Managed Care, Limb Salvage or Amputation?
Do You Prefer Your Doctor or a Government B'crat Deciding Amputate or Save?
(Please see the link at the very end of this post regarding NF)
The coming decision by the Supreme Court of the United States regarding the legitimacy of the Obama Health Care law will change your opportunities for medical care forever. Decisions for treatment, as stated in the new law, must conform to the best use of medical dollars as prescribed - not by your current doctor - but by a government bureaucracy who has no idea who you are or how you may otherwise be affected. This will mean that if your doctor has a breakthrough product available that may well save a limb due to the capabilities of the advanced product, due to factors, NOT ONLY COST, the use of these products may well be declined. If you are too old - whatever that means as there is no determination as to what "too old" means - you may not receive the treatment as it would be less valuable to you than it would to someone much younger. If you are too sick, even though this treatment may provide a way for you to stay mobile, because of other illness, you may well be declined because others may be able to make better use of the treatment. Or, just because the product hasn't waited enough time to get around to the next year when they can issue the form needed so it can actually be billed to your account - but by then your limb is being consumed in an incinerator at a local hospital. What in the world could be treatments like this and how much reality is there in a decision like this actually having to be made? It is happening every day - NOW.
An Example Of Treatment
Diabetes is a debilitating disease that affects a significant population world-wide. Circulation is affected, first in the most remote areas of appendages, particularly feet and toes. Small injuries may not heal, larger injuries may well expand and become a chronic wound requiring some treatment on a continuing basis - unless it can be healed. Venous stasis sores are circulatory related as well and are typically on lower legs with similar results. Decubitous ulcers, or pressure sores can be found on almost any part of the body where it has been pressed against a hard surface for a period of at least 30 minutes - really, just 30 minutes. So individuals that have been strapped to a backboard for a period in excess of two or three hours may well see evidence of DU expressed by open wounds that take a long time and are typically very expensive to heal. You don't have to be diabetic to gain a decubitous ulcer.
Currently, there are several treatments being used by podiatrists, wound specialists and plastic surgeons across the country and around the world that have proved some limited improvement in the case of these chronic wounds. Some of these products utilize extensive exposure to oxygen to enhance healing while working hard to keep out infection. Silver based dressings where the actual dressing fibers are coated with elemental silver actually reduce the potential of bacterial infection during the repair. There are all sorts of variations on these and even these treatments may be affected by the new health care law. A hyperbolic oxygen chamber is expensive to maintain and operate. If it isn't being used, it is even more expensive so keeping someone in there makes it more efficient. But the government doesn't necessarily see it that way, and that will drive up the cost and reduce the chance of having that line of treatment available to you if you ever need it.
The Medicare Model
If you are a single payer, "health care is a right" kind of thinker in the U.S., consider the model you will be having if the Supreme Court doesn't overturn the legislation that brought "Obamacare" forward. Medicare, the single payer program currently operating all health care for seniors not covered by private health insurance in the United States, is generally thought to be the model with some changes.
The biggest changes will be the limitations on care. Currently, if someone on Medicare requires an X-ray or MRI or other test for cancer or some other medical issue, their doctor prescribes it and the individual goes in for the procedure. A predetermined payment for services is already in place so everyone along the line knows how much they will be paid to accept that patient. The amounts paid to doctors has gone down by law every year for several years - yet every year Congress has passed legislation stalling the cuts in the payments. The result is an artificially high number of people still being treated because if the current payment designed by the law were being paid, a large number of physicians would quit seeing Medicare patients. Think about it like this. If you had been a patient of a general practitioner for your 30 years while you worked for an automaker on your great union insurance plan, your doctor may have been paid upwards of $150 for a physical or even more for some special office calls. Normal office visits would have been closer to $100. Under Medicare for the same time, the doctor today might receive as little as $27. Wonder why he doesn't want to set around and chat about your health anymore? And it is scheduled to go down from here which is driving doctors to hire more nurse practitioners and PA trained personnel that he has to oversee. If they have a particularly curious case, the doctor may involve himself but otherwise his or her time is best used going over the charts instead of personal involvement. How you liking that care now?
