Gene's Joint

Our work cited in the NY Times!

Pulse Oximetry: A breath-taking historical view

As an anesthesiologist, my job is to keep patients alive and safe from surgical harm. The product I rely on most is a medical device called the pulse oximeter. This simple device clips onto a patient’s finger and measures the saturation of oxygen molecules bound to a patent’s hemoglobin, the protein responsible for carrying oxygen to bodily tissues and sustaining life. Today, it is easy to take this device for granted. After all, you can purchase a pulse oximeter on Amazon for less than $20. Yet the advent of the pulse oximeter in the late 1970s was a large reason why anesthesia-mortality risk has declined from about 1 death in 1000 surgical procedures in the 1940s to 1 in 10,000 in the 1970s and to 1 in 100,000 in the 1990s and early 2000s.

Why is this device so wonderful? Besides solving a critical unmet need (prior to pulse oximetry, anesthesiologists put their finger on a patient’s pulse and watched to see if the patient’s lips turned blue to see if they were asphyxiating), pulse oximetry is the epitome of the simplifying innovation. It converts a complex physiologic process (i.e. the differential absorption of light from the binding of oxygen and carbon dioxide to hemoglobin in pulsatile blood) into a simple percentage which is expressed both visually (numeric display) and aurally (a soothing beeping noise whose pitch varies based on the percentage saturation and rate varies based on the heart rate). It is used widely across almost all medical care settings from operating room to emergency room to doctor’s office to measure vital signs.

Pulse oximetry owes its origins to the anesthesiologists William New and Mark Yelderman of Stanford University Medical School. New recognized the potential importance of and market for a convenient, accurate oximeter in the operating room and all other hospital and clinic sites where patients are sedated, anesthetized, unconscious, comatose, paralyzed, or in some way limited in their ability to regulate their own oxygen supply. New, with engineer Jack Lloyd, founded Nellcor, which began the mass manufacture of the Nellcor pulse oximeters. The Nellcor pulse oximeter was evaluated by Yelderman and New, the manufacturers in 1983 [2. M. Yelderman and W. New, Jr., Evaluation of pulse-oximetry. Anesthesiology 59 (1983), pp. 349–352. View Record in Scopus | Cited By in Scopus (77)2].

After an initial period of skepticism, the Association of Anaesthetists of Great Britain and Ireland recognized the pulse oximeter as their standard for intraoperative monitoring in 1988, and 2 years later, the American Society of Anesthesiologists recognized it as their standard for intraoperative monitoring.

By 1993, there were about 40 companies making and selling pulse oximeters, and over 750 books, reviews, and papers concerning pulse oximetry were published. Nellcor was founded in 1981 and sold to Mallinckrodt (now Covidien) in 1995 for $2 billion.

The pulse oximeter revolutionized patient care in the operating room and in doing so, generated breath-taking clinical and commercial success.

Patient Choice

Transparency + patient engagement = True Patient Choice

Great Primer on P4P

An awesome primer on pay for performance by one of my mentors Todd Dorman and his colleages at SCCM

http://www.sccm.org/SiteCollectionDocuments/Current-Issues-Pay-for-Performance.pdf

A few more Hawaii tidbits

Swim spot 
Basically below the Doris Duke Shangri-La

Doris Duke’s Shangri-La
4055 Papu Cir
Honolulu, HI 96816
(808) 734-1941
http://www.yelp.com/biz/doris-dukes-shangri-la-honolulu-3

Best sushi place
This is the place I told u about that used to be a hole in the wall but now has moved to bigger location. Omakase is best I’ve had outside of the fish market in Tokyo!

Morio’s Sushi Bistro
1160 S King St
Honolulu, HI 96814
(808) 596-2288
http://www.yelp.com/biz/morios-sushi-bistro-honolulu-2

Chinese hot pot
Sweet Home Café
2334 S King St
Moilili
Honolulu, HI 96826
(808) 947-3707
http://www.yelp.com/biz/sweet-home-caf%C3%A9-honolulu-2

Japanese Izakaya (Japanese style tapas), try whatever they suggest on yelp plus the Norichos (spicy tuna with jalapeño on toasted nori/seaweed)

Tokkuri-Tei
449 Kapahulu Ave
Kaimuki
Honolulu, HI 96815
(808) 732-6480
http://www.yelp.com/biz/tokkuri-tei-honolulu

Best dessert on the island is their honey toast (besides red velvet pancakes at Cinnamons). Their food is just so so though

Izakaya Tairyo
514 Piikoi St
Ala Moana
Honolulu, HI 96814
(808) 592-8500
http://www.yelp.com/biz/izakaya-tairyo-honolulu-4

Brunch

Café Kaila
Market City Shopping Ctr
2919 Kapiolani Blvd
Honolulu, HI 96826
(808) 732-3330
http://www.yelp.com/biz/caf%C3%A9-kaila-honolulu-3

Le Crêpe Café
2740 E Manoa Rd
Manoa
Honolulu, HI 96822
(808) 988-8400
http://www.yelp.com/biz/le-cr%C3%AApe-caf%C3%A9-honolulu-9

Where to play in Hawaii?

