We had a great discussion this month about two articles from the March issue (Volume 46, Issue 3) of The Journal of Hand Surgery: Impact of Insurance Type on Self-Reported Symptom Severity at the Preoperative Visit for Carpal Tunnel Release and Variation in Use of Electrodiagnostic Testing: Analysis From the Michigan Collaborative Hand Initiative for Quality in Surgery. Thank you to everyone who chimed in!
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
J Hand Surg Am- ASSH @JHandSurg:
The March #JHSJC is happening NOW! Let’s get the discussion started. #CTR #CarpalTunnelRelease #insurance #ElectrodiagnosticTesting
Brent Graham @BgTalkinman:
Welcome to the March session! Let’s start with article no.2, the study by Billig et al on #EDS and clinical eval of #CTS #jhsjc
I misspoke in my discussion points about this one. It wasn’t done in 1 geographic area. M-CHIQS participants are from a few states #jhsjc
My question remains the same: are these findings generalizable? #jhsjc
RyanC @RPCalfeeSTL:
interesting article. I suspect findings would be same in other systems as ncv not ordered according to evidence #JHSJC
I’m often one “at fault”. Getting ncv to give objective data to patients and sometimes to get insurance approval for surgery #JHSJC
Brent Graham @BgTalkinman to @RPCalfeeSTL:
so, to cut to the chase, why aren’t #EDS ordered according to the well-established evidence on this issue? #jhsjc
Brent Graham @BgTalkinman:
If there are false +ves is it really evidence — more than their symptoms? #jhsjc
RyanC @RPCalfeeSTL:
good point. No test (ncv, us) perfect so have to put together with clinical picture #JHSJC
Brent Graham @BgTalkinman:
The insurers are often blamed for this but doesn’t it cost money to get #EDS? #jhsjc
Obviously insurers want to avoid paying for #CTR but the surgery happens anyway. Seemingly they are paying more than they need to. #jhsjc
Warren @whammert to @BgTalkinman:
While it does, they look at it differently – they are making sure they have some control over who gets surgery #jhsjc
RyanC @RPCalfeeSTL:
I have had ctr denied and even with peer to peer told be insurer that they wanted the ncv before they would let me do surgery. Not often but has happened #jhsjc
Warren @whammert to @RPCalfeeSTL:
and WC, at least in NY is made up of non hand surgeons who make the regulations #jhsjc
and WC requires EDX prior to approval for surgery #jhsjc
Brent Graham @BgTalkinman:
This seems like a fertile area for reform that will save $. Is it a matter of poor dissemination of evidence? #jhsjc
RyanC @RPCalfeeSTL:
for WC I always liked ncv as subjective complaints frequently persisted #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @RPCalfeeSTL:
too many restrictions may prevent use when it might be helpful. #jhsjc
Brent Graham @BgTalkinman:
I might understand the WC piece but one of the adv of CTS-6 is that the prob of #CTS considered +ve can be raised for that group. #jhsjc
Warren @whammert to @BgTalkinman:
I am not sure how much insurance carriers look at evidence? Seems tom need a clear wrong to make a change #jhsjc
Daniel A. London, MD MS @LondonDA to @BgTalkinman:
Unless the insurance companies are already saving money in the grand scheme of things by requiring the test. Insurance companies often don’t do things that make clinical sense, but they definitely do things that make financial sense for them as a business. #JHSJC
Avi Giladi @theaviram:
our concepts article this month (#humblebrag) tries to discuss this, albeit briefly. when ambiguous CTS-6, is EDX helpful? #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Are you referring to the cases where #EDS would be useful? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
yes. because if we agree there are use cases, then adding too many restrictions can be problematic too #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I understand. It seems excessively rigid! #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
The authors raise idea of baseline as a reason but is there evidence to support that? I don’t think so. #jhsjc
Warren @whammert to @BgTalkinman:
I think probabliliies are hard for insurance to get a handle on – they want black and white, which works with fx #jhsjc
Warren @whammert to @BgTalkinman and @RPCalfeeSTL:
Not sure about evidence, but helpful when patient says they are worse or the same and EDX shows improvement #jhsjc
Brent Graham @BgTalkinman to @whammert:
Seemingly one thing they understand is $ but they are wasting it with this kind of thinking. #jhsjc
Brent Graham @BgTalkinman to @whammert:
There are no studies looking at post-op #EDS in pts who are doing well. #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @whammert:
how many CTS surgeries are ‘avoided’ (aka denied) because insurance insists on EDX and then EDX is neg? #jhsjc
Brent Graham @BgTalkinman to @theaviram:
This is an important question! #jhsjc
Warren @whammert to @BgTalkinman:
if looking at their entire bag of money, this is probably small and one explanation limited interest to change #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @whammert:
I assume that number must be very low…but perhaps not? I haven’t had that happen fortunately #jhsjc
Daniel A. London, MD MS @LondonDA to @theaviram, @BgTalkinman, and @whammert:
Or never scheduled? Or based on the study from last month’s #jhsjc — never referred to the hand surgeon in the first place?
