Tag Archive for 'Surgery'

Expensive back surgeries are often risky and unnecessary

Published
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Jana
on May 12, 2010
in Health and Wellness
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According to a study of Medicare patients, more complex and expensive spinal fusion surgeries are increasing. Sometimes they are even performed unnecessarily for common lower back conditions that are the result of aging and arthritis.

The scary part is that these challenging operations are riskier and can lead to even more complications and sometimes even death.

The researchers claim that the cost to Medicare, for the hospital charges on the three types of back surgery reviewed, is around $1.65 billion annually.

In the study, all of the patients had  a condition called stenosis in their lower back. This is a painful squeezing in the spine that is common in people over 50. Three different types of surgery for the condition were compared by the researchers: simple fusion, decompression and complex fusion.

Dr. Richard Deyo of Oregon Health and Science University in Portland said, “It’s not necessarily true that the more aggressive surgery is better, at least in terms of safety.” There is currently not much agreement when it comes to the best way of treating chronic lower back pain. A lot of it depends on exactly what is causing the pain.

Deyo said that before considering surgery, patients should ask their doctors about other avenues to complicated operations. Perhaps steroid injections or physical therapy could be tried first. Maybe even a simple decompression procedure could be as effective as a spinal fusion and with less risk.

A decompression procedure is the simplest method in the Medicare study. In this procedure, a surgeon cuts away part of the bone that is pressing painfully on the nerves. It can run around $30,000 in hospital and surgeon fees.

During a fusion, a surgeon secures two or more vertebrae together using a bone graft, sometimes using plates and screws. A complex fusion, as defined by the researchers, involves three or more vertebrae or more than one side of the spine. Fusions can cost $60,000 to $90,000.

Data, from more than 32,000 Medicare patients who had one of the three types of surgeries in 2007, was reviewed by the researchers. It was found that a complex fusion was performed on more than half of the patients who only had a simple stenosis condition. Usually this condition calls for just decompression only. They did not have curvature of the spine or a slipped vertebra, which are specific conditions that suggest a fusion might be necessary.

Checklist for surgeons prevents patient deaths

Published
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Jana
on January 23, 2009
in Health and Wellness
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checklistThe amount of deaths and complications was reduced by mote than a third when surgeons and their associates went by a checklist in the operating room, such as marking part of the patient’s body where it will be operated on, conversing about any patient allergies and making sure that all surgical items are checked. This was all determined through a project that involved eight countries over a period of a year.

Apparently, surgeons are now realizing what airline pilots having been doing for years: That a person’s brain can not remember all things, so it’s much more beneficial to concentrate on the perplexing problems, and have a handy checklist for simple but important things that need to be checked routinely.

There are more than 234 million surgeries done each year in the world. Between 3 and 17 percent of these results in major complications, like an infection that is life threatening. The average complication due to surgery can cost $12,000 or more to treat, but according to studies performed during the past 15 years, about half of these are preventable.

A checklist appears to be an automatic must, but it is obvious that it needs to be used in more operating rooms. Now that the use of a checklist has proven to save lives, it will most likely be adopted by more surgeons.

This checklist, developed by the World Health Organization, idea could have huge financial benefits, because it is not costly or too technical. Calculations by the authors revealed that the U.S. alone could save as much as $15 to $25 billion a year in the amount of money it costs to treat preventable complications, if every U.S. operating room followed the surgical checklist.

During the one -year pilot study using 7,600 patients, the hospitals observed that the amount of substantial complications went from 11 to 7 percent. Also, inpatient deaths fell by more than 40 percent all together.

More demand for locum tenens jobs

Published
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Jana
on January 13, 2009
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Due to the business of general surgery getting harder, there is more demand for locum tenens jobs. On January 13, the WSJ reports that numerous surgeons are moving their focus from established practices to locum tenens. Some, like myself, may not know about  locum tenens. Well I found out that they are temporary  jobs in which a hospital pays a day rate for general surgeons to come in when needed.

So what specialties are more in demand than others? Staff Care, a national locum tenens company, revealed its’ report that was assembled last year by basing findings on 2007 data. It seems that most providers are seeking primary doctors, although the demand for surgeons is increasing.

During the staffing days that were demanded by the company’s clients, here is how the specialty areas were broken down:

* Primary Care, 41.5%

* Anesthesiologists, 20%

* Behavioral Health, 17.6%

* Radiology, 11.6%

* Surgery, 7.7%

* Dentistry, 1.6%

The report said that the total number of locum tenens provider days that were sought after by Staff Care clients rose by more than 20% between 2006 and 2007.

