that are surgeon advisors on multiple companies, it is difficult to challenge an incorrect consensus when it walks to the same beat.  So the question must be asked are evidence based guidelines anything but evidence based guidelines, or is it another way of protecting each and everyone's stake in the game?  Regardless of whether you have a medical degree of not, how many of you have seen surgeons perform surgery on patients that could have benefitted from a conservative treatment?  The syllabus spells intervention and not any conservative modality of treatment.

So the question must be asked, has the system been built on greed and fraud? Has the system built on billable trial and error? Obviously the industry isn't preparing for the future, it still believes that it's business as usual blaming everyone and everything for the current environment rather than performing due diligence on its own behavior, until then, let's party like its 1999!  TSB wants to know what our readers think?

"You can check out any time you want, but you can't never leave!"


  1. MM- I think you have underestimated the influence of the insurance industry in your blog, yes you mention the difficulties they present, but IMHO they are at the root of many of our collective problems.
    As you admit, physicians and hospitals have to hire huge numbers of personnell just to file and collect on claims filed. How much extra does that cost??
    Add to that the "games" these insurance companies play with those claims...add to that the "games" the providers have to play to try and get paid a reasonable fee for service. How much extra cost does that add to Healthcare??? and not just in hard dollars, in time and effort!
    All of us are so quick to blame the surgeons/hospitals, but when the CMS CPT coding manual changes as often as the tax code and is similarly as complex what should we expect??

    You claim that far too often it is the economic incentives that drive the quality of care a patient receives, and that is not my personal experience, but you are entitled to your opinion.

    I would suggest a sales rep take some time and listen in on a few calls between the hospitals/surgeons and the insurers. From pre-certs for MRI's to Pre-certs for surgeries to follow up care, it is a battle along the entire continuum of care! And don't even get me started on how much of the bill is paid even after it is pre-certed! The patient and provider both are left awe-struck at how little was actually covered. Thanks to the ever confusing insurance coverage contracts that no one can decipher (except the ins. companies themselves) we are all left to ante up even more $$.

    Now, multiply that by 10000 with Obamacare, after all if the insurance companies can get so fat off of us, the gov't can get even fatter....and at the same time tell us they are "helping us"
    If Obamacare is passed everyone better get used to the phrase..."as was determined by the HHS Secretary"

    1. so should i get into the insurance biz?

  2. Men will occasionally stumble over the truth, but most of the time he will pick himself up and continue on.
    - Winston Churchill

  3. Every single person, group, company, institution is trying to grow their revenues (profits) in healthcare (even the non-profit organizations). With the government putting the insurance industry on a pedestal above other entities in the system, that drives a cascade of activities from everyone else to try and grow their revenues. And the direction the govt is going will only make things worse. What stinks in all of this is that there are patients that are suffering because of this machine that has been built. What I would be curious to know is how many suffer vs how many are benefiting, because there is also a whole lot of greatness that comes from the US system as well (though as TSB mentioned, it may only be great for rich people).

  4. TSB raises a very salient point and one I have never quite wrapped my head around.

    Considering the personal and public costs, the less than world-leading healthcare metrics and the tortuous experience most of us endure getting and paying for a health incident, how can one be satisfied in saying that we have the best healthcare in the world?

    I think we have best and most advanced medical treatments in the world but as a healthcare system what is the evidence to say that little can and should be improved? More importantly, what is the incentive to demand improvement with such a position?

    I tend to see the "America has the best healthcare in the world" line as one in a growing catalog of uninspired and unsatisfying political slogans that seem to infer if you question or doubt the superiority of an American Institution you are, by association, questioning the American ideal / culture / people / insert noun here.

    For something as complicated as healthcare, there is undoubtedly benefit for many to package the issue up in a slogan and then move on. But to me, there is something, I guess, un-American in the concept that we should be satisfied in claiming we are the best as a way to discourage discussion on how we might get better.

