The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Advocacy- why it matters
Chuck and Chris discuss advocacy. In this episode, we start with an adolescent elbow case as a warm up and then pivot to advocacy. Starting with a simple definition and explaining why it is so important for all of us. We use practical examples for discussion on all types of advocacy and why we should all engage in some manner.
Jon Lundy can be reached at jlundy1313@gmail.com
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Chuck, welcome to the upper hand podcast where Chuck and Chris talk hand surgery.
Chris Dy:We are two hand surgeons at Washington University in St Louis, here to talk about all things hand surgery related, from technical to personal.
Charles Goldfarb:Please subscribe wherever you get your podcasts, and thank
Chris Dy:you in advance for leaving a review and rating that helps us get the word out. You can email us at hand podcast@gmail.com so let's get to the episode. Oh,
Charles Goldfarb:hey, Chris,
Chris Dy:hey, Chuck, how are you?
Charles Goldfarb:I am better than you this morning. I think, yeah, it's been
Chris Dy:a rough one. I, you know, recovering from a cold and also recovering from call. So two things that start with C that are, you know, interfering with my life, and now we've got a third with Chuck, but he loves that alliteration. But I got beat up a little bit on call last night, so, but I'm happy that we're here together.
Charles Goldfarb:Yeah, that is tough. I, you know, call is, and I generally don't mind it while I'm doing it, but as one ages Chris, it doesn't get any easier. You'll have
Chris Dy:to tell me about that one day. I'm not sure how that what that feels like. I was telling our fellow Dan Hong that I used to like taking call with him, but now I'm not sure he's clearly is making me change my mind. Still a good guy, but he does like his podcast mentioned, so I did mention to him that I would shout him out again. I had, apparently he gets it. He gets a lot of text saying that he's famous when this happens.
Charles Goldfarb:Oh Lord. Well, he and I have worked together a little bit, not formally, on service has been fine. And I had spoke to our previous resident, Liz grasser, who's out at Utah, and she also seems to have developed a black cloud reputation, but she said the right thing. She goes, I think I'm a black cloud, which my attendings don't like, but you kind of sort of want that as a fellow,
Chris Dy:you got a year to learn, right? So you got to get it all done. I mean, you know, you look at, you know, as as a fellowship director, I study people's case logs. Nice and, you know, you have to, you see that some people get a lot of cases, other people don't. It's been pretty uniform this year, but, yeah, I think there's just stuff that comes in unplanned that you got to take advantage
Charles Goldfarb:of absolutely and, and it's been, you know, the fellows are always part of the joy of call, part of the pain of call, and you know it's all sometimes it gets mixed as one into my head, fellows paying call. But let me give you a little
Chris Dy:let me give you a little perspective. It's a hell of a lot better than not having a fellow call. So let's just put it that way.
Charles Goldfarb:There is no doubt that is very important truth.
Chris Dy:Funny. Funny story about Liz and Dan is that when we were at the hand society in Minneapolis this year, it was the end of Dan's rotation with me. He had spent his first I guess we split it up, so he did six weeks with me, or something like that. Yeah, and I was very excited. I said, Dan, we're both getting on a Monday night at a hand society. Why don't we go get dinner? We're on the same flight, you know, let's go. Let's go have a post, rotation, recap, little bonding time at dinner. And I know it's coming. I set up a reservation. It was great. I was super excited. It was late. So, you know, I if it was anybody else, I would have said, No, I'm not really interested. I'm just gonna go to bed. So he's like, Yeah, sounds good. He's like, do you mind if Liz grasser comes? Said, I love Liz. Liz, great. Sure she's already eating. She's not going to eat. So I was like, as somebody who kind of knows a little bit about restaurants and restaurant business, like they're not going to like that. But of course, that'd be great if Liz can come. I would love to see Liz. So Liz, Liz crashed our mandate, and it was lovely to see Liz. She had a cocktail, had some dessert, watched him, Dan and I mainly me eat excessively.
