Maintaining Perspective With Changes In Coverage For High-End Products

Approaching my 10th year in practice, I have seen more than a few changes, not only in the field of healthcare but also in the field of pharmaceuticals. As a resident, I caught the end of the era of golf trips, high-priced dinners with wine and baseball games with unlimited snacks. As I began practicing with my multispecialty group, I was still seeing weekly lunches and Starbucks, which ended up being a second cup of coffee for the morning.

Today, I have to buy my own pens. Fortunately, I have been using electronic medical records (EMR) for the past six years so that has not really affected me. As a runner, I do not miss the lunches because my backpack is filled with fresh fruits and raw veggies to get me through the day.

The biggest impact I have seen is with products I am allowed to use in the OR as well as wound centers. Eight years ago, I was able to choose the latest and greatest plates and screws available for fixation as well as hammertoe implants. Then more and more surgery centers started tightening up their budgets as the physicians who were owners were seeing less reimbursement. Basically what was happening was the insurance companies could only reimburse a certain dollar amount for a case and the implants were costing way more than the collected fees. It is not a matter of greed at this point. It equates to keeping the facility running. The representatives for these high-end products then had been advised to bring some of these products to the hospitals as they are able to bill for the individuals’ devices and implants, which makes the case more affordable.

This became a challenge for the physicians who have block time at a freestanding surgical center and are easily able to perform several cases in the morning and head to the office in the afternoon. Now they had to rearrange their schedule to do a 45-minute hammertoe implant at a hospital just to get the implant or device covered.

As time progressed, hospitals began watching their numbers more closely and began seeing that certain healthcare plans (both private and Medicare) were either lowering reimbursement rates or refusing payment altogether on select implants. Imagine scheduling a case and having to call a patient who has a high-end popular private insurance policy and tell him you cannot do his surgery because it is going to cost too much.

Where am I going with this? My point is that just because there are new devices on the market or advanced wound healing products available does not mean that we have to use them. Each physician needs to be well informed of indications for products and devices before using them.

For example, there are numerous agents available to help advance the stages of wound healing with some of them costing over $1,000 per application. While the patient may meet the requirement for this product, ask yourself, “Is the wound going to heal without it?”

Don't feel that you should use the product just because it will be "covered." We definitely want to do what is best for the patient but sometimes the best doesn't mean the newest and greatest.



Ron Raducanu DPMsays: March 18, 2013 at 1:40 pm

Interesting Blog.

I'd like to make a couple of comments on some of things you wrote about.

1) Freestanding surgery centers in some states are owned by physicians. It IS a matter of making a profit. The owners want their monthly checks due to shareholders.

2) It is not up to us as physicians to call patients if their insurances don't cover implants we want to use. It is up to the facility that won't "let" us use the product. We must be our patients' biggest advocates. If we won't insist on the products we think are the best for our patients, who will fight for them? We don't make the reimbursement decision. The patients' insurance company does. If there is any controversy over this, I invite patients to contact their carrier and discuss it with them.

3) When a wound isn't healing is when I would imagine most of use products to help them along. That's when I use them. I wouldn't just use a product just because.

Ultimately, we have to be our patients' protector. I don't own a hospital nor do I own a surgery center. I use the products I think are in the best interest of my patients. The line I use to the hospital's administration is this: "This is the product I think works best in my hands and my patients do very well with it. If I was treating your family member, this is what I would recommend for him or her. Wouldn't you want that for YOUR Mom?" That usually sways them. If the hospital/facility will not "let" me use the product, I will and have sought other places to work that will let me do the best for my patients.

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