I thought I would just put this up on the blog since I have been answering some emails about how to spend a 1-2week vacay in Hawaii:

If its more than 1 week would suggest you check out the Big Island, one of either Kauai or Maui and Oahu. Maui may not be a bad idea since you can go whale watching which is in season during December.

Hikes: There are some amazing hikes in Oahu of which I think the highlights are Maunawili falls, Makapuu lighthouse and tidepools, Olamanu, Stairway to Heaven. Volcanoes national park is a MUST on Big Island as are the green and black sand beaches there, there are some great hikes on Haleakala as well as the sunrise from there.

Snorkel spots on Oahu: I love Shark’s Cove on the north shore and you can go to my fav shrimp truck place in Haleiewa, Hanauma bay is the touristy snorkel place near Waikiki but I would only go early in the morning as it gets really really crowded there. I also really like a specific spot near the ShangriLa house in Kahala area of Oahu.

Beach: Hands down my fav beach in Oahu is Lanikai followed closely by sunset beach on the north short. Its nice to go Kayaking off of Kailua beach (also close to Lanikai).

If you want to go off the beaten track, I would suggest Molokai which is an island off Maui and doing the Kalaupapa trail, and I LOVED it

How do anesthesiologists get paid?

The 2011 National American Society of Anesthesiologists meeting is coming up on October 15-19. My program like many others around the country will be sending a number of delegates to the meeting including residents, faculty, administrators. No doubt much of the discussion at the meeting will be about the impending budget crisis and its trickle-down effects on medicare reimbursement and anesthesiologist reimbursement. In the popular anesthesiology literature most put out by the ASA and other anesthesiologists the rallying cry is that Anesthesiologists are getting underpaid. These arguments cite data such as anesthesiology getting reimbursed 34% of commercial rates by Medicare compared to more than double that for other specialties. I thought I would look into how an anesthesiologist gets paid relative to say a PCP office visit.

So beginning with a little background, a “regular” doctor is paid according to something called the Relative Value Unit system which is a schedule set by the Centers for Medicare and Medicaid which decide how much doctors are paid. This system determines how much a physician is paid based on several factors including physician work (52%), practice expense (44%), and malpractice expense (4%). These factors combine in determining the Relative Value Units (RVUs) a physician gets which is then adjusted for the costs in their particular region (for example, there is an upward adjustment in higher cost regions such as New York City compared to Iowa City, Iowa). This is then multiplied by something called a conversion factor (CF) which is ties the reimbursement to overal economic conditions and prior year healthcare expenditures to “adjust” the rate that a physician is paid. It serves as an automatic benchmark rate that tries to keep aggregate healthcare spending in line from year to year. The components of this conversion factor include the current year’s 1) Update Adjustment Factor (which incoporates last year’s target total healthcare expenditures relative to the actual expenditures, target healthcare expenditures relative to actual healthcare expenditures for a base year 1996-current, and the Sustainable Growth Rate which ties this factor to systemic changes like GDP, rate of growth in medicare beneficiaries, growth in physician fees) and 2) the current year’s Medicare Economic Index (an estimate of medical inflation) and 3) the prior year’s conversion factor.

For example, a primary care physician seeing a patient for a routing visit (CPT code 99213 which is incidentally the most popular code in the country) in Baltimore would get paid $72.77 which equates to approximately 2.14 RVUs times $33.97 conversion factor (see Medicare Fee schedule calculator: https://www.cms.gov/apps/physician-fee-schedule/overview.aspx). Clinically, depending on the visit and physician I have seen these visits take from 30-60minutes.

Interestingly, Anesthesiologists have a different structure for getting paid. In addition to RVUs which are determined by ASA’s Relative Value Guide (RVG) fee schedule which assigns RVUs or “base units” to 270 different types of procedure codes (keep in mind this is far less “granular” than the 4000 code schedules that other specialties like surgery have) , we also have time units which are 15minute chunks added to our base units which multiplied by our conversion factor would determine our billing for a given case. Note, our conversion factor is different from the conversion factor calculated for other providers. The latest conversion factor for Maryland for example is $21.87 compared to the National rate for anesthesiologists of $21.05.

So to summarize, for an anesthesiologist, we are paid by
(Base Unit + Time Unit) X Conversion Factor. So for example, an anesthesiologist administering anesthesia to a patient in Baltimore undergoing a cataract surgery CPT code 00142 would be reimbursed at 4 Base Units and 4 time units (approximately 60 minutes for the total procedure including preop and pacu stay). This is multiplied by the conversion factor $21.87 results in a medicare reimbursement of $349.92 or $87.48 per 15 minute block.