Charles Goldfarb:You know, that is hilarious. And Dan's connected in the in the restaurant world in St Louis, I didn't, I didn't know he shared with me his connection with, I'm going to get the name wrong, Mr. Bogner, who has the really delicious sushi restaurants and has opened a third, is opening a third,
Chris Dy:celebrated, celebrated chef Midwest and perhaps nationally great place. So Dan, Merry Christmas. Happy New Year. You've gotten your, you know, unsolicited four minutes of airtime on our discussion. So we have to get rolling on the actual topic today.
Charles Goldfarb:Yes,
Chris Dy:we do before we do that, we should thank our sponsors at practice link, and I'm gonna read the copy this time. So the upper hand is sponsored by practice link.com, the most widely used physician job search and career advancement resource.
Charles Goldfarb:Becoming a physician is hard. Finding the right job doesn't have to be join practice link for free today at www dot practice link.com, backslash the upper and now
Chris Dy:we got a really cool. Email about some advocacy topics, which is something that doesn't really come up very often, I think, for most practicing surgeons and therapists, but it does affect our lives on a daily basis. And before we jump into that great email, I hear you have an interesting elbow case that you wanted to discuss.
Charles Goldfarb:Yeah, I I've talked about pediatric and adolescent elbow on this call, and for those who haven't heard discussions, I think it, first of all, it's a good example of recognizing opportunities when they are presented to you. Elbow in general, was not something I plan to focus on, but increasingly, those, those challenging Pediatric and Adolescent elbows, have become a part of my practice. And, you know, you may have always planned since you were three years old, to take care of patients with nerve injuries, maybe. But elbow, to me, is not like that. We have.
Chris Dy:We told the second. You know, I've talked in many venues, and I cannot remember, as you have, when I've told what stories, but have we talked about why, how I got into the nerve practice at WashU, if
Charles Goldfarb:we have my seen, senior status is showing because I do not remember,
Chris Dy:maybe, maybe a topic for another day. But I was definitely voluntold, and it worked pretty well, but I was voluntold by one of our partners that that was what I was going to do. So good match. Of course, he knew, he knew it was going to work. So it was
Charles Goldfarb:good. It's nice when people have that foresight before us. But what's interesting about pediatric elbow? And you know, maybe I would say pediatric is less than 12, someone may write in and tell me I got the definitions wrong. But so much of the elbow is cartilage that when you have a distal humor or proximal radius or ulnar injury, it can be hard to pick up radiographically. I think we all know that you're looking for fat pad signs where the X rays show a little dark around the bones, which is fluid where an anterior fat pad sign is okay, but a poster is not. But the message is that X rays don't always tell the tale. Would you? Would you agree with that?
Chris Dy:I agree with I remember being tortured on the PED service as a resident trying to analyze these elbow X rays of adolescents and some kids I have peds, really, and always struggling. I mean, has anything changed since many, many years ago, when I was in training about, you know, how to think about, you know, radiographically, have any of those findings changed? You know, clearly, the X ray technology itself hasn't changed. But, you know, do you jump to other types of imaging earlier?
Charles Goldfarb:I think, well, yes, I think we do. And I would say to start you have to know the basics. Have to know what you generally should be looking for. But there is never shame in getting the contralateral elbow. And I've been doing this a long time, I get contralateral X rays all the time. Really helpful, but not always. They don't always tell the tale. So your point is good. I mean a CT or CT angio, which was ordered in this particular case, I'm sorry, not CT, angio, CT, arthrogram, but for me it's usually an MRI, which I think gives us what we need to know. Briefly, this case was of a child who had a sheer injury of the trochlea and Capitol, which was incredibly subtle on X ray, where there's just a sliver of bone that you could couldn't really see. Could see maybe, and ultimately, a CT scan was ordered. It did show there was something going on. So we did, so this is a young patient, maybe 10 years of age, and we did an oboe arthroscopy to better understand the problem, which, which, thankfully, I feel comfortable with now, but scoping a kid where, you know, the safety margins are small, it's always a little hairy. And then we ended up opening and fixing just an unbelievably distal shear injury with just a tiny bit of bone. Ultimately, was great, but tricky case, and again, gets back to the point of finding enjoyment even when it wasn't what you set out to look for.
