April 2008 Archives

• How do I know when I am ready for surgery?
• When you have endstage or "bone on bone" arthritis, injections are helping the pain less than three months and your pain is affecting your quality of life then you will be a surgical candidate.  Until you reach this point Dr. DiGioia will continue to advise conservative treatment.
• Why have I been asked to lose weight prior to my surgery?
• Knee and hip replacements wear out just like your regular knees and hips.  For every pound of extra weight that is six pounds of pressure on both your knees and hips!  If you are 10 pounds overweight, that is 60 pounds on your knees and hips! If you would wear out your new knee or hip, it would require a revision or redo surgery which can have more complications and higher risks. We know it is hard to lose weight because of pain, but the role of the injections is to relieve pain and allow you to be more active.  Dr. DiGioia wants you to be in the best shape possible before your surgery so that you can have the best results afterwards.
• What is arthritis?
• Cartilage acts as a cushion for the weight bearing surfaces of the joint.  When arthritis sets in, the cartilage between your joints begins to wear over time, and eventually the bone wears down too.   This causes the inflammation and pain which prevents you from maintaining your active lifestyle. 
• What is minimally invasive total joint replacement?
• This surgery is not truly "minimally" invasive, but, more accurately, "less" invasive.  There is a smaller incision and less muscle work involved, but the implants are still the same.
• What medications do I stop prior to surgery?
• All medications with ASA base (aspirin), blood thinners, NSAIDs (such as Aleve and ibuprofen), all arthritis medications (except for Celebrex) and vitamin E.  Please ask about any herbal supplements you may be taking.
• Can I take Tylenol?
• Yes.
• Can I take Celebrex?
• Yes.  Unlike other arthritis medications, you can take Celebrex right up to the day of your surgery. We also use Celebrex as a pain medicine after surgery.
• How long can I expect my total joint replacement to last?
• 75% of people are still with their original implants in place and doing well at 15 years. This is not to say that once it is year 15 that you will start having problems. TJR can wear out just like your normal knee, and the longer you have the joint replacement the greater the risk wear.  Also, the modern implants are modular systems so we can often catch wear early enough and replace ONLY the part that is worn. This is why we recommend that you get new x-rays every three years!  

BACKGROUND INFORMATION:

In the last decade, there has been increasing evidence that a significant number of Pennsylvania physicians are choosing to practice in other states, are retiring early, or are no longer performing high-risk procedures.  This is especially true for specialists, such as orthopaedic surgeons, obstetricians, gynecologists, neurosurgeons, cardiologists and cardiothoracic surgeons.  The reason for this decline in Pennsylvania physicians is due to the surging malpractice insurance costs coupled with low private insurer reimbursement.  Not only are Pennsylvania physicians choosing to leave the state, but graduating residents are choosing not to practice in this state at all. 

Data from a study conducted by the U.S. Bureau of Health Professions and the American Medical Association revealed that between 1985 and 2002 Pennsylvania lost 143 orthopaedic surgeons, a reduction from 892 to 749, or 16%.  Furthermore, the number of orthopaedic surgeons per 100,000 population dropped from 7.42 in 1997 to 5.83 in 2002, the lowest in the 18 years studied.  This decline in specialists paired with the increased demand as baby boomers age, is putting patient access to medical care in jeopardy.  In addition, the high turnover rate of specialists is extremely disruptive to the care of patients, especially those with chronic illnesses.

Physicians are not only leaving the state but those who stay are restricting their practice to lower risk procedures.  For example, according to the American Association of Orthopaedic Surgeons, rising liability premiums have caused 55% of orthopaedic surgeons to avoid certain high-risk procedures, with 6% eliminating all surgery.  Some physicians are choosing to not "take call" for hospital emergency room departments to minimize their risk of lawsuits.  In extreme cases, emergency and trauma centers are even shutting down completely.

SO WHAT IS FACT FROM FICTION?

Doctors are no longer performing complex or high-risk medical procedures due to medical liability.  The unrestrained escalation of jury awards is driving up doctors' liability insurance premiums and even forcing some insurance companies out of business.  According to the Physicians Insurance Association of America (PIAA) the median jury award doubled from $157,000 to $300,000 from 1997 to 2003.  This in turn has caused insurers to stop selling medical liability insurance altogether. The June 2003 GOA report found that in 2002 nearly 40% of orthopaedic surgeons in Pennsylvania were not able to renew their coverage with the same carrier and 31% did not find new coverage.  In 1999 jury awards in Philadelphia alone exceeded the total amount of jury awards for the entire state of California.

Doctors are not only avoiding high-risk patients, but also even practicing defensive medicine, which involves ordering a battery of tests to reduce their exposure to malpractice liability.

Demand spike is also promoting the increased MD shortage.

The baby boomer generation is one of the main factors adding to this increased demand.  Between 2001 and 2030, the demographics of the baby boomer phenomena will quadruple, leaving the elderly with the greatest shortages.  It is predicted that there will be a shortage of between 27-43% physicians by 2020, with the shortage in orthopaedic surgery in the range of 40-50%. 

WHAT ARE SOME SOLUTIONS TO THE MD SHORTAGE AND MEDICAL LIABILITY CRISIS? 

            We need to minimize insurance premium increases and provide damage caps so that physicians not only want to stay in this state, but so we can attract physicians from other states.  By stopping the medical liability crisis, we will enable more physicians to be here to handle the increasing demand that is inevitably going to come as the baby boomer generation ages.  In order to provide appropriate and fair compensation to those who are truly injured, but also protect physicians from excessive damage payouts, the Pennsylvania Orthopaedic Society has developed several goals, including:

•  Amending the Pennsylvania Constitution to adopt caps on awards for non-economic damages of $250,000.
• Ensuring a stable liability insurance market and reducing costs to high-risk specialty doctors, such as orthopaedic surgeons.
• Lowering mandatory malpractice insurance coverage levels to $250,000 per occurrence and $750,000 per annual aggregate.
• Establishing a no fault medical liability proposal, which would limit lawsuits to those cases involving death, serious impairment of bodily function, or permanent disfigurement. 
• Permanent MCARE abatement, the state run insurance program, which provides catastrophic medical liability insurance.  By providing high-risk specialists like orthopaedic surgeons with 100% abatement through a cigarette tax to pay the doctors' premiums, orthopaedic surgeons have saved $109,000 in the past few years.

Both physicians and patients need to work together to change state policies concerning medical liability.  If we do not change liability policies soon, we will face a future with limited access to healthcare.  Once the physician shortage occurs, there could be pressure to decrease demand by increasing co-pays, denying care to certain groups, physicians not accepting new patients and increasing the use of physician assistants and nurse practitioners.  Patients would be forced to wait longer to see doctors, have shorter physician visits and possibly be denied care altogether.  Patients might even have to travel out of state to seek specialty care.  This would then force patients to use the already overcrowded emergency rooms for routine primary care.  

For more information, please visit the American Academy of Orthopaedic Surgeons (AAOS) www.aaos.org or the Pennsylvania Orthopaedic Society www.pasociety.org.  

Patients can get involved by contacting the Patients And Physicians Alliance (PAPA) at 215-271-9590.