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March
22, 2010 |
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Call To Action:
Senate Health Care Reform Bill Passed
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 By John Early, MD
President, Texas Orthopaedic Association
Yesterday, the Senate health care reform bill was
passed by the House of Representatives. Please read
the following AAOS message and stand ready to fight
for the changes we need to take place in this flawed
bill when the budget reconciliation package is
considered by the Senate.
You can also read the
Dr. J. James Rohack, AMA President comment that
"AMA
will work with Congress and the administration to
make critical changes that cannot be addressed
through the reconciliation process."
You
can read the full article
here.
Dr. John J. Callahan, AAOS President, sent you this
message.
"While the House's vote today sends the Senate
health care reform bill directly to the White House
to be signed into law, they have also sent the
reconciliation package to the Senate. This package
aims to retroactively change parts of the Senate
bill to the liking of the House.
Senate leadership pledged that they would address
House concerns through budget reconciliation, but
with the Easter/Passover recess approaching and
Senate Republicans pledging to fight, there remain
questions about if, or when the reconciliation
package will be considered. Should the Senate
Democrats follow through on their pledge; the AAOS
will continue to push for the changes we have
outlined since the Senate bill was first announced.
As stated previously by the AAOS, we opposed the
flawed Senate bill for some of the following
reasons:
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An unaccountable Medicare Advisory Board. This Board
would grant an unelected body authority to make
policy and payment decisions about the Medicare
program without sufficient checks, balances, and
the oversight from elected Members of Congress
that Americans deserve and expect from their
government.
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No reform of the Medicare flawed physician
reimbursement formula.
With practice costs continuing to rise in the
face of devastating cuts due to the Medicare
Sustainable Growth Rate (SGR) formula, many
physicians can no longer afford to stay in
practice or to accept Medicare patients. By not
repealing and replacing the flawed physician
payment formula, this legislation severely
threatens seniors' ability to access timely and
appropriate care from their physicians.
-
Mandatory participation in the flawed Physician
Quality Reporting Initiative (PQRI).
This program is still experiencing significant
problems in providing accurate, actionable
feedback to physicians and has not demonstrated
an ability to improve the quality of care
provided to patients. Furthermore, a mandatory
and punitive approach would increase the already
high cost of defensive medicine.
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Direct access to physical therapists. The CMS Innovation
Center would conduct a demonstration project
that would allow physical therapists direct
access to Medicare patients. Current Medicare
law requires a physician to authorize the type,
amount and duration of physical therapy and
other health care services furnished to a
patient. These laws protect patients and ensure
that appropriate, timely treatment is given by
the most qualified provider, a physician.
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Restricted physician hospital ownership. We believe that
physician-owned hospitals are an important
component of our health care delivery system and
strongly oppose the language included in the
bill that would prevent physicians from owning
hospitals in this country in the future.
Physician owners in physician-owned hospitals
have greater control over the facility and the
quality and efficiency of care (e.g., scheduling
of surgeries, surgical equipment, staffing,
etc.) which lead to higher quality patient care.
Furthermore, these facilities tend to have
greater patient satisfaction, reduced costs, and
lower infection rates. We believe it is a
disservice to our patients to eliminate these
successful partnerships.
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Lack of adequate medical liability reform. We believe that
meaningful medical liability reform at the
federal level and/or constitutionally
sustainable state medical liability reforms are
a necessary component of any viable health care
reform proposal. Absent liability reforms,
billions of dollars will continue to be wasted
on defensive medicine, driving up the cost of
health insurance.
Today's vote is clearly not what we had hoped for,
but your many calls to Congress and your continued
engagement are appreciated and are encouraging to
all of us. We will continue to fight for changes
that address our concerns and improve health care
for our patients during the budget reconciliation
process."
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Medicare Cuts ... Please Take
Our Brief Survey
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If
you were wondering about the Medicare Cuts
... Lou Goodman, Texas Medical Association EVP sent this message last Monday.
"The U.S. Senate passed another Band Aid for
Medicare's SGR formula - this time freezing
current Medicare payment rates until Oct. 1.