Chris Dy:Right exactly. So how did you make the decision to go from the scope to opening. Did you say this is something I can't I can diagnose it through the scope, but I can't fix it through the scope. Is it something that you were better off fixation wise doing open?
Charles Goldfarb:Some might have skipped the scope to be honest with you. In fact, I would say most might have skipped the scope. For me, the scope was beneficial in the sense that it gave me a better sense of both what had been shared and also the injury site, and finally, looking for other injuries. So it gave me a kind of 360 view of anterior elbow, posterior elbow, and I was hoping that I could break the piece was anteriorly and so. I could bring it back posteriorly and then approach the elbow through an ink and the split and keep it really simple. Didn't turn out to be that simple. And I had to take down the lateral ligament complex to get exposure, to get the repair, and then to and then on my way out, I obviously repaired the lateral complex, yeah. So I think the scope was potentially a step that could have been skipped, but this was a big open procedure in the end.
Chris Dy:Now, is this different fracture or injury morphology than the Capitol shear fractures that Dr wall had a run of a couple of years ago. I know that she was describing a particular approach to get there.
Charles Goldfarb:Yeah, I would say this is similar to, but younger patient than and far more subtle. Those fractures that she was addressing had a clear, major bony component, and there was never subtlety. This was just harder to pick up, and therefore, you know, took a little longer.
Chris Dy:How'd you fix it?
Charles Goldfarb:I use three bio absorbable headless compression screws. And the trick there is that you are then balancing fixing this fragment, which you have to do, obviously with the growth plates and stability, and then obviously early motion, because an elbow and elbows get stiff.
Chris Dy:How long does it take for those bio dissolvable, bio absorbable compression screws to absorb Yeah,
Charles Goldfarb:I don't know if there's a difference in adults and kids, but I think we're looking at 12 plus months. Always worry a little. I don't use a ton of bio absorbable screws. I always worry a little bit about a joint reaction to that, but our sports colleagues use them regularly and seem to be happy with them. Now,
Chris Dy:are these typically trans facial or are they all epiphyseal? Or are they,
Charles Goldfarb:I hope to avoid the physicists in this particular we don't need to go to the details. There's a 16 millimeter length. Was the shortest length. I thought about cutting it, but I didn't think I'd get the fixation, so I just went ahead and put it in, and I think it tickled the physicists, and hopefully it won't bother
Chris Dy:I don't know the last time I said the word epiphysis. It's been a very long time.
Charles Goldfarb:Well, say it a couple times in a row.
Chris Dy:One of my friends was a deep sports person up in New York, and I remember him going on and on about all epiphyseal ACLs and also not my thing at all.
Charles Goldfarb:Yeah, you know, it's it does add another level of challenge sometimes, but you know, that's what makes it fun,
Chris Dy:exactly. So before we jump into this advocacy topic, I did want to note that the upper hand is sponsored by checkpoint surgical, a provider of innovative solutions for peripheral nerve surgery. Checkpoint now offers a specialized notepad to assist in documenting Guardian stimulator device starting settings during surgical procedures such as decompression. You
Charles Goldfarb:have to explain to me what that means. I have lots of notepads, but not one related to checkpoint. But if you're interested in receiving a threshold stimulation notepad to facilitate accurate tracking of stimulation, settings, contact your local checkpoint sales representative or email marketing@checkpointsurgical.com checkpoint surgical driving innovation in nerve surgery. What does this mean? Does
Chris Dy:you know what this is? Because I was at a meeting with checkpoint recently, I think it was back in August, and I was like, What do you remember those notepads you had where you could, like, record, you know, like, what if you stimulate at certain settings, what kind of response you get? And you know, one of my and anybody who's used a nerve stimulator in general, whether it's checkpoint Medtronic, whatever other ones you use. The anesthesia setup knows that we don't have a great way of documenting how we use the device and what kind of responses we get, and that's incredibly valuable information. So then they said, Oh yeah, we have this notepad that says, like, this is a setting, this is a pulse duration, the pulse width, etc. You should record this so it's there. It's an interesting thing. I think that we should be great if it was sterilizable and could be written down by the surgeon interop, which I think is very challenging, because otherwise you're just rattling off a bunch of numbers to a circulator who is not terribly interested in recording this information for you. So we've actually in our lab, we've taken this to a the next level and created a more detailed version of it in red cap that we're starting to use for all of our nerve transfer and nerve reconstruction cases.
