http://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedics-today/%7B50036aa0-ebf6-4c3a-919a-5f9823e938ab%7D/we-have-a-responsibility-to-promote-healthy-lifestyle-programs
We have a responsibility to promote healthy lifestyle programs
Tenemos la responsabilidad de promover los programas de estilo de vida saludables
La epidemia de la obesidad y cómo afecta a la atención ortopédica son problemas bien reconocidos . Una visión egocéntrica plantea preocupaciones acerca de nuestra
capacidad para gestionar con éxito los problemas ortopédicos comunes ,
como los resultados después de procedimientos ortopédicos de rutina
pueden ser afectados negativamente por la obesidad.
Los
cirujanos ortopédicos han evidenciado , como escrito en la cubierta de
la historia de este mes, que los resultados operativos no siempre son
los mismos para los pacientes con obesidad en comparación con los
pacientes no obesos. Los aspectos técnicos de la cirugía son más desafiantes y procedimientos tardan más tiempo . Otros
miembros del personal a menudo son necesarios para el transporte , así
como su lugar y asegure los pacientes obesos en las mesas operativas. Los implantes son más caros debido a los materiales añadidos . Aderezos
y productos médicos duraderos son más grandes, y las incisiones
quirúrgicas más grandes, instrumentos únicos y retractores pueden ser
requeridos . Riesgos
de la anestesia también son mayores , ya que toma más tiempo para
gestionar las vías respiratorias y la apnea obstructiva del sueño
comúnmente asociado. Post- anestesia tiempo de sala de recuperación es a menudo más tiempo
debido a la retención de los agentes anestésicos en un mayor porcentaje
de grasa corporal , y la rehabilitación postoperatoria puede ser más
largo también.
Con
todos estos desafíos conocidos , hay una comorbilidad no reconocida en
el sistema de salud en términos de apoyo a los cirujanos ortopédicos que
manejan pacientes con obesidad . Hay
un código ICD - 9 para la obesidad , 278.0 , que puede ser incluido en
la descripción de diversas condiciones de la enfermedad de un paciente ,
sin embargo , no existe un método claro para definir el impacto de la
obesidad en un procedimiento quirúrgico en el sistema de codificación
CPT para los procedimientos . También podemos indicar en notas de operación que se requieren
procedimientos adicionales y el equipo más grande para el cuidado de un
paciente obeso .
Los
cirujanos ortopédicos también pueden optar por modificar el código CPT
con un 22 - modificador , que es apropiado para " informar o indicar que
un servicio o procedimiento que se ha realizado ha sido alterado por
alguna circunstancia específica , pero no cambió en su definición o
código. " por
desgracia , los terceros pagadores no reconocen la dificultad añadida
en todos los aspectos de la atención para los pacientes con obesidad. De
hecho , en por lo menos dos estudios basados ortopédicos , la adición
de la 22 - modificador para la obesidad cambió positivamente el
reembolso en menos de 5 % de los casos . En algunos casos , la adición del modificador condujo a la disminución de reembolso .
The epidemic of obesity and how it affects orthopedic care are well-recognized problems. A self-centered view raises concerns about our ability to successfully manage common orthopedic conditions, as outcomes after routine orthopedic procedures can be negatively affected by obesity.
Orthopedic surgeons have evidenced, as written about in this month’s Cover Story, that operative results are not always the same for patients with obesity compared to non-obese patients. The technical aspects of surgery are more challenging and procedures take more time. Additional staff members are often needed to transport as well as place and secure obese patients on operative tables. Implants are more expensive because of the added materials. Dressings and durable medical products are larger, and larger surgical incisions, unique instruments and retractors may be required. Anesthesia risks are also greater as it takes more time to manage airways and the commonly associated obstructive sleep apnea. Post-anesthesia recovery room time is often longer due to the retention of anesthetic agents in a higher percentage of body fat, and postoperative rehabilitation may be longer as well.
With all these known challenges, there is an unrecognized comorbidity in the health care system in terms of supporting orthopedic surgeons who manage patients with obesity. There is an ICD-9 code for obesity, 278.0, which can be included in the description of a patient’s various disease conditions, however, there is no clear method to define the impact of obesity on a surgical procedure in the CPT coding system for procedures. We can also state in operative notes that additional procedures and larger equipment were required for the care of an obese patient.
Orthopedic surgeons also may chose to amend the CPT code with a 22-modifier, which is appropriate to “report or indicate that a service or procedure which has been performed has been altered by some specific circumstance but not changed in its definition or code.” Unfortunately, third-party payers do not recognize the added difficulty in all aspects of care for patients with obesity. In fact, in at least two orthopedic-based studies, adding the 22-modifier for obesity positively changed the reimbursement in less than 5% of cases. In some cases, the addition of the modifier led to decreased reimbursement.
As orthopedic surgeons are more responsible for their own outcomes, which define their ability to provide value-based health care, there will be an increased disincentive to manage patients with obesity. Overall reimbursement is the same as that of non-obese patients despite the added complexity. This means less financial benefit per unit of time spent with the patient. We also will be penalized in the overall system because outcomes will be worse in this patient population. We have already seen an increase in the referral of “complex patients” where the only obvious comorbidity to a relatively routine orthopedic condition is obesity. For many orthopedic surgeons who receive significant referrals from other orthopedic surgeons, we accept the challenges as leaders in the profession. However, as this cost increases and affects our partners or employers, we are more likely to restrict the opportunities to help manage these complex patients.
This microcosm reveals a number of concerns about the health care system, which is not a true system, but a patchwork of various concepts and incentives put together to provide health care to as many people as possible. Many other developed nations have instituted national health care systems for their entire population, but the United States has been reluctant to accept this method of health care delivery. Statistics would suggest that other countries have done an overall better job in management of common medical conditions in terms of access to care and overall cost.