We don't know if the House will follow suit
before the 21.2% cut comes back again
on April 1. The other piece of the puzzle is
House Speaker Nancy Pelosi's announcement
that the House will consider the same "reform" bill the Senate approved on
Christmas Eve. TMA opposed the Senate bill
in December because it was bad for patients
and bad for the profession. It is still bad
for patients. It is still bad for the
profession. We still oppose it."
Now more than ever before, please help us with this brief TOA Survey on
Medicare by clicking
here and using the password: Medicare.
We will compile the results and our TOA
leadership will use this information during
their Capitol Visits in Washington DC during
the National Orthopaedic Leadership
Conference April 28 to 30. If you are
interested in attending the National
Orthopaedic Leadership Conference please
contact Andrew Kant, MD at
kant@ksfortho.com or call TOA
(800) 370-1505.
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This Week In Texas: Mignon
McGarry's Memos
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By Mignon McGarry
TOA Legislative Advocate
TOA Online Version: All Memos
Wednesday, March 17, 2010
The 2010 election is
very important to Democrats and Republicans in Texas
because it will determine who will have the upper
hand in redistricting. You may be asking yourself,
what exactly is redistricting and why should I care?
Generally, redistricting is done every 10 years
after the conclusion of a U.S. Census in order to
equalize population among state and congressional
districts by redrawing the boundaries of a district
to increase or decrease population. Sometimes the
word "reapportionment" is used interchangeably with
redistricting. Reapportionment means the division of
a set number of districts among units of government.
In the United States, we have 435 congressional
seats that are reapportioned after each census among
the fifty states. Texas currently has 32
congressional districts and is expected to gain
three or four more seats after the 2010 Census.
The Texas Legislature is tasked with re-drawing
legislative, congressional and state board of
education district boundaries in 2011 after
completion of the federal census in 2010. During the
interim, legislative committees may hold hearings
around the state to discuss redistricting and
possible effects on local communities. The House has
a standing Redistricting Committee. Although the
Senate does not currently have a standing
redistricting committee, the Lt. Governor could name
a select committee to focus on the redistricting
task. Once the official population data from the
2010 census is received by the state in March or
April of 2011, the 82nd Legislature will begin
drawing maps.
If the legislature fails to redistrict the Texas
Senate or House during the regular session, or the
governor vetoes a house or senate redistricting
bill, the Texas Constitution requires that the
Legislative Redistricting Board (LRB) meet and adopt
its own plan. The LRB is composed of the lieutenant
governor, the speaker of the house, the attorney
general, the comptroller, and the land commissioner.
Any legislative or LRB plan must be submitted to the
U.S. Department of Justice or the U.S. District
Court for the District of Columbia for preclearance
under the Voting Rights Act of 1965.
If the legislature fails to pass a congressional or
State Board of Education plan or the plan is vetoed,
the governor may call a special session to consider
the matter. If the governor does not call a special
session, then a state or federal district court
would draw the plan.
So what's the big deal with redistricting?
Redistricting is all about political power. The
drawing of a district a certain way can virtually
ensure the hold of that seat by one political party
for several years. The 2010 elections take on even
more meaning as the Republicans seek to build on
their current majorities in the Texas House and
Senate and the Democrats seek to chip away at those
majorities.
In anticipation of increased public interest in the
redistricting process, the Texas Legislative Council
has spruced up their website with detailed
information. Check it out
here.
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TMLT Risk Management
Department: Complications Following Knee Surgery
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 The following closed claim study is based on an
actual malpractice claim from TMLT. This case
illustrates how action or inaction on the part of
physicians led to allegations of professional
liability, and how risk management techniques may
have either prevented the outcome or increased the
physician's defensibility. The ultimate goal in
presenting this case is to help physicians practice
safe medicine. An attempt has been made to make the
material less easy to identify. If you recognize
your own claim, please be assured it is presented
solely to emphasize the issues of the case.