Charles Goldfarb:Excellent. I don't know that I have a need for a notepad. Maybe, yeah, do. Maybe I just don't know it. But hey, you
Chris Dy:exactly. It's the thing you never knew you needed. That's marketing, baby. That's marketing.
Charles Goldfarb:Well, I, you know, as you know, I'm in business school, and I'm learning about this kind of stuff, and it is that, you know, Steve Jobs quote about the public doesn't know they. Something until you show them that they need it. Maybe this is that. I think
Chris Dy:it is. So why don't we jump into the email? We have an email from John Lundy, who is a private practice hand surgeon in Austin. So John emailed us at this point, probably about a month or so ago, saying that he retired from the military about a year ago and has been in private practice and has noted some issues, and there is a lack of a formal professional group in Texas. And he has founded the Texas hand society with his colleagues. Their vision is to improve access to care by working to to get access to appropriate and high quality hand surgery care for all patients in Texas. And then you need an organization to collaborate and coordinate all of that, of the surgeons with the health care providers, health systems, payers and policy makers. And to his recollection, he has about 55 members so far, and they're looking to expand recruitment efforts and emailed us so anybody who is a hand surgeon practicing in Texas. If you wouldn't mind reaching out to John Lundy, his email address, we will put in the show notes. I won't shout it out on the air, but that way you can reach out to him. He's in Austin, and that actually not only do we want to applaud John for his efforts, for for gathering his colleagues, but also talk a bit about advocacy and the role it might play in the practice of hand surgery and hand therapy.
Charles Goldfarb:Yeah, kudos to John. Sounds like an important step, and off to a good start. I'm not sure how many hand surgeons are in the state of Texas, or how many surgeons who also perform hand surgery are in the state of Texas, but there is power in numbers, and that's the point. And you know a great deal about advocacy. I know how important it is, and recognize that many of us, sometimes myself included, don't think enough about it. So first, maybe tell me how you think about the term advocacy and what it means to most of us.
Chris Dy:You know, I think the advocacy term is a pretty broad one. I mean, I think it's thinking about how to, you know, advocate for oneself and for a group of like minded individuals to in, not say, negotiations, but discussions with other people who control power, essentially, whether that's, you know, because I know that you have had a lot of efforts in terms of our group practice in advocating with payers, with insurance companies. We can go through maybe the example of the needle app and Neurotomy. But then there's also advocacy at, you know, a political level, you know, you can have advocacy at a local level in terms of advocating for for your group of practitioners, surgeons, therapists, with a hospital system, etc. So it really is rallying the troops in a way where you are trying to to make people know what you're feeling, how things might be able to change in a mutually beneficial, ideally way to to improve delivery of care.
Charles Goldfarb:Thank you. I think that was, that was well said. You know, we sometimes we can have tunnel vision and believe in, perhaps in a perfect world. This is how it would be, that if I just take really good care of my patients, everything else will work out. As I've gotten more cynical with age, that's just not true. And you know, taking care of the patients the right way is great, but there are so many different factors to our ability to do that, and we could go down a million different tangents why private practice is struggling. There's just so many things that affect our ability to practice that tunnel vision is not helpful. Or, I guess I would say bigger success.