    But in the age of "Taste Great / Less Filling" public discourse where mouths dominate ears, I have little, nay, zero, optimism that most people are interested in changing their mind.

    I say keep the fee-for-service, lawsuit ridden circus going until it burns down. Because in the end, necessity is the mother of invention.

    1. go back to Tora Bora Osama! You're with the ter'ists!!!!


  5. 1. America remains the country that best fosters a climate for invention
    2. Those inventions are made in >50% of cases by first generation Americans
    3. On a per capita basis the French lead the world in medical inventions and discoveries
    4. The 'healthcare' system in the US is the most expensive, and probably the most cumbersome and least efficient in the world. Obamacare will neither improve or worsen that.
    5. Insurance companies do not have the best interest of the patients in mind
    6. Spine is an area of medicine where a continued and significant lack of understanding of the diseases (especially DDD!) has led to a plethora of unproven yet expensive, invasive and sometimes debilitating therapies.
    7. Because of 6, spine has attracted a disproportionate number of unsavory characters, both in hospitals and industry.
    8. The STEGO meeting is a showcase of point 7......

    I subscribe to the conclusion of 11.02; let the system run itself into the ground and than rebuild. In the mean time, if you have just back pain, keep a minimum distance of at least 10 feet from any spine surgeon.

  6. 11:45

    11:02 aka Bearded Lady Here. Agreed!

    I couldn't agree more with respect to Obamacare.

    In its current form it's an overwrought series of laws that will likely expand but not improve healthcare coverage. Worst yet there appears to be little if any mechanisms to address the 800lb hemorrhaging gorilla called cost. Now try to imagine it without the personal mandate? Stay tuned!

    I hope it's the first pass on the road to true reform. The system is unsustainable and needs fixing. Putting it into a larger unsustainable system that needs fixing is not the final answer.

  7. Obamacare is just another law to funnel money from the general population & private companies to special interests aligned with the party that drafted it.

    It will not make care better or cheaper. Probably the opposite. That is usually what happens when governments intercede in markets. I suspect we'll end up looking a lot like the NHS in England if it isn't struck down or repealed. Let's just hope it doesn't end up looking like old Soviet universal health care...

  8. ENOUGH ALREADY! For those of you who incessantly cite the ranking/average life expectancy of the US (or any country) as the telling indicator of the effectiveness of its healthcare system, (insert Tommy Boy voice here) please for the love of rational thought... STOP IT! Those who do so are either politically savvy and know better or have not thought out the issue. There are countless other confounding factors that affect life expectancy. Ask a physician what kills patients faster than obesity, smoking, and stress. The US has the highest obesity rate in the world... by a mile. The top 5 industrialized countries in life expectancy also have among the lowest obesity rates in the world. Mere coincidence? A quarter of our population smokes and we consistently rank at the bottom in vacation days (again, by a mile) and near the top for hours worked. Also, if you must look at rankings for comparison, look at developed or OECD nations. The 50th ranking in life expectancy cited above must be put into proper context. It includes approx. 20 island "nations" with populations in the tens of thousands. The country that ranks #1 in the world in LE at nearly 90yo, Monaco, is essentially a giant resort in the South of France with a population of 30,000. They have no income taxes, have zero unemployment, and live in as close to paradise as is imaginable. Where does their healthcare system really rank in terms of relevant factors contributing to their LE? That the US lags only a few years behind leaders (real countries) in LE (ie. Japan) in spite of being the fattest and among the most stressed, is a testament to the quality of our medical care, not an indictment of it. The US does have the best medical care in the world, period. We do not have the best system and TSB is spot on here. We have a major cost/overutilization problem. Anyone who thinks our system doesn't need a major tweak is just plain wrong.

    1. The US does not have the best medical care, but it could have. It doesn't because the patients well being is only of quinternary interest, after the financial interests of the insurance companies, the hospitals, the industry and the clinicians, especially when they are surgeons.