2009 Blue Cross fee structure for non-emergency surgery for federal workers is changed

Published
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Jana
on January 5, 2009
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Blue Cross/Blue Shield has announced that it will pay 70 percent of the fee that it permits for non-emergency surgery by out-of-network doctors. This will put the patients responsible for 30 percent of the charges, plus any difference between the allowed amount and the actual charge.

This alteration of the fee structure is in reaction to distressed Congress members as well as some upset federal workers who have the Blue Cross/Blue Shield standard option.

According to the company’s initial fee structure for 2009, 100 percent of the surgery fee, to a maximum of $7,500 per surgeon, per surgical day, would have had to be taken care of by Blue Cross/Blue Shield members. Under the office of Personnel Management, health insurance companies were allowed to change their surgical benefit and permit employees to change their insurance selections through the end of January.

In situations where the surgeon’s bill will be $5,000 or more, Blue Cross is currently offering members a better service system that will give members information ahead of time that will show them what the company will pay when concerning a procedure.

Considering Cosmetic or Reconstructive surgery in North Carolina?

Published
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Scott
on March 20, 2007
in BCBSNC
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The skin is the most important organ of the human body to protect and manage. So, therefore the best thing you can do is to find out the truth about what causes skin problems or diseases and how they can be treated. You need to make it your mission to study facts about acne and skin from un-bias sources like dermatologists, doctors or skin care specialists, none of whom sell their own products. Blue Cross Blue Shield of North Carolina (BCBSNC) Corporate Medical Policy for Cosmetic and Reconstructive Surgery.

Cosmetic procedures are those services intended to improve appearance, and not primarily to restore bodily function or to correct significant deformity resulting from disease, trauma, or previous therapeutic process. Reconstructive procedures are performed on structures of the body for the purpose of improving/restoring bodily function or correcting significant deformity resulting from disease, trauma, or previous therapeutic process. BCBSNC will not provide coverage for cosmetic procedures as defined above. BCBSNC will provide coverage for Reconstructive Procedures when they are determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefits Application

Please refer to Certificate for availability of benefits. Benefits may vary according to benefit design, therefore certificate language should be reviewed before applying the terms of the policy. Some certificates limit coverage of reconstructive surgery following trauma or injuries occurring while a member.

When Cosmetic or Reconstructive surgery is covered

Cosmetic surgery is not covered, however reconstructive surgery is covered for either of the following indications:

  1. The procedure is intended primarily to improve/restore bodily function or to correct significant deformity resulting from disease, trauma, or previous therapeutic process.
  2. The procedure is intended to correct congenital or developmental anomalies that have resulted in significant functional impairment.

Obtaining coverage for Gastric Bypass Surgery with BCBSNC

Published
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Scott
on February 1, 2007
in Health and Wellness
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Gastric bypass surgery is a common form of weight loss surgery that results in outstanding weight loss with minimal side effects. But once you undergo the gastric bypass surgery procedure you have to accept lifelong changes in your diet. The post-diet of gastric bypass surgery includes an adequate intake of protein, taking vitamin and mineral supplements including multivitamin, iron and calcium, B12 and avoiding sweets and fatty foods.

BCBSNC Covers Gastric Bypass Surgery for those eligible

Blue Cross Blue Shield of North Carolina (BCBSNC) covers gastric bypass surgery; the requirements for coverage is listed below. Please inquire further to confirm your eligibility to be covered for gastric bypass surgery.

Surgery for Morbid Obesity is covered when all six of the following criteria are met:

  1. The patient must have morbid obesity as defined below:
    1. have a BMI > 40 or
    2. have a BMI > 35 associated with at least one of the following problems:
      1. The obesity interferes with daily function to the extent that performance is severely curtailed(i.e., impending job loss or job loss with documented disability); or
      2. The obesity causes incapacitating physical trauma as documented by the medical historyrecords including x-ray findings and other diagnostic test results; or
      3. There is significant respiratory insufficiency or sleep apnea documented by respiratory function studies, blood gases, sleep studies, etc.; or
      4. There is significant circulatory insufficiency documented by objective measurements; or
      5. There is documentation that management of primary diseases such as arteriosclerosis, diabetes, heart disease, hypertension, etc., is significantly (e.g. requiring prescription drug treatment) complicated by morbid obesity; AND
  2. Morbid obesity (BMI > 35 associated with at least one of the problems listed in A.1.b. or BMI > 40) has been present for four of the previous five years; AND
  3. The patient has no specifically correctable cause for the obesity, e.g., an endocrine disorder; AND
  4. Patient has achieved full growth (for adolescents-bone age shows closure of epiphyseal plates); AND
  5. A thorough evaluation (see Policy Guidelines section) has been documented to assess the patient’s suitability for surgery and their ability to comply with lifelong follow up; AND
  6. Surgery for morbid obesity is eligible for coverage when it is part of a comprehensive pre-surgical, surgicaland post-surgical program (see Policy Guidelines Section).