Chris Dy:Yeah, no, the put your head down and take care of the patient mentality is probably the best and worst thing about being a doctor. And you know, I think that those who are on the other side, those who control the purse strings and the power love that about us, because then they can then take advantage of us, and then when they need the care that they want, they get what they want. You know, so are in I think this extends beyond American health care. You see advocacy playing a big role, especially in the UK, with with the NHS, and honestly, with residencies around the world and the question about unionization, you know, so not only, you know, in other parts of Europe, but also here in the States, you're starting to see residents residencies at different hospital systems unionized. And that's clearly another advocacy piece. But yeah, the best part about what we do is getting to take care of people, and I don't think we pay enough attention. Get our, you know, get the high level view until you've been doing it long enough you don't have to worry about the patient, not worry about but you can think more than just about the patient in front of you, because it's so hard to do, you know, to do what we do. Um. And to take care of people that it's easy to just miss the rest of what's going on around you,
Charles Goldfarb:right? And I think a lot of us think that our societies, which is one reason we all do and should belong to various societies, do this, I would say, quote, unquote, for us, but they do it in different ways and simplicity. Maybe we should talk a little bit about that, and then we could go back to some kind of boots on the ground examples. But you know, the hand society does work around coding and assuring that there is appropriate identification of rbus for procedural codes. But the hand study, I would not say lobbies like the aaos for orthopedic surgeons out there, is that accurate? Yeah, I
Chris Dy:think that's accurate. I think because of what most hand surgeons do is there are a ton of unique advocacy issues for hand surgeons that are different from what plastic surgeons, orthopedic surgeons, general surgeons, physicians in general are feeling, you know, and most of you who are listening know that to become a hand surgeon, at least in the US, you either train in orthopedics, in plastic surgery or general surgery. By far, it's usually in orthopedics or plastics. And at least for orthopedics, there is an incredibly powerful political arm in Washington. It is actually, if not the biggest, it's the second biggest, relative to the American Medical Association political action organization pack committee in DC. And you know, I think it's pretty incredible, the machine that they have. So just for context, when I was a resident, I was very much interested in health policy at this time, the Washington Health Policy Fellowship still existed at the American Academy of Orthopedic Surgeons, and I was fortunate enough to do that policy fellowship, you know, in one of its last years of existence. And there's a really neat experience, because my my co Policy Fellow, Eric macney, who was a resident Columbia now, as an attending in Detroit, doing sports, he and I would go down to DC. We would, we were both in New York, so we would just take the train down and we would go lobby on the Hill, which was super, super interesting to see. You know what the the American Academy of Orthopedic Surgery pack was doing, how, what issues they organized around participating in the health policy efforts that they had with big you know, they call it the national orthopedic Leadership Conference, but it's when they get everybody in from the state orthopedic societies and a bunch of orthopedic surgeons and related disciplines hit the hill, and You meet with congressional leaders, people that represent your district and you honestly, it gets down to telling stories. Nobody really cares about data. Initially. The good thing about a lot of physicians is that we have a lot of stories to tell, if you really think about it, because you have patients, and people can relate to patients. And I think one of the examples that we did recently when I went to the hill as part of the hand society group, is that, and this is a few years ago now, but it's prior authorization and something that seems relatively mundane, but trying to make sure that you don't get bogged down in prior authorization before a procedure or an MRI or something like that, and explaining to somebody in Congress who has no idea what your day to day life is, trying to find a compelling way, compelling story about why this is important for them to pay attention to, to make sure that you know, they you know, include details in whatever upcoming legislative package that make sure that they can't have too much, Too much too much process before you get prior authorization. For example,
Charles Goldfarb:yeah, it's funny. Every sentence or two, my brain would go in a different direction because you said so much, all really important stuff.
Chris Dy:That's that's you saying, keep it concise. Next.
