We do knees, Too
Dr.’s Bargar and Taylor have become prominent “hip surgeons”
because of their interest in research and development of hip implants
and devices. Approximately 70% of their practice is total hips. Nearly
30% (and growing) is devoted to knee surgery. This is mostly total knee
replacement, but Dr. Taylor maintains an active interest in knee arthroscopy
as it relates to management of early arthritis.
Dr. Bargar began his research in orthopaedics at UCLA in 1977 with a project
investigating the stability of knee replacements. He has published several
papers relating to total knees and is a member of the prestigious Knee
Society.
Total knee replacement has evolved significantly since the early days
of so called “hinged knee replacements.” These were developed
in the 1950s when it was thought that the knee joint functioned primarily
as a hinge-type joint (as compared to the hip which is a ball and socket
joint). These early hinged devices had a high failure rate because they
were metal-on-metal bearings, and because they did not account for the
important rotational and gliding movements necessary for normal knee motion.
The modern concept of total knee replacement developed as a spin off of
total hip replacement in the early 1970s. These so-called “second
generation knee replacements” used polyethylene and cement as did
hip replacements. They performed better, but still were not as successful
as hips. This was because the design was either too unstable or too constrained.
The “third generation” knee replacements were developed in the
late 70s. These had just the right balance of freedom of movement and
constraint. We now have nearly 15 years of data on these devices and they
are performing very well – better than hips! There is over a 95%
success rate that is holding at 10-15 years. There have been some modifications
since, mainly concerning preserving or substituting for the posterior
cruciate ligament in the knee. Some people refer to the current devices
as a “fourth generation,” but the changes have been relatively
minor.
As in the hip, Drs. Bargar and Taylor take on many difficult and “high
risk” cases of total knee replacement. Nearly half are revision of
failed cases referred in by other orthopaedic surgeons. They also do many
straight forward, so called “primary” knee replacements. We
just thought you’d like to know WE DO KNEES TOO!
Dear Doctor… Q. Why do I have to have blood work every four months while I’m
taking Relafen? A. Actually, any patient taking a nonsteroidal
anti-inflammatory drug (NSAID) of which Relafen is just one, should have
a blood test every four months to monitor for potential liver or kidney
toxicity as well as anemia from occult GI bleeding. These major side effects
are rare and reversible if caught early.
Q. How should I dress when I come to the office for X-rays? A. X-rays will go directly through your clothes, what they can’t
go through is metal. You should be sure not to have change or keys in
your pockets and no zipper or rivets in your pants. The best thing to
wear in the winter time is sweatpants or something similar.
Q. I have a handicap plaque for my car, but I was still asked to
pay for my parking when I left your building, shouldn’t it have been
free? A. NO sorry – you still have to pay to park, you just get
to park near a doorway in a larger parking spot. Remember, if you use
handicap access, the best place to park is on the 2nd floor of the parking
garage then take the elevator. This will avoid steps and minimize the
distance walked. When you return to your car remember to push “G”
for garage.
Office Update
It is office procedure for the receptionist to call and confirm all office
appointments the day prior to your visit. If you think you have an appointment
and are not telephoned the day before, please call our office to be sure
you are on our schedule.
GOOD NEWS FOR OUR Medicare patients. As of January 1, 1994, Drs. Bargar
and Taylor will be accepting Medicare assignment. This means the check
from Medicare will come directly to our office and we will be able to
automatically bill your secondary insurance. You will not receive a bill
from our office until both insurance companies have paid.
We must have your secondary insurance information to bill.
A Joint Parade
On June 12, 1994, at U.C. Davis Medical Center there will be a nationwide
one-mile walk to raise public contributions to fund both research and
education programs in the field of orthopaedics and build awareness of
all that orthopaedics has done to improve mobility and quality of life
for Americans of all ages.
This function is conducted by the Orthopaedic Research and Education Foundation
on behalf of all orthopaedics and with the cooperation of the major specialty
organizations.
For more information call the National JOINT PARADE Office at 1-800-TEL-OREF.
Barbarians at the Gate
By William V. Healey
An insidious destruction of patient care is occurring now, never mind
the future of the Clinton health plan. Gatekeepers, HMOs and insurers
are tearing apart the doctor-patient relationship.
Let me be specific. A 52-year-old man had a total hip replacement on a
Thursday. Two days later, while making rounds, the surgeon was wanted
on the phone by another doctor. It was the gatekeeper of the HMO the patient
was in. He had not seen the patient.” “Are you going to send
the hip home? the gatekeeper said, “it’s costing me $800. a
day to keep him in the hospital. He can be cared or at home. I wish you’d
discharge hip.” The surgeon refused.
Another example: a 60-year-old woman underwent a proctocolectomy - the
removal of the anus, entire colon and the creation of an ileostomy by
which the intestines empty into a receptacle on the abdominal wall. On
the third post-op day, the surgeon was asked to send the patient home
by the HMO gatekeeper, a family physician who had not seen the patient.
