June #JHSJC Transcript

We’ll be posting all #JHSJC transcripts from here on out (including past conversations!), so be sure to check back in case you miss a discussion!

The June #JHSJC was a lively discussion on two articles from Volume 44, Issue 6 of The Journal of Hand Surgery: An In-Depth Review of Physician Reimbursement for Digit and Thumb Replantation by Rachel C. Hooper, MD, Jennifer M. Sterbenz, BS, Lin Zhong, MPH, MD, and Kevin C. Chung, MD, MS and The Feasibility and Usability of a Ranking Tool to Elicit Patient Preferences for the Treatment of Trigger Finger by Lauren M. Shapiro, MD, Sara L. Eppler, MPH, and Robin N. Kamal, MD.

Feel free to continue the conversation below in the comments!

J Hand Surg Am- ASSH @JHandSurg:
#JHSJC starts now! Let’s get the discussion going!

Brent Graham @BgTalkinman:
Let’s begin the discussion! Use the #jhsjc hashtag so that we can track the comments. These will be curated and posted starting this month.

Ray Raven MD, MBA, MHCI @RayRavenMD:
ARTICLE #1: An In-Depth Review of Physician Reimbursement for Digit and Thumb Replantation #jhsjc

Brent Graham @BgTalkinman:
Let’s begin with the paper on #reimbursement for #replantation. #jhsjc

David Ring @DrDavidRing:
#jhsjc many problems related to claims databases.  If you see 4 in 5 miscoded, hard to trust.  I would stop.

Brent Graham @BgTalkinman:
There were about 200 replants and 6200 revision amps studied. Is that a sufficient sample? #jhsjc

David Ring @DrDavidRing:
#jhsjc  A key to research is good data and good questions.  If you don’t have a great question or you have imperfect data, your study has a substantial probability of being misleading

Brent Graham @BgTalkinman to @DrDavidRing:
Do you think that invalidates the findings?  #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC  200 replants is more than enough, but again seems odd.  If that is what’s in the sample, the sample is likely flawed.

#JHSJC I don’t like the terms “flawed” or “invalid”.  It’s a question of how useful the data is.  I don’t feel like this data inform what we do.

Brent Graham @BgTalkinman to @DrDavidRing:
I don’t disagree but the question seems reasonable and the number of cases seems enough to judge the reimbursement.  #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Would you say that the reimbursement info is likely to be inaccurate? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC  A large number of crappy data doesn’t make the data better. I’ve backed off of claims database studies.  Need to be very selective to be meaningful.

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC  Caution.  Extreme caution.  ncbi.nlm.nih.gov/pubmed/25724835

Brent Graham @BgTalkinman to @DrDavidRing:
Here they assembled a sample and looked at reimbursement data. Is it enough cases to accurately estimate that? #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I don’t disagree! I feel the same way about RCTs! #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Appropriate replantation is one of the most noble things in hand surgery. And it is rare.
#jhsjc I hope it’s not just you and I Brent, but these do live on.

#jhsjc  Bottom line motivation for study that I agree with: We need a way to incentive helping people get and stay healthy.  Often with fewer fingers.

Brent Graham @BgTalkinman to @DrDavidRing:
The imperfections of claims based data notwithstanding, do these figures seems accurate? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @DrDavidRing & @BgTalkinman:
– Claims data lacks important clinical detail & excludes other important data such as labs and radiology.    #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
It might be but I love discussions with you! #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I don’t disagree at all. I’ve done hundreds of replants – not always what we’ve aimed for but not for a lack of trying. #jhsjc

The concern is that poor reimbursement is a reason why surgeons won’t do replants even if they are indicated. #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD:
That is true but this is about payment to surgeons and that has been shown to be an important incentive – right or wrong. #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC  Appropriate re-plantation should be reimbursed higher than anything we do.   Off hours. Technical expertise. Emotional strain.  I get the motivation for the study and I like the point of discussion.

Brent Graham @BgTalkinman to @DrDavidRing:
Does this data help with that struggle?  #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @DrDavidRing & @BgTalkinman:
“Appropriate” is the operative word. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Given the disparity in wRVU what is the answer for that? #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD & @DrDavidRing:
More money isn’t coming. Could this information lead to a decline in the wRVUs for the small elective cases? #jhsjc

Replants are already not done by most hand surgeons. Is changing the reimbursement going to help that? #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @DrDavidRing & @BgTalkinman:
such information may lead to the decline in wRVUs for other cases. #jhsjc

Must factor in the facility or location to get a better idea of the value delivered to the system. #jhsjc

Brent Graham @BgTalkinman to @RayRavenMD @DrDavidRing:
That’s my point. It’s unlikely they will increase for replants. Are the other procedures overvalued?  #jhsjc

I’m not sure I agree. This is just about getting the surgeons interested in even trying. #jhsjc

Ray Raven MD, MBA, MHCI @RayRavenMD to @DrDavidRing & @BgTalkinman:
I would like to say no, but a CTS take takes 6 minutes under local and can be done in the office. #jhsjc

David Ring @DrDavidRing:
#jhsjc Uncommon problems get neglected by payers, no matter how important.

#jhsjc When payers can be confident that an important procedure is worthwhile, they might pay for it.

Brent Graham @BgTalkinman to @DrDavidRing:
That is a challenge! #jhsjc

Looks like an intimate discussion tonight! Let’s move on to the study on eliciting pt preferences #jhsjc

This study didn’t contain much info on the sample but was conducted in a relatively affluent area. Does that matter? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC  Generalizability to all humans should be the baseline. We have more in common than different.

Brent Graham @BgTalkinman to @DrDavidRing:
What I’m getting at is whether that sample made it easier to do than would be the case in a less affluent area. #jhsjc

Trigger finger is a comparatively simple condition. Would this be feasible with a more complicated problem? #jhsjc

Patient preferences are essential to elicit but can this approach be generalized? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC  Easier to study decision making?  Easier to involve people in decisions?

Brent Graham @BgTalkinman to @DrDavidRing:
It’s our duty and responsibility to explain and counsel . What I wonder is whether it can be approached like this. #jhsjc

Brent Graham @BgTalkinman:
Will this approach find its way into decision support systems in EMRs? #jhsjc

This approach seems amenable to being made into a decision aid that fits with value-based reimbursement #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC I’m not sure this is the best approach, but I love focusing on tools that help people consider what matters to them and how misconceptions can interfere with those goals

Brent Graham @BgTalkinman to @DrDavidRing:
Agreed! It’s the right thing to do without question. Is this the way to approach it? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC  An evolution is in progress to develop and test tools for gently correct misconceptions, depersonalize expertise, and optimize alignment of patient choice with values.  This is a step forward for sure.

Brent Graham @BgTalkinman:
My concern is that a formulaic approach may be too simplistic to have application for more complex conditions. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Agreed – very thoughtfully articulated! #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
#JHSJC  Complexity and Magnitude are in the eye of the beholder.  Trigger finger is a crisis for some people.

Brent Graham @BgTalkinman to @DrDavidRing:
That is true but it is less multifaceted than some other decisions. #jhsjc

The concept is universal but the approach may have to be varied. #jhsjc

Thanks for sticking with the discussion! The comments will be collated tomorrow and posted in the coming days. #jhsjc

Brent Graham @BgTalkinman:
We will return next month. Go Raptors! #jhsjc