Charles Goldfarb:It was all good. One thing that came to mind was that were, you know, is the challenge of Medicare Advantage plans, which I think is actually a, probably a pretty good example of why we need to advocate for ourselves. You know, in the United States, Medicare is the big government payer. Medicare Advantage was proposed as a way to help control cost for Medicare patients. And in reality, it is not worked out that way. Has become a really challenging insurance payers, and every major commercial insurance has a Medicare Advantage plan. And actually that is where commercial insurance makes their money in 2024 and it is really, really challenging, and it is setting up roadblocks and and they do little things like they want to attract Medicare Advantage plans, they want to attract healthier patients, because it's essentially capitation. And by attracting healthier patients, they have to pay out less. By setting up roadblocks for prior authorization or declining to pay for inpatient rehab, they make more money. So one way to do that, as a good example is they offer free gym plans. So if you join Medicare Advantage for so and so firm, you get a free gym plan. Well, who's gonna be interested in going to the gym? The younger healthier. You know, I put younger in quotes, Medicare Advantage. So anyways, I'm off a little bit on a tangent, but that's one of the things you
Chris Dy:definitely are off on a tangent. The way I'll bring it back, is that, if you're an insurance company in states, you want to make more money, you sign more people up who are going to pay to be part of your service, and then you pay less and, you know, you you give out less money in terms of services. So if they can make it as hard as possible to to pay for services, the more money they make, you know, so, and this is something that is common throughout medicine. It's not only hand surgery, definitely specialties that are procedure based, like surgeons, they get effects and more just because of the way that the system has been set up, whether you like it or not, in the US is that proceduralists tend to get paid more, and proceduralists depend more on making sure that they get paid for the procedures. And it's not a zero sum game in terms of the money that's available. Everything in the States is based around what Medicare, which, as you mentioned, is the largest government payer pays for a certain procedure. Now, insurance companies and work comp, they may pay a certain percentage higher, but everything, the bar is set by Medicare or by CMS. And you know, if they value the procedure codes more, they're going to value the primary care, you know, diagnosis, EM codes less, and vice versa. So it's this constant battle. They've set us up to fight each other for the same amount of money. The pie is not growing. So to say, which is why it is really important to have a big pack behind you, which is what orthopedic surgeons and by virtue of that, hand surgeons benefit from a lot.
Charles Goldfarb:Yeah. I mean, the pie is massive. You know, almost 20% of our GDP goes to you know, medical care, which is incredible and so much higher than every other country, true or false. The American Hospital Association is not our friend.
Chris Dy:No, they're not our friend at all. Not at all. I mean, I don't know what you're what you were looking for with that, but they also get a piece of the pie on this, and the more that they pay the doctors, the less they have to pay the hospitals. And, you know, just this is a broad over generalization, but I feel like a lot of people talk about how Medicaid, which is the government, based insurance in the US for those under a certain income level, it was the crux of expanding care under Obamacare back in 2008 is, I guess, when that effort started, the more Medicaid is traditionally not a great payer. For physicians, you get a certain fraction of what you would get paid for Medicare. It's probably the same thing for therapists, too. But the hospitals do very well with Medicaid because it's, it is a state based program, and especially at some state based hospitals, like university based hospitals that are public universities, they have carve outs which they will get a much better rate if you get care at a certain University Hospital in our state, that hospital, we have paid a lot more, as opposed to if you got care at a non government based hospital like ours. So anyway, there's a lot of money in healthcare in the US like you mentioned, and it's encroaching on 20% of our gross domestic product. And this is actually a pretty timely discussion. I think healthcare has not been part of the conversation as much this year in the US election, but we are recording two days before the United States general election, which is crazy to think of and you know, all of these healthcare issues really matter, and whether you lean one way or the other politically, I think that the the single minded focus on protecting the interests of physicians, providers, etc, at the pack tends to make it relatively politically agnostic. I had a hard time with so I was actually Chair of the hand society's Government Affairs Committee, and my political views personally don't necessarily align a lot with the with the aos. And so while the assh is a sub special society, typically falls under the AOS for a lot of things, and I differed a lot with the academy, and I struggle with that, and I know that some of my predecessors and successors on that committee also do. But at the end of the day, they support the candidate and candidates at local and state races that are going to help orthopedics. So I have a hard time. I struggle with that, but you know, at the end of the day, they really are trying to protect the interests of the healthcare professional,
Charles Goldfarb:yeah, the election talk is super interesting because you're right. Remarkably, it's not been a primary discussion point. But there are huge implications for the results of the election here in the US, with which candidate prevails, and the concept of single issue voters and orthopedic surgeons only voting. For the candidate that may support orthopedic surgeon priorities is really an interesting one, but not for this discussion. What about the AMA, the ultimate advocacy group for physicians? Share a few thoughts, and I have a few as well, given I interacted a lot with the AMA in preparation for an AOA American orthopedic Association session this past summer. Yes,
Chris Dy:I'm a little bit out of my depth on the AMA. I mean, I know of the AMA, and I think a lot of us, at least in you know, schooling and training, participated in the AMA. I know that we have a loyal podcast Lister Andy German, who is also active on the listserv, and amazingly, this is an incredible shout out to Andy. He was president of the AMA as a hand surgeon not that long ago, probably about 10 to 12 years ago, I think, really amazing accomplishment. So Andy, if you wanted to give us some thoughts about the AMA, please feel free to email us, but it is, I think, a different organization in terms of the priorities. It's got to serve the entire house of medicine. And typically it is nice when the House of medicine aligns on issues and everybody can get behind and the AMA is the face of things. But there are some issues within medicine where, you know, the specialists and the procedure lists will differ from the primary care oriented groups. And I think, you know, the AMA is tasked, you know, for better or worse, or trying to unite the house of medicine. Because, you know, people from outside of medicine don't understand that we have all these different factions within us. They view us at sometimes, as a monolith.