“Are you crazy?” the surgeon said, and refused to discharge
the patient.
Across the country gatekeepers, HMOs and the big insurance companies have
combined to see to it that the gatekeepers’ salaries, or year-end
bonuses, come in part from “eliminating wastefulness in the system,”
“becoming more efficient,” and “getting the unnecessary
costs out of medical care.” What they are saying is that the speed
by which a patient can be diagnosed by a specialist, the rapidity of the
cure and the reasonable amenities that should be part of the care and
science of medicine don’t matter. The only thing that counts is the
corporation’s bottom line and you, Doctor can share in that profitability
if we “save” together on patient care.
A 57-year-old had a modified radical mastectomy on a Friday and on Monday
the insurance company started calling me stating that “we allow three
days for a mastectomy,” despite the fact that the patient had drains
in and lived 150 miles from the hospital.” I asked the harassing
insurance company physician, who was calling from a city 200 miles away,
if she was a surgeon. “No.” Had she ever seen a mastectomy?
“No.” What was she “A hematologist.” When I told this
gatekeeper that the patient was preparing to file a formal complaint against
the company with the State Insurance Commission, nothing more was heard
from the physician or the company, which paid the hospital bill in full.
What we seem to have forgotten in our discussion of health care reform
is the fact that the physician best able to keep the costs of health care
down is the individual who recognizes the patient’s problem right
away-quickly-because of experience and judgment. That doctor is the one
who will know which lab test, X-rays, MRI, CT scan or consultant can give
the correct answer without unnecessary tests or delays in obtaining what
is needed for the correct diagnosis or treatment.
Many of my colleagues and I have received phone calls about a patient
from a gatekeeper physician hundreds or thousands of miles away who had
a little or no knowledge of the clinical problems involved.
Any physician who is trying to feather his own nest by keeping the patient
from seeing a specialist, by “let’s try the” or “we’ll
see how you are next week,” may be doing just the wrong thing for
the patient and the cost of health care. I don’t know of any statistics
kept on gatekeepers’ mistakes or insensitivities. They should be.
Before specializing in surgery, I was a busy family practitioner. I have
great admiration, affection and respect for these men and women, who are
usually the first to see the patients when signs and symptoms can be confusing
or misleading. But forcing patients to go through a gatekeeper is nonsense.
No one sophisticated in health care will swallow that pill. We go straight
to the physician or surgeon whose opinion we want.
HMOs and managed-care programs threaten that direct access by forcing
their clients (they used to be patients) to dally with a gatekeeper. Doctors
don’t see gatekeepers for themselves or their families. Why should
patients be forced to do so if they know whom they want to see?
But if the Clintons and our senators and representatives force us to use
gatekeepers, the least we can do is make sure that the gatekeepers’
compensation is a flat rate with no bonuses for patients kept from or
referred to other M.Ds. Such “bonuses” used to be called fee-splitting.
Moreover, he should be thoroughly familiar with the condition under consideration
or at least be aware of the possibilities. Does a patient benefit for
the cost of care diminish if what’s on either side of the gate is
unknown to its keeper?
Those best able to make sophisticated triage decisions are senior internists,
family practitioners and general surgeons rather than the young family
practitioners who usually have the job. There are always exceptions, but
by and large the younger the gatekeeper, the greater the potential for
errors in medical judgment and cost.
Gatekeepers should be required to see the patients in the hospital, especially
post-op, before harassing the clinicians. Let them judge for themselves
how much “fraud and abuse” are going on in a given patient’s
care, a subject Ira Magaziner and Hillary Clinton like to stress.
The benignity of the gatekeeper concept is not only fallacious but threatens
to destroy the advocacy of doctors for their patients. Whom is the clinician
supposed to serve? In the terror of illness, whom is there to trust?
Reprinted with permission from the Wall Street Journal 1993. Down Jones
a Company, Inc. All rights reserved.
Staff Profile:
I moved to Sacramento from the Bay Area when I married my high school
sweetheart in 1972.
I have four children ranging in age from 6 years to 16 years. I am on
the board of directors for Arden Manor Parks and Recreations Department
and am the referee coordinator for Sierra Oaks Soccer Club. When not at
work I spend most of my time with family activities and when time allows
I love to sew and do crafts.
Many of you don’t know me because I spend most of my time in my office
doing billing and the accounts receivables. Occasionally I have filled
in for Karen at the front desk. And beginning the first of the year, when
Karen returns from maternity leave, we will be job sharing. I will be
at the front desk two days a week and Karen the other three. I am really
looking forward to getting to talk to more of you in person. My office
days will be Tuesday and Thursday at the receptionist desk and Wednesday,
Thursday and Friday in the billing office.
Karen had a baby boy on Monday, November 15, Timothy Patrick, Jr. arrived
at 11:44 a.m. and weighed in at 9 lb. 7 oz. and 20 _” long. Mother
and baby are both fine.
We
do knees, too