And that test we were talking about earlier? Your doctor says, "I'm really not sure what I am feeling or suspect." So he wants to have you take some tests. Since there isn't enough money for everyone to get paid along the way for every test someone wants to run - a committee will determine if you really need the test. This will only take a few months, right now, but what problem is that if you have potential blockage in your heart or cancer or some kind of hemorrhage going on in your brain. In other words, this managed care thing will determine who lives, and who dies. Sarah Palin was chastised for her comments about death panels. This is what she was talking about and they are very real.
Cutting Edge Technology
Up until now we have limited ourselves to current technology. What about new technology, breakthrough treatments that may heal us faster or better? What is the incentive to come up with them? Altruistic sentiments are great but they don't pay any bills. If you look at a company today that is working with potential treatments or possible cures for everything from diabetes to myocardial infarction to healing decubitous ulcers using stem cells, and they are told these cutting edge products are great but it is so much cheaper to just amputate.
I recently attended the SAWC (Symposium of Advanced Wound Care) in Atlanta, Georgia. This was a pretty significant show with manufacturers of everything from models of wounds, wound treatment dressings to hyperbolic chambers and sand beds. Most of the product offerings were new plays on old technology where the new products were repackaged in prettier or sharper packages. It has been 10 years since silver impregnated dressings were introduced, yet at least 10 booths were touting "new" silver dressings. Several of the larger booths were offering software packages to assist the doctors in keeping up with how they are to be reimbursed for their work. What other profession has had so much regulation imposed upon it that it requires,not desires, its own specialized software for billing and record keeping?
Probably the only area of substantial "new" products were those based on some kind of stem cell platform. Some of the older names in the room were Apligraft and Dermagraft. These two products have been around a couple of years and have been the standard of care for DFUs (Diabetic foot ulcers) or venous stasis sores. They are similar, in that they both have a matrix that they seed with cells from a human source, that is skin cells in the case of Apligraft and cells from penis trimmings during circumcision for Dermagraft, and they grow more cells that are then applied to the wound to encourage the host cells to begin faster healing. Other companies present in this general genre was Mimedix and Osiris. There are similarities to these products in some areas. The concepts of these companies is a different source altogether for more active, live mesenchymal stem cells and growth factors that speed healing and reduce inflammation.
The source of the product for one of Osiris' products (Grafix Prime) and Epifix from Mimedix is the inner lining or amnion layer of a placenta that is processed and then frozen or freeze dried. In the case of Grafix Prime, the product is cryo-preserved, a special process lowering the temperature of the product after it is processed down to a temperature below minus 59 degrees Fahrenheit which is where it is believed all biological activity stops. In this way, the tissue containing live, mesenchymal stem cells and other biologic growth factors are preserved for future use. In the case of Mimedix products, the same part of the placenta is processed then freeze dried to preserve the product. This dried product, when re-hydrated, is suggested to have similar characteristics of the cryo-preserved product per Mimedix literature. Both products are considered allograft as they are brought from one human and applied to another human. The key here is that MSCs (mesenchymal stem cells) when sourced from the placenta have no issues with immunogenicity - that is there is no rejection from the patient. Osiris take it one step further and salvages the second inner layer of the placenta producing two more products, Grafix Core and Ovation. These are for all intents the same product in two forms. Grafix Core is the chorion layer of the placenta in a sheet-like form. Ovation is a suspension which can be blended with other products or injected into the patient for tendons or even bone applications like Charcot's foot.
These are cutting edge products that can heal chronic wounds in much faster time than anything else on the market. They can be used across a wide variety of maladies from DFUs or diabetic foot ulcers to venous stasis sores, decubitous or pressure sores, burns, bone repair (particularly non-unions), spinal surgery, any muscle surgery where adhesions may be an issue, even oral surgery as this is known to be able to regrow gingiva. Right now Medicare doesn't pay for these products and it will be at least January before that decision can be made. Even then, it will only pay a part under certain conditions for these products. What is the difference? If you could be healed in two or three weeks instead of months and months, what is that value? And yes, that means there will be extreme savings over time, but that kind of reasoning has never been much of a part of the government oversight.
Be aware of these kinds of issues as we go forward. Take the initiative to learn about just what is in the bill before they pass it. We really need some leadership in this country and world-wide that makes the most sense for the best possible care.
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