Types of gastric bypass surgery

In gastric bypass surgery, the surgeon takes off a large portion of the stomach leaving behind a tiny pouch. It is this small pouch that prevents overdose of eating as it can take very less amount of food. Moreover, with large parts of your stomach and small intestine bypassed, most of the nutrients and calories in the food do not get absorbed at all. This helps the person from gaining excess weight.

There are several types of bypass surgery operations:

  • Roux-en-Y gastric bypass (RGB) – this is a common surgery where a small stomach pouch is created by stapling part of the stomach together or by vertical banding. This reduces the amount of food to be taken. Then a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the duodenum as well as the first portion of jejunum. This causes reduced calorie and rapid nutrient absorption.
  • Extensive gastric bypass (biliopancreatic diversion) – in this complicated surgery, the lower portion of the stomach is removed. The small pouch that remains connected to the final segment of the small intestine completely bypasses both duodenum and jejunum.

People who undergo gastric bypass surgery always lose two-thirds of their excess weight within two years.

Risks of gastric bypass surgery

Gastric bypass surgery causes “dumping syndromes” where the stomach contents move too rapidly through the small intestine. The usual symptoms of gastric bypass surgeries include weakness, sweating, fainting, nausea, diarrhea, as well as inability to eat sweets.

People who undergo this procedure are at risk of:

  • Band erosion – the band closing off part of the stomach disintegrates
  • Pouch stretching – stomach gets bigger overtime, stretching back to its normal size before surgery
  • Leakage of stomach contents into the abdomen (acid can eat away other organs)
  • Nutritional deficiencies causing health problems
  • Breakdown of staple lines – band and staple fall apart, reversing procedure
    Gastric bypass diet

Gastric bypass diet helps the patients to drop 50% to 90% of their overall excess fats. The diet is designed to bring about significant weight loss. It basically includes foods that are high in protein and low in fat, fiber, calories, and sugar. You should have lots of vitamins and minerals. Iron, vitamin, folate and calcium are the best nutrients for patients undergoing gastric bypass surgery.

You can undergo gastric bypass surgery only if you have been obese for at least 5 years, do not have a history of alcohol abuse, and do not possess untreated depression and range between the ages 18 to 65.

Prior Approval is now needed for some imaging procedures

Published
by
Scott
on January 29, 2007
in BCBSNC and Health and Wellness
. 0 Comments

In an effort to control medical costs, under the benefits of certain plans with Blue Cross Blue Shield of North Carolina (BCBSNC) the following diagnostic imaging services that are received in an outpatient setting, such as in your doctor’s office, the outpatient department of a hospital or at a freestanding imaging center may require prior plan approval (for dates of service on or after February 15, 2007):

  • CT/CTA scans
  • MRI/MRA scans
  • PET scans
  • Nuclear cardiology studies

Prior plan approval is not required when these procedures are performed in an emergency room, hospital (related to an inpatient stay), mobile unit, urgent care center or ambulatory surgical center.

Prior plan approval is not needed for “low-tech�? procedures such as X-rays and mammograms. To learn if your plan requires prior plan approval for these services, review the diagnostic imaging section of your policy documentation.

CT scan: Computed tomography (CT) scan uses x-ray imaging to make detailed pictures of structures inside of the body.

CTA scan:Computed tomography angiogram (CTA) scan uses x-ray imaging to make detailed pictures of blood vessels inside the body. It is a type of computed tomography (CT) scan.

MRI scan: Magnetic resonance imaging (MRI) is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body.

MRA scan:A magnetic resonance angiogram (MRA) uses a magnetic field and pulses of radio wave energy to provide pictures of blood vessels inside the body. It is a type of magnetic resonance imaging (MRI) scan.

PET scan: Positron emission tomography (PET) is a test that uses a special type of camera and special nuclear medicine to look at organs in the body.

Prior plan approval is not required for diagnostic imaging procedures in emergency or urgent care situations (meaning the absence of medical attention could jeopardize the patient’s life, health or ability to regain maximum function) or when they are performed in an emergency room, hospital (related to an inpatient or observation stay), mobile unit, urgent care center or ambulatory surgical center.

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