AAOS Now

Published 11/1/2012

Checking on Audits, Glucosamine, and History

The article “New Medicare Audit Reporting Tool” (September) mentions paybacks to Medicare, but is missing what is really happening in Texas as Obamacare rules have been allowing for huge clawbacks of legitimate cases.

The auditors are going through the hospital records for this and last year and retroactively denying the entire total joint case, using no set criteria. Any criteria that now exist are not written and are applied at the whim of the auditor.

At one hospital where I work, all 10 board-certified, Academy fellows have each had at least five cases retroactively denied. When this occurs, the surgeon’s fee is immediately refunded, the hospital reimbursement is taken back, and any fees paid to the anesthesiologist and for all postoperative ancillary services are refunded to Medicare. One surgeon, who has published hundreds of articles and two textbooks, has up to 10 retroactive denials.

It’s my belief that surgeons, anesthesiologists, and hospitals are now being shaken down to basically fund the $700 billion shortfall expected with the costs of Obamacare.
Peter F. Holmes, MS, MD

San Antonio, Texas

The Centers for Medicare & Medicaid Services (CMS) is making it harder for my patients to get appropriate care. I can’t think of any patients who simply sign up for total joint replacement (TJR) without previous conservative treatment with either their primary care physician or orthopaedic surgeon. Where does the impression that TJRs are done on minimally symptomatic patients come from?

Electronic medical records are great, but hospital charts need good information about medical problems, not regurgitation of previous office notes on efforts to avoid surgery with appropriate nonsurgical treatment. More rules with unintended and unfunded mandates take away time that nurses and doctors can spend with patients. My nurses in the hospital spend more time with the computer than with patients. I can only guess some “suit” thought that would be better patient care.

The AAOS Washington, D.C., staff is devoted, and the AAOS staff, Board of Directors, and president are tireless, but how can we explain all this to CMS? CMS can cut costs if they spend more time and money on educating seniors and families on stuff that is not necessary in the last 6 months of life. Can’t we get someone from CMS to shadow doctors during their clinic and operating room days?
William Joseph Laughlin Jr, MD

Baton Rouge, La.

Editor’s note: AAOS fellows who are experiencing clawbacks due to MAC or RAC audits are urged to visit www.aaos.org/medicare101 and report them, using the online audit reporting tool. AAOS is continuing to engage with CMS to address these issues.

Alternative views on glucosamine
I enjoy Dr. Canale’s regular column in AAOS Now. The September topic of glucosamine was of particular interest to me. As a spine surgeon, I don’t think glucosamine would benefit my patients, but I have been impressed with how much it has dramatically helped Bella, our 3-year-old Labrador retriever. She is a very smart dog, but I am assuming that she has yet to hear about the placebo effect. We have had her for 2 years and, like all good Labs, she lives to retrieve the ball. Trouble was, after we had her about 9 months, she was limping so badly and was so stiff in her hips that I was actually considering a total doggie hip arthroplasty.

A friend who is really into the dog scene suggested glucosamine chondroitin. I have been truly amazed with the response. Not to use hyperbolae, but Bella now runs without limit. This has been for more than 1-year’s duration without let-up. We have not done follow-up radiographs or checked cartilage height, but unless Bella has been sneak reading some orthopaedic journals when I was not looking, I’d say clinically, she really is better. I hear that this is not uncommon in dogs. The effect supposedly lasts for a few years, but by then their running enthusiasm will likely dissipate to an occasional stroll and the squirrels will tread more carefree again in our yard. So you might want to check out the veterinary literature during your knowledge quest.
Michael F. Coscia, MD

Indianapolis, Ind.

I enjoyed both the article (“Supplements for OA: An Unconvincing Story”) and the companion piece by Dr. Canale (“To Glucosamine or Not to Glucosamine”) in the September issue of AAOS Now.

For many years, it has appeared to me that these things work to a certain extent (in about 50 percent of people) and, frankly, we had little else to offer in that realm. It has been apparent that older horses and dogs that are given glucosamine generally seem to romp around a good bit better for a while. There’s even an intramuscular preparation, which I am told works well on my physiatrist’s old black Labrador retriever.

Unlike Dr. Canale, I recommend that my patients “shop for price” when it comes to vitamins and other supplements, but then, I am just an old country orthopod who lives in the economically decimated state of Michigan. Up here, we need Vitamin D big time, but not everyone seems to understand or believe that. Perhaps you might care to look into that?
Kenneth S. Merriman, MD

Hastings, Mich.

Physician signers
It was great to read about the “Physician Champions in Congress,” but Dr. Bumpass failed to do historical fact checking. Before AAOS fellows begin misquoting history, they should know that the Declaration of Independence was signed by four physicians—not five as stated in this article. They are: Benjamin Rush (Pennsylvania), Lyman Hall (Georgia), Josiah Bartlett, and Matthew Thornton (both from New Hampshire). Two of three signers from New Hampshire were physicians.


Dr. Joseph Warren, physician and American Revolutionary leader, sent Paul Revere and William Dawes on their midnight rides and was himself killed at the Battle of Bunker Hill. (Portrait attributed to a member of the Peale family, based on a painting by J.S. Copley, Second Bank Portrait Gallery, Independence National Historical Park, Philadelphia, Pa.)

Historically, even more significant is James McHenry, a physician and Irish immigrant who signed the Constitution and subsequently became Secretary of War under both George Washington and John Adams. Fort McHenry, at the opening of Baltimore Harbor, the site of the battle during which the Star Spangled Banner was written, is named for Dr. McHenry.

And let us not forget Dr. Joseph Warren, the hero of Bunker Hill, who died there prior to the Declaration or Constitution, when common citizens joining as militia laid the groundwork for the freedoms we still embrace today.

Now that was physician leadership.
Yolanda A. Cillo, MD, MBA

Princeton, N.J.

Dr. Bumpass responds:

In addition to the four physician signers Dr. Cillo names, I also counted Oliver Wolcott of Connecticut. Wolcott was a graduate of Yale (where he was a classmate of Lyman Hall), who obtained a militia commission during King George’s War. After the hostilities concluded, Wolcott returned home and completed a medical apprenticeship under his older brother, Dr. Alexander Wolcott. No definitive evidence indicates that the younger Wolcott ever set up his own medical practice, but he went on to a distinguished career in public service that included serving as a general in the Continental militia during the American Revolution. Because he did complete the standard training for physicians at that time, I included him in this list.

Setting Now Straight
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