    2. so let's look at other countries who spend less per capita (yet another entirely irrelevant statistic) where the patient's interest [comes first]"... In Britain, if a pt has a ring-enhancing lesion in the brain (looks like a glioblastoma and most often is) they will be radiated with no further tests to confirm the diagnosis. 5% of pts with no known cancer that have a ring-enhancing lesion actually have an abscess, not a tumor. so, that 5% essentially gets a death sentence; not to speak of a significant number of the remaining 95% who don't have a GB but rather a much more treatable tumor. Translation: Effectively 100% of people with a ring-enhancing lesion are going to die. But, I'm certain they take more time to explain to these people that they are screwed regardless of their true diagnosis. This lowers that all-important metric that all too many are fixated on... Britain spends way less per capita and than the US. Release your dogma and let it get flattened by a passing truck.

  9. I completely agree with the post above. Obesity, smoking, sedentary lifestyles and an overall lack of control contribute greatly to the life expectancy equation. It also is predictive of the success of any proposed preventative care programs. While great in theory, that 400lb guy I saw smoking a marlboro outside of McDonalds is probably not gonna be a compliant preventative care patient.

    People in America are motivated by money. It is the reason surgeons get loose with surgical indications. It is the reason companies and reps try to upsell everything in the bag regardless of whether or not they believe a product is useful. It is a main reason for the existence of consulting agreements and campaign contributions. To lower cost and promote health, pay surgeons a salary instead of fee for service and allow insurance companies to charge that train wreck mentioned above a premium for his health insurance that is proportionate to his increased risk instead of letting him slide into the risk pool with the rest of us. Surgery volumes will drop dramatically and that fat bastard will quit eating whoppers and chasing them down with an oreo blizzard and a cigarette. I don't want any new taxes but I say tax the shiite out of cigarettes and fast food and give premium discounts for weight loss and smoking cessation. Then take all of the reps off of straight commission. If you can take the financial gain out of over utilizing services and products and put financial gain into achieving better outcomes AND reducing costs for docs, then put patients into the same situation with their own health (higher costs for the fat ass, lower for the gym rat), then you will see the tide turn.

    Its sad to have to bribe individuals to give a damn about themselves, but if we are all paying for their bad decisions, then I am OK with it.

    1. Agree with all you say, except the cigarettes. Already in 1997 NEJM published a study that showed that if all smokers quit tomorrow and everything else remained equal the cost of healthcare would briefly dip and than stabilize at a higher level than before. The explanation is simple: heart attacks and lung cancer are cheaper than Alzheimer's and diabetes.

    2. Smoking doesn't cause Alzheimers or diabetes to my knowledge, but they do cause heart attacks (quick and cheap unless you survive it), lung cancer which is fairly quick but not cheap, COPD which lasts a long time and not cheap, emphysema, other cancers, poor healing and overall poor health. You will never convince a rational person that we shouldn't try to end smoking because it would be cheaper for the healthcare system.

    3. N Eng J Med 1997; 337:1052-1057, freely available on line.

    4. ... and of course studies are infallible. especially if they're in the NEJM

    5. Just looked at the study. Yes, overall healthcare cost go up if people live 7-12 years longer. But in every single year of a persons life, smokers healthcare cost are higher, as much as 40% higher than the non-smoker according to the study. So it is easy to extrapolate that if everyone smoked, their healthcare costs would go up and they would die sooner. The fact that the non-smokers live longer, and contribute to healthcare payments, should not be used as an argument to promote smoking in an effort to lower healthcare costs. It doesn't seem that the study adjusted the costs for the fact that fewer people smoke than do not. They also didn't factor in that under our system, as long as you live, you contribute to the payment of your healthcare so the total bill to the government would not necessarily go up because people live longer. That was also among the Dutch, who probably don't have the same degree of compounded health issues as obese Americans. Thats just a guess.

  10. Interesting point however, the data that MM uses doesn't establish a correlation between national healthcare expenditures and life expectancy.

