This blog will be an effort to share some very important lessons I’ve been learning over the past 14+ years about how we as surgeons play a key role as “stewards” in our complex healthcare system.  I’ve given a couple talks about this in May 2012 and 2013 at the Duke Piedmont Orthopedic Society, and more recently to the CFO for the Duke Health System.  Now seems like a good time to share at a wider level, since the stakes are so high, and “time’s a wastin’.

Why are we in a healthcare crisis?  There is no doubt that our desire to do everything possible for each individual (of infinite worth), when combined with our human ability to constantly learn and improve and create new innovations can, by itself lead to a real stewardship issue when we acknowledge the fact that we live in world with finite resources.  This makes it absolutely essential to focus on stewardship — making the most of our finite resources for the greatest good.

While our main emphasis as a surgeon is to do whatever we can to help serve our individual patient and their family, in order to best serve that family as well as many other families and society as a whole we have to think about stewardship and sustainability as well — how can we do the most with our limited resources to do the most good for the most number of people.

There is no doubt that we are in the midst of a healthcare crisis, with costs sky-rocketing to unsustainable levels, potentially even threatening our national stability and security in the long run.  But how can we, as surgeons really make any difference?  I certainly didn’t learn anything about the costs involved with the things that I prescribed or implanted during my training years — we never talked about costs!!  When I ask people why that is, the only answer they can come up with is that since we are dealing with individuals with infinite worth, how could we possibly talk about skimping on buying the very best for each patient?  

But what if you could still get the same quality, but cut the cost?  That is probably one of the best ways to improve the VALUE we deliver to patients.

My education about the costs and scarcity of things really came during my 3 month time working in a mission hospital in Zambia at the end of medical school.  For those 3 months, we had real scarcity — we had only a few doses of certain antibiotics left, certain numbers of malaria, HIV and other blood tests that we could get, and limited supplies for X-Ray film and orthopedic implants.  As a result, you had to “Think Lean” because the scarcity was in your face and on the shelf every day.  It was quite amazing how much good we could do with so very little.  I was “Mr. Fix-It” over there — not throwing out old equipment, but constantly fixing old equipment and keeping it working, as long as it did the job.

When I came back from Zambia and headed back to the wards at Harvard at the Brigham and Women’s Hospital in General Surgery, once again the veil of no discussion of cost was lowered once again — a taboo subject.  Then, as I entered the orthopedic rotation and then residency, no discussion of costs… for total joints, screws, washers, plates, spinal hardware….professional costs… hospital costs…. nothing.  We just focused on patient care and putting broken bones back together, and delivering excellent compassionate care.

I then finished my pediatric scoliosis and adult spine fellowship and chief residency training and started on faculty at Duke, doing complex spine reconstructions.  Every day I went to work and put in 20+ pedicle screws, rods, cross-links, bone graft, ALIF spacers, anterior hardware  — all to reconstruct people who were in sad shape.  But I have to admit, I had absolutely NO IDEA how much the implants cost.  “That was someone else’s job,” I guess I thought.  Once again, I just need to think about the patient.

After 7 years in practice, though, I wasn’t completely happy with the hardware that I was using, and started to look for another implant company and type of hardware.  At that point, I felt convicted that I needed to learn about the costs of the implants.  BOY WAS I SHOCKED!!  The pedicle screws were way over $1000 each, and some of the interbody spacers were several thousand dollars!  Biologics like bone morphogenic protein could be $5000 or more per patient.  Wow.  This was an eye opener.  As I researched it further, including talking to people who had experience machining titanium screws, etc I learned that the actual cost to manufacture a pedicle screw could be down around $30, making the $1000+ dollar/screw number appear quite high even for medical.

So, after doing all my research and finalizing my choice for my next spine hardware system, I had a thought:  why couldn’t I, the surgeon, tell the vendor(s) what price I was willing to spend for each screw, rod, cap, cross-link, etc.?  They obviously wanted my business, since I put in a lot of spinal hardware each year.  To my pleasant surprise, after the vendors got over the initial shock of a surgeon asking for a set lower price, I was able to get the system I wanted for less than HALF the price they were selling it to other surgeons, and less than HALF the price I was paying for my old system!!  Now that is a WIN, WIN.  The instrument vendor could still make a very reasonable profit, but the patient and hospital could save money, with the hospital/health system then able to use those savings to help pay for the parts of the Duke Health System that always lost money — clinics in poor neighborhoods, uninsured patient care and the like.

For 7 years I used that instrumentation system, and every day I went to work in the operating room I knew that my stewardship efforts were translating into real dollars saved for the system as a whole.

Five years ago I went through this same decision-making process again, and found an even BETTER system for the complex surgeries I perform, and lo and behold was able to cut the cost down ANOTHER 30%!!”  Over the last 5 years since I made that switch, we have very good data that this change helps save Duke Health System $2 million per year, below the “Matrix” fixed costs negotiated for all of the other spinal instrumentation vendors that want to work at Duke.  $2 million savings per year x 5 years is $10 million dollars saved thus far.  JUST THINK ABOUT HOW MANY SAVED NURSING JOBS THAT COULD BE?  WHY GO CRAZY TRIMMING  A HALF A DAY ON LENGTH OF STAY, BUT DO NOTHING TO CURB THIS COST?  This $10 million savings over 5 years is just with one surgeon willing to just ASK his potential vendor for a set price, as the steward who actually makes the decision about what implant gets used for his or her patients.  All of this savings comes from one surgeon telling the vendor he wished to use that he was not willing to agree to use the instrumentation unless the pedicle screws cost $325 or less.

Now the question is … where do we go from here?  As Chairman of the Adult Deformity Committee for the Scoliosis Research Society (SRS.ORG), I have brought up this whole issue of stewardship and sustainability up to our Adult Deformity Committee, our President, Dr. Steve Glassman, and the entire SRS Cabinet this fall.  We have actually gotten great support for doing further research and possible interventions in this area.  My idea here is not to hurt one particular area of business.  Instead, I’d like to see us form a collective alliance among surgeons, hospitals, vendors, payors, employers and patients to actually have us all “TIGHTEN OUR BELTS” in order to create a sustainable, affordable future for our kids and grand-kids, driving out waste, and moving toward a LEAN system.

We’ve got lots of questions to answer, and our Adult Deformity Committee is just framing up some new surveys and data collection methods to begin this process, even at a global level.  While some research has already been completed showing that in some cases we can have less screw or hardware “density” — meaning not using as much hardware per patient to accomplish the same goal — it seems evident that the main issue is “Dollar Density” — which has just as much to do with cost per screw / implant as well as how many implants you use per patient.  Density or use of things like interbody spacers like TLIF’s and XLIF’s for example, as well as the use of expensive biologics like bone morphogenic protein (BMP) is another large area for potential impact.  Some of our biomechanical research that we have been doing over at NC State with Finite Element Analysis (FEA) modeling has shown us that perhaps when the discs are stiffer, we can avoid some of the more expensive, and potentially more risky interbody implants at those levels.

The biggest question I have right now is how do we nurture this new Stewardship and Sustainability mindset among surgeons who are actually making the decisions about the use of expensive technologies like spine implants?  I have a few ideas, but welcome your ideas as well.  I have a meeting in early January 2014 with a special Duke Raleigh Hospital Committee which has oversight for controlling operating room costs —- share your ideas with me and I can possibly use them for that meeting.  I am also working with our SRS Adult Deformity Committee to create some surgeon surveys that we hope to conduct during January and February, to learn about variation in hardware pricing and their level of awareness of the prices, and what role they could possibly play to make things more sustainable.