Presentation
A 28-year-old man came to the emergency department
two days after a water skiing accident. His chief
complaint was severe knee pain. The emergency
medicine physician diagnosed bruised ribs, and
possible meniscus tear and knee sprain. He
instructed the patient to follow up with his
orthopedic physician in 2-3 days. The ED x-rays were
sent to the patient's preferred orthopedic office,
where he had been treated for previous
sports-related injuries. The patient made an
appointment two weeks later.
Physician action
The orthopedic physician, the defendant in this
case, determined that an MRI was necessary in order
to make an accurate diagnosis. The MRI, which was
conducted on site, showed a torn anterior cruciate
ligament with medial meniscus involvement.
Outpatient surgery to repair the knee was scheduled
for the next afternoon. The surgery went well, and
the patient was discharged with his girlfriend as
the primary caretaker. Written discharge
instructions were reviewed and provided to the
patient and girlfriend. The instructions included
his postoperative follow-up appointment and
prescriptions for pain medication and an antibiotic.
The patient was told to return in 3 days, and to
call the office if he experienced any of the signs
or symptoms of infection as reviewed in the
discharge instructions.
Three days later, the patient did not return for his
appointment, and a phone call was made to his home.
The patient stated that he did not have a ride to
his appointment and that he would come in the next
day. The office nurse asked the patient how he was
doing, and was told that other than some foot
swelling and numbness in his toes, he felt fine. The
nurse noted this in the medical chart, and expressed
to the patient how important his follow-up
appointment was. She also notified the physician of
the missed appointment and the swelling and numbness
mentioned by the patient. The physician contacted
the patient herself at the end of the day to express
her concerns and stress the importance of follow up.
This phone call was documented in the chart.
The patient came to the ED that night with fever,
knee and foot pain, swelling, and obvious signs of
wound infection. There was substantial dehiscence at
the suture line. He told the ED staff that he had
stopped taking the antibiotic on the second postop
day because it made him nauseated. He also mentioned
"banging" his leg around in the boat when he went
out with his friends a few days earlier. The patient
was admitted and seen by the orthopedic physician
the next morning. He was taken to the OR for further
evaluation and repair of the knee.
Allegations
A lawsuit was filed against the orthopedic
physician. The allegations included improper
performance of the initial surgical repair and
failure to instruct and communicate.
Disposition
Expert review of this case included a review of the
surgeon's preoperative examination and assessment,
the operative note, and discharge instructions.
Taking the patient's accountability into
consideration, and the fact that the office
procedures for preoperative appointments had been
well documented, the plaintiff's attorney decided
not to pursue this case any further because it was
without merit.
Legal implications
Fortunately for this physician, her office protocol
for preoperative patients was written and followed.
The informed consent discussion was completed in the
office prior to outpatient surgery. The discussion
was documented, and a copy was provided to the
patient. In addition, this physician used
pre-printed consent forms for surgical procedures
that included the risks, benefits, and alternatives
to treatment. She did not rely solely upon the
outpatient facility or staff to obtain the patient's
consent on her behalf. She also made a brief note in
the chart that the consent discussion was done with
the girlfriend present and the patient understood
and wished to proceed with the knee surgery.
Most favorable for this physician was the documented
office protocol, which was consistently followed for
all postoperative patients. The fact that discharge
instructions provided by the physician to the
patient were orally reviewed prior to the surgery
day, well documented in the medical chart, and
included the importance of medication compliance,
follow-up appointments, and instructions to call if
there were problems, greatly assisted in the quick
dismissal of this claim.
Risk management considerations
• Evaluate and enhance communication with patients
and family members. Communication is the primary way
to ensure efficient outpatient management, proper
follow-up, effective informed consent, and
satisfactory patient rapport. All of these areas
have been implicated in claims when a failure in
communication arises.
• Keep in mind the most common areas of potential
diagnostic difficulties. Diagnostic problems most
frequently involve trauma-related issues, including
hip fractures, shoulder dislocations (especially
posterior), and hand injuries, including nerve and
tendon lacerations as well as hand fractures that
require extra attention (special splinting or
surgery). Failure to diagnose also commonly involves
testing techniques; poor quality or inadequate views
on x-ray.