Charles Goldfarb:Yeah, you're right. And Andy, obviously, we're proud of his leadership of the AMA and advocacy in general. You know a non hand surgeon, Michael Sook, who I don't know if you know him or not. I do not know him well, but he has the best collection of initials after his name, because I'm looking at it. I looked him up, but you know I'm going, are you jealous,
Chris Dy:Chuck? Because I know you're adding more initials. I'm a
Charles Goldfarb:little jealous. He is an MD, JD, mph and MBA. That is impressive. But he's also, for the point of this conversation, the current chair of the Board of Trustees of the AMA. So incredibly important position, which, you know, again, they are the ultimate advocacy, advocacy committee for all physicians and some of our listeners. Many of our listeners are in the therapy world. And sometimes these advocacy efforts, actually, you know, can can be head to head clashes such as autonomy and independence in in caring for patients and the like. And ultimately, one of the AMA's primary goals is to encourage teamwork, but always have the physician as the leader of the team.
Chris Dy:Yeah. I mean, it's, I mean to put it differently, it's scope of practice. You see, I remember when I was a resident the AMA battling with the podiatry organization about scope of practice for podiatrist in the state of New York at that point, and I don't know if they have gotten that success, but trying to do things like knee arthroscopy as a podiatrist, and just encroaching on things that are typically viewed as the purview of the orthopedic surgeon and I think the hand therapy group, at least in Missouri, scored a recent win, which was nice for them, that they can now get direct access evaluations. So if you call up, typically, how it's worked in the past is that you would need a referral and a prescription from somebody like me or chuck to go see a hand therapist before your insurance company would authorize that. But now I think they do have direct access for I think it's PT and OT, you know, to see to see a therapist, at least get worked up and diagnosed, which I think is a change. And not saying it's for better or worse, I think in a lot of ways it is a beneficial thing to help access for patients. But those are the kinds of tensions that you can see with scope of practice and between professional organizations.
Charles Goldfarb:Yeah, well said. And then, to be very specific, it's scope of practice and scope of practice creep, as it's been labeled by the AMA. I think we, we've I like the content of our conversation. I wonder if we could have organized it a little better, but I think some of the points we made are hopefully, many of the points we made are important. And my takeaways from this conversation is, number one, I have become better about supporting organizations that advocate for physicians and surgeons and hand surgeons. And I think we all should really think hard about that, because practicing in a bubble or practicing, you know, in a very you know, stay in your lane way is just not the way to do it in 2024
Chris Dy:right? And I think there are a couple of issues I could, you know, ideas I could bring to the forefront here that would maybe draw some attention to those of you that are practicing or training and don't quite get it. I mean, first. Up, like in Missouri, and you know, Medicaid is a state based program, as we mentioned earlier, and you have a patient with Medicaid, and you want to do therapy after they're just a radius fracture. Guess what? Physical Therapy isn't covered after surgery, amazingly, after, you know, by the state of Missouri for Medicaid. So this is, you know, relevant for us as hand surgeons, but also, like say, for example, you want to do a total knee replacement on somebody. Replacement on somebody, and you need them to get access to therapy. If you know that they're not going to be able to go to the therapist after surgery, are you still going to do the total knee replacement? So it becomes this cycle that's very vicious and very puts the patient at a disadvantage. So you know, if we were to look at efforts to rally and advocate at the state level to improve access to Medicaid or access to therapy for Medicaid patients. That'd be one example where a practicing surgeon could really provide some compelling stories, also a practicing therapist, we could work together on something like that. And then, you know, people paid more attention to politics when it evolves the economy and their pocketbook. And you can see that's the leading, one of the leading issues in the current US election. And as a surgeon, if you are paid a certain amount for a certain procedure for years and years and years, and then it just starts to go down, like the devaluing of the total hip and knee replacements over the last two decades. And you can see that the American Academy of hip and knee surgeons has a huge advocacy arm that has developed even outside of the academies pack, because they really want to protect the value of those codes so they can continue to be paid at least the same as what they've gotten paid in the past, as opposed to getting cut two to three to 5% if not more, every year. So people pay attention unfortunately or better or worse when it affects their pocketbooks too, you know. And I think that maybe you could just close us with that little snippet about, you know, advocating for our Surgeon group with doing needle app and neurotomies.