Brent Graham @BgTalkinman:
Is the problem just the insurers? What about the studies that show surgeons want #EDS before the pts are even seen? #jhsjc
RyanC @RPCalfeeSTL:
that may be issue too. We don’t have any requirements like that #jhsjc
Warren @whammert to @BgTalkinman:
that is just trying to improve efficiency and conversion rate to surgery at initial visit #jhsjc
Warren @whammert to @BgTalkinman and @theaviram:
same thing for requiring X-rays and mri #jhsjc
Jeffrey G. Stepan MD, MSc @JeffStepanMD to @BgTalkinman:
From what I understand this is simply a workflow issue to avoid seeing nonoperative patients in busy private clinics. #jhsjc
Brent Graham @BgTalkinman to @LondonDA:
That study showed that even when referred only 1/2 the pts with “severe” #EDS underwent surgery. #jhsjc
Warren @whammert to @BgTalkinman and @LondonDA:
I am not sure any of understood that then or now #jhsjc
Brent Graham @BgTalkinman to @JeffStepanMD:
That was the implication of the Sears et al study from a few months ago. #jhsjc
Brent Graham @BgTalkinman to @whammert:
That doesn’t seem to be in the best interests of pts #jhsjc
Warren @whammert to @BgTalkinman:
no argument here. But that is done frequently #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
That may be a very regional thing. This study showed that most of the variation was at the level of practice. #jhsjc
Jeffrey G. Stepan MD, MSc @JeffStepanMD:
Is it possible that surgeons and patients just like objective data prior to surgery? Until disincentivized to order… #jhsjc
Warren @whammert to @BgTalkinman and @RPCalfeeSTL:
Practice level is not surprising as many have guidelines all follow #jhsjc
Brent Graham @BgTalkinman to @JeffStepanMD:
I agree and that is coming. I talked about that with the authors in the podcast https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/March_2021.mp3 #jhsjc
Brent Graham @BgTalkinman to @whammert:
Presumably those guidelines are driven by productivity issues rather than evidence – that seems to be what this shows. #jhsjc
Jeffrey G. Stepan MD, MSc @JeffStepanMD to @BgTalkinman:
Yes was a great discussion – I know I fall victim to this early in practice despite “knowing better” – or get an u/s. #jhsjc
Brent Graham @BgTalkinman to @JeffStepanMD:
At least u/s doesn’t hurt and costs less. And it will soon be in everyone’s office so no waiting either. #jhsjc
Brent Graham @BgTalkinman:
This topic never ceases to fascinate me. A smart investigator should partner with insurers to study this in a way they’ll understand #jhsjc
Warren @whammert to @BgTalkinman:
bundle payments for total care #jhsjc
Brent Graham @BgTalkinman to @whammert:
My understanding is that now the bundles are only for post-op care. That’s going to change. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
insurers are focusing on restricting which surgical facility now, diagnostics soon to follow #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I’m sure that is correct. #jhsjc
Brent Graham @BgTalkinman:
Well, @whammert is here so let’s move on to the other paper on which he is senior author #jhsjc
Warren @whammert to @theaviram and @BgTalkinman:
I think it varies, but that is the case for joints. A greater impact than any level I study- sadly #jhsjc
Brent Graham @BgTalkinman:
Paper 1: is this purely and simply an access issue? #jhsjc
Jeffrey G. Stepan MD, MSc @JeffStepanMD:
Great paper, similar findings to Wright/Calfee social deprivation and Kamal pearl-diver study on Medicaid insurance #jhsjc
Brent Graham @BgTalkinman to @JeffStepanMD:
Also Cheng and Rodner on cubital tunnel #jhsjc
Warren @whammert to @BgTalkinman:
not for us as we all see all insurances, but may effect the time they present #jhsjc
David Sollaccio, MD @drs462 to @BgTalkinman:
I think it must make fiscal sense for insurance companies – otherwise why would they pay for it. I think it also depends on culture of network or region. I agree it should be reformed to improve quality of care #jhsjc
Brent Graham @BgTalkinman:
What else explains Medicaid pts worse on all of the PROMIS scales when they present with a relatively simple problem like CTS? #jhsjc
RyanC @RPCalfeeSTL:
I bet affects time to presentation and some severity before coming in. #jhsjc
Jeffrey G. Stepan MD, MSc @JeffStepanMD to @BgTalkinman:
PROMIS scores may not be due to CTS severity alone, however, can be due to many issues/comorbidiites/health lit #jhsjc
Brent Graham @BgTalkinman to @JeffStepanMD:
My guess is that it has very little to do with #CTS itself. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
That is what the earlier study on CuTS showed. #jhsjc
Warren @whammert to @BgTalkinman:
This seems to be present across many conditions and not specific to CTS – more pain and less coping as a whole #jhsjc
Brent Graham @BgTalkinman to @whammert:
You mean among Medicaid pts, right? Commercial insurance had higher scores. #jhsjc
Warren @whammert to @BgTalkinman:
correct. But guessing we would have had similar results almost regardless of DX #jhsjc
David Sollaccio, MD @drs462 to @BgTalkinman:
I think this sheds light on complex interwoven issues of health disparity, socioeconomic status, access to care #jhsjc
Avi Giladi @theaviram to @whammert and @BgTalkinman:
with what we continue to see re mental health and PRO scores, not clear these findings reflect CTS severity #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Agreed! The concern is just that – that it has nothing to do with #CTS. #jhsjc
Daniel A. London, MD MS @LondonDA to @BgTalkinman and @JeffStepanMD:
Sounds like a great question to ask the patients themselves….a future qualitative study? @RPCalfeeSTL @whammert #jhsjc
RyanC @RPCalfeeSTL to @theaviram, @whammert, and @BgTalkinman:
agree complex interplay mental, social, perceived physical health #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
If that is true – it surely is – what are the implications for hand surgeons? #jhsjc
RyanC @RPCalfeeSTL:
health literacy is hard to study. Imperfect measures in my opinion #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Seemingly, it can be simply assumed even without measuring it. #jhsjc
Brent Graham @BgTalkinman to @whammert:
I agree #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
not to mention, unclear how literacy/interpretation of the questionnaires impacts scores esp in lower SES populations #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Is this just a paradigm for the US healthcare system in general? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
probably. @ChaoLong and I are elbow-deep trying to untangle issues with PROs and literacy/usability. very complex issue. #jhsjc
Jeffrey G. Stepan MD, MSc @JeffStepanMD to @BgTalkinman and @theaviram:
We are hoping to look at this topic specifically, objective CTS severity and health lit in underserved pts #jhsjc
Brent Graham @BgTalkinman to @JeffStepanMD and @theaviram:
That is very important. #jhsjc
Avi Giladi @theaviram to @JeffStepanMD:
interested to hear about your work. it’s a topic we are focusing on, major issue for inner-city Baltimore #jhsjc
Brent Graham @BgTalkinman:
If these pts are more likely to have poor results and surgeons are eventually penalized for that, will that make access even harder? #jhsjc
David Sollaccio, MD @drs462 to @JeffStepanMD, @BgTalkinman, and @theaviram:
Objective quantification of CTS severity and time to treatment would be useful measures #jhsjc
Brent Graham @BgTalkinman to @drs462:
This gets back to the other paper and the idea that severity can be quantified better using #EDS. I doubt that is true. #jhsjc
Warren @whammert to @BgTalkinman:
I think “poor results” harder to quantify for simple outpatient procedure, so not like injections or more hospital days #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @RPCalfeeSTL:
agree, difficult to measure. and literacy doesnt = health literacy. #jhsjc
Warren @whammert to @BgTalkinman and @drs462:
EDX and severity of symptoms are often not equal #jhsjc
Brent Graham @BgTalkinman to @whammert:
That may be true. Continued symptoms? Will that be measurable as a quality indicator? #jhsjc
Warren @whammert to @BgTalkinman:
too subjective, so I don’t think so #jhsjc
Avi Giladi @theaviram to @whammert and @BgTalkinman:
too subjective, so i hope not!! #jhsjc
Brent Graham @BgTalkinman to @whammert and @drs462:
Actually I think it is rare that they are closely correlated. #jhsjc
Brent Graham @BgTalkinman to @theaviram and @whammert:
Maybe that gets us back to #EDS as an “objective” piece of data!! #jhsjc
Avi Giladi @theaviram to @BgTalkinman and @whammert:
haha yeah, maybe EDX and US will have that important place after all!! #jhsjc
Warren @whammert to @BgTalkinman and @drs462:
often inversely so #jhsjc
Brent Graham @BgTalkinman to @whammert and @theaviram:
I agree with both of you – it is too subjective and subject to confounding. #jhsjc
David Sollaccio, MD @drs462 to @whammert, @BgTalkinman, and @drs462:
I agree. I was not necessarily referencing EDX per se #jhsj
Brent Graham @BgTalkinman:
What is clear is that #CTS, a very common condition for hand surgeons, is actually a very substantial quagmire! #jhsjc
Where do we go from here in managing this problem? What kind of investigation is most needed? #jhsjc
I will venture to say that care pathways that are evidence based will be proven to be effective and cost-effective will be developed #jhsjc
Warren @whammert to @BgTalkinman:
I think there has to be something financial to move the needle – not a level I study. Bundle payment for episode of care #jhsjc
seem to need something financial-bundle payment rather than investigation. More money in surgeons pocket and less waste #jhsjc
Brent Graham @BgTalkinman to @whammert:
That always seems to work #jhsjc
Bundled payments for the whole episode of care pre- and post -op #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
until care is vertically integrated it will be hard to insist on care pathways. too many zigs/zags #jhsjc
David Sollaccio, MD @drs462 to @BgTalkinman:
I think paper 1 raises interesting questions. Socioeconomic factors impacting Tx, how pts respond to symptoms, etc #jhsjc
Brent Graham @BgTalkinman to @drs462:
I agree – its very pervasive. #jhsjc
Jeffrey G. Stepan MD, MSc @JeffStepanMD to @drs462 and @BgTalkinman:
Yes, lots of work to be done in this area to get more granular information. #jhsjc
Brent Graham @BgTalkinman:
Another excellent session!! Great comments and insights. Thanks to all! Back here April 13. #jhsjc