• Develop practice protocols to guarantee correct
anatomic site/structure. This includes appropriate
level for spinal surgery, appropriate digit for hand
and foot surgery, and appropriate side (right/left)
for extremity surgery.
Analysis of more than 1,000 orthopedic closed claims
reveals that the majority of claims with no clearly
identifiable risk management issue had an outcome in
favor of the defense. However, when a risk
management issue was identified, the plaintiffs
prevailed in a majority of the cases. Common
pitfalls include operating on the wrong anatomic
site, improper performance of the procedure, missed
or delayed diagnosis, misuse of equipment, and
finally, poor communication with patients.
The information and opinions in this article should
not be used or referred to as primary legal sources
nor construed as establishing medical standards of
care for the purposes of litigation, including
expert testimony. The standard of care is dependent
upon the particular facts and circumstances of each
individual case and no generalization can be made
that would apply to all cases. The information
presented should be used as a resource, selected and
adapted with the advice of your attorney. It is
distributed with the understanding that neither
Texas Medical Liability Trust nor Texas Medical
Insurance Company is engaged in rendering legal
services. © Copyright 2010 TMLT. |
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TMB Seeks Orthopaedic
Surgeon Expert Panelists
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Currently,
the Texas Medical Board is in need of
additional board certified orthopedic
surgeon expert panelists. Because orthopedic
surgeons are typically very busy, a
relatively few physicians have offered to
serve as expert panelists for the TMB. As
you can imagine, the TMB receives multiple
complaints against orthopedic surgeons every
year. As a result the discrepancy between
the number of complaints received and the
number of expert panelists available to
review cases, some investigations take
several months to complete. We can all
appreciate the anxiety and frustration felt
by our fellow orthopedic surgeons who are
the subject of an inordinately lengthy
investigation.
You are in a position to help us solve this
problem by volunteering to serve as an
expert panelist for the TMB. The TMB
recognizes the time and effort it takes to
perform these reviews as an expert panelist.
As a result, the TMB will allow expert
panelists to earn up to 6 hours of Category
1 CME each year they serve as an expert
panelist and will compensate $100 per hour
for their time.
As a TMB Board member, I urge you to accept
this opportunity to serve both the
orthopedic community and our patients. If
you are willing to serve as an expert
panelist, please contact the Medical
Director of the TMB, Dr. Alan T. Moore via
email at
alan.moore@tmb.state.tx.us.
Thank you for your consideration.
Wynne M. Snoots, MD
411 N. Washington, Ste. 7300
Dallas, TX
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TOA eConnect Recognized With
All Star Award For Email Marketing
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TOA
was recently contacted by Constant Contact
and was recognized with a 2009 All Star
Award for email marketing.
From their
communication: Kudos
to you!
In 2009, you did email marketing the way
it's supposed to be done.
You stayed in touch with your customers or members
with regular email communications. You made sure
your list was up-to-date and that everyone on it
gave you permission to send them emails. Finally,
you delivered engaging information that your
audience was eager to receive, open, and read.
That's why we named you a
Constant Contact Email
Marketing All Star for 2009 and we want
to congratulate you for being part of this special
group.
Thank you for being a Constant Contact customer -
and for making email marketing a part of your
organization's success.
Best wishes,
Gail Goodman
Chief Executive Officer
Furthermore, from
their website, the criteria for this
award was defined as follows:
A "2009 Constant
Contact All Star" is a customer or business partner
who we have given special recognition for their
email marketing success and
continued commitment to following best practices.
Their accounts qualified for this special status by
meeting all of the following standards of excellence
during the entire year of 2009:
-
Had used Constant
Contact for a minimum of 1 year starting on or
before 12/31/08
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Averaged a bounce
rate less than or equal to 15%
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the TOA eConnect averaged a less than 1% bounce rate
(0.42%) during 2009
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Averaged an open
rate of 20% or higher
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the TOA eConnect averaged a 23.82% open rate
during 2009
-
Sent Constant
Contact emails regularly (in all 4 quarters in
2009)
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Averaged a click
through rate of 2% or higher
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the TOA eConnect averaged a 14.75% click through
rate during 2009
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Received no
compliance related complaints or inquiries
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