    Analyzing the life expectancy statistic is missing the forest for the trees. It's important, but the real take away is that many developed nations spend less on healthcare and benefit more, oh and by the way they live longer.

    The real question is while healthcare is rapidly growing as a percentage of household expenditures why are we not getting more for our money? I see the international data as less a guide of what to do than as way to highlight the context of our situation.

    The problem is with incentives and a lack of true market forces.

    Healthcare providers are incentivized to treat disease not necessarily prevent it.

    Healthcare providers are incentivized to do as many diagnostic tests (fear of lawsuits) and interventions (fee-for-service) as possible.

    Healthcare providers are not systematically incentivized to evaluate the cost of the care they deliver.

    Vendors need a 5% price increase annually.

    The payers are, after the work is done, highly incentivized to control cost.

    As for the patients they can't negotiate cost because they are unaware of it, they're focused on their medical issues and likely mis-comforted with the thought: "Thank the lord I have insurance." And while insurers can pay pennies on the dollar of what a hospital bills, a patient will likely see the working end of a collection agency if they don't cough up the money.

    In lieu of full socialization, we are going to have to create a model that harnesses the efficiencies of market forces while balancing our personal desires of top-tier care and our collective duty to ensure people aren't needlessly dying due to lack of basic care.

    This is doable with motivated parties. At present, vendors, providers and payers show very little signs of making the concessions needed and by default are putting hard work at the feet of highly partisan and ineffective government. The irony is no one wants socialized care, but they'd rather lobby senators than make concessions.

    Oh and as to life expectancy. It will take a generation of concerted effort to unwind the distorted and destructive patterns we developed. And like the tobacco battle of the 80's and 90's unfortunately it will take external forces to change behavior. Because, sadly, in a nation that so readily espouses the values of self-reliance and personal responsibility we demonstrate very little self-control when we get the question: "Do you want fries with that?"

    1. So people in the virgin islands and Monaco live longer bc their healthcare system is better/more efficient? Please people. Use your brains

    2. That is a very good post. But I would like to know how you deduce that other developed nations benefit more from their healthcare systems that cost less. I think it is hard to argue that access to care is easier in the US for the insured patients. I think it is also hard to argue that other developed nations expectations for healthcare are as high as they are in the US. We want our MRI and we want it this week, and we normally get it. I think the perceptions and the expectations play a huge roll in a persons satisfaction with the healthcare they have. In other words, a British man would probably marvel at the number of diagnostic tests available to him for otherwise simple and benign conditions. For the most part, those tests are overused here and unnecessary but we have come to expect that. Maybe some rationing would reset our expectations to a reasonable level.

    3. I argue that maybe you can get your MRI within a week, but you cannot find any clinician who is willing to spend more than 3 minutes explaining it to you, 2 of which are spent covering the legal bases. Good healthcare is so much more than access to high tech tools, and that's where the US falls on its face.

    4. Fraud and revenue "mining" are huge problems. Get on the OIG website and sign up for emails for enforcement actions. There are scams posted every single day and we all know they haven't touched the tip of the iceberg. By revenue mining,, I mean the active search by clinicians and vendors to find ways to make money in the system and then applying those methods to patients. For example, a rep for a nerve conduction study device tells one of his surgeon buddies that he can bill $X for a nerve conduction study and the nurse can do it and it only cost $y so the doc starts ordering nerve conduction studies on a bunch of patients when he never used that diagnostic tool in the past. I'm not picking on nerve conduction studies, I completely made up that example, but we all know of such things. In office prescription dispensing, bracing, bone growth stimulators, various blood test kits, etc. We also see it in the OR in the form of facet dowels to bill for a fusion on a case that normally would only be a discetomy, changing to peek cervical spacers to bill the inter body device code since you can't bill it for bone anymore, etc etc.

      This kind of thing goes on uniformly throughout the medical professions and results in huge expenditures of unnecessary treatments and diagnostics with no perceived or intended benefit to the patient. Only for the dollars.