Charles Goldfarb:Yeah, it's a great it's a great way to close, even though we could go on, I think for a really long time, I was told that a needle app and Neurotomy procedure that I had done in the office was not going to be reimbursed despite having, you know, pre authorization or or pre approval. I guess, I'm not sure the terminology for this particular insurer. And I said, Well, why is that? Which led to conversations with in our group at the department orthopedic surgery at Washington University, and ultimately with the medical director for this particular insurance company. And we had a great discussion, and he was a physician, and he recognized the cost savings to the insurer, to society, the benefits to the patient. All of those things were true if we did the needle procedure in the office, but he said, based on the insurer's interpretation of Medicare and CMS rules and regulations, they would no longer be paying for the needle procedure in the office. He agreed that it was nonsensical, but he felt he could not do anything about it, and so, and that's been six months. And so for that particular insurer, we no longer do needle procedures in the office, which is a shame, which
Chris Dy:is crazy, because they probably would pay for it if you did it in the or 100%
Charles Goldfarb:they wouldn't have done some. And what we do is they just wide awake in the operating room, and we're adding, you know, many multiples of cost.
Chris Dy:You got that not only you paying so before you would pay Chuck Goldfarb the physician fee, I don't even know if we were charging a facility fee as a university for that. Now you're paying Chuck Goldfarb the physician fee, probably the same you're paying the hospital for their time, and through the facility fee, you're adding this cost on which, depending on your insurance plan, does affect the out of pocket for the patient, which is absolutely insane with the given the caveats and acknowledgements that you made before. Yeah,
Charles Goldfarb:it's really crazy. And for the younger listeners, just to be very clear, if a surgeon may charge$5 for a procedure. You can guarantee yourself that the hospital is charging four to five times multiple of that, and so the money is in the hospital system, maybe for good reason, but to add that unnecessary cost to procedure like this is crazy, so we will continue to fight on this, because it's the right thing to do in every respect,
Chris Dy:at least you're not adding the anesthesis into that, because that's another professional fee and more facility piece. Crazy. So I think the point today of a discussion which is timely given the at least the political calendar in the US, is that you have to be part of the advocacy efforts, and whether that's doing great things like like John is doing with his organization, participating in your local organizations, contributing money to the political action committees if you're you know, if you're not at the table, you're on the menu, is what they like to say in the in DC. So if you're not advocating for yourself, you're the one that's going to get eaten up. So please, please support those efforts in whichever way you feel most appropriate. Everybody's a little bit different with how they want to engage with that kind of stuff. Absolutely
Charles Goldfarb:fun to talk about this stuff, and it will be interesting by the time this podcast drops, we will have, at least, hopefully, we will have an identification of the next president, which will affect all of us
Chris Dy:specifically? Oh, yes, it will in
Charles Goldfarb:the healthcare realm. All right, have a good day. You too. Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sounds good. Well, be sure to email us with topic suggestions and feedback. You can reach us at hand podcast@gmail.com
Charles Goldfarb:and remember, please subscribe wherever you get your podcast,
Chris Dy:and be sure to leave a review that helps us get the word out. Special,
Charles Goldfarb:thanks to Peter Martin for the amazing music, and
Chris Dy:remember, keep the upper hand come back next time
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