Based on this simple analysis, Anesthesiologists are actually paid quite well and certainly no less per 15 minute time period worked. What is missing in these calculations however is a risk adjustment of the severity of the patient’s condition. A routine office visit may be complicated by a patient who is actively experiencing chest pain. A routine anesthetic for a cataract extraction can be complicated by the patient who obstructs their airway or has an allergic reaction to one of the sedative medications. Another issue is that of outcomes. None of these calculations takes into consideration appropriate outcome measures to keep both physician and patient accountable to optimizing their health. For example, could there be a clawback provision for the anesthesiologist who ignores a patient’s allergy and causes an allergic reaction that prolongs the surgery(Medicare is trying to do this with Never events to some degree). Interestingly, the anesthesiologist does not care (economically) if a case is prolonged due to complications because of the time component of their reimbursement which continues to adjust their reimbursement upward whereas the PCP with the complex case is tacitly disincentivized to develop a complication.

Either way the key issue is not whether we as anesthesiologists get paid enough but rather whether we are paid for doing the right thing. In some ways our time component frees us as providers to focus on our imminently vulnerable patient laying on the table in front of us. If a complication arises, we are not punished for focusing on our patient. Our classification system is implicitly built into our reimbursement model. We have a risk stratification system in which ASA 1-2 patients are not upwardly adjusted from a reimbursement standpoint while ASA 3s,4s,5s are as our emergent patients.

The alignment of a specialty in anesthesiology which has these unique features as well as a focus of attention on reimbursement, I believe represents a unique opportunity to shift the focus of the debate and for Anesthesia to take a leadership role in innovating a reimbursement model tied to patient outcomes.

The following link goes into more detail about the terms described above
http://www.cms.gov/SustainableGRatesConFact/Downloads/sgr2011p.pdf
incorporates a year to year adjustment for all physicians (except anesthesiologists)

The following link is to all the medicare payment schedules for Anesthesia:
https://www.cms.gov/center/anesth.asp

Rat Racing at Hopkins

Week number two at the great Johns Hopkins! It occurs to me that large gatherings of highly intelligent, successful and ambitious people share a common pattern. Whether it is the highrise offices of Wall street, the late night halls of the Johns Hopkins Hospital, we are all a bit rat racers at this level. So as someone who came from (and frankly got a little used to) the hedonistic lifestyle of beach, sand and the good life in Hawaii, it feels decidedly anachronistic to be in Baltimore gunning away at a life in academic medicine. Will I find it to be all that I wanted it to be? One in which I could have prestige, power and “meaning” in what I do? Or do I long for a more balanced lifestyle being stretched but not to the breaking point? I have always made choices that seem extreme and adapted to them. It will be interesting to see what happens the next 3 years.

Why people who like talking to patients should go into Anesthesiology

Cool study I came across in my reading by Egbert et al called “The Value of the preoperative visit by the anesthetist” which showed that a comparison of two groups of patients 1) those who received pentobarbital (a sedative) and 2) those who just had a preop visit by an anesthesiologist the group with the preop visit had lower rates of drowsiness (26% compared to 30%), nervousness (40% compared to 61%) and higher rates of feeling adequately prepared for their surgery (65%> 48%) and that doing both doesn’t really help you too much (people feel about the same level of nervousness and adequate preparedness while feeling more drowsy)

Cool eh!?

Egypt . . . China . . . history

First of all, congratulations to all Egyptians and free democracies everywhere. Your voices have been heard and your example empowers all of us who are so fortunate as to live free societies.

I can’t help but look at pictures of the battered but defiant Egyptian protesters at Tahriri square and feel inspired. Their almost blind passion for change is uplifting, thought-provoking and energizes me to the core. It makes me think about the history of my own people and how much I would have loved living during the 1920s and 1940s when China itself was awash with a similar fervor for change. It is all I can do not to compare and speculate about whether Egypt’s uprising will lead to a butterfly effect in China. Below are some links to others thoughts about this topic.

http://www.roubini.com/emergingmarkets-monitor/260489/china__egypt_and_democracy

What has been missing in the discussion for me is the cooptation of China’s elite. I remember having a discussion about a fairly obvious topic whether Taiwan was a part of China with one of my bschool friends and feeling absolutely shocked when she answered unblinking “Of course Taiwan is a part of China and of course it is still a big deal in the minds of all Chinese”. This well educated, new “elite” in China does not care to deviate from the party line and is well appeased by her job at a major consultancy in China, her parties, clubs.

However, this same person may be encountering some turbulence on their flight. The average Chinese in their 20s and 30s within 10 years will be taking care of their aging parents in addition to grandparents as well as paying for what will inevitably be a state led creation of a safety net in China. What will this person think then? Will the winds of Egypt take that long to blow to China’s shores in this age of Facebook/Twitter/Google censorship notwithstanding?