Why are medical costs skyrocketing?......its not your doctor!

I had a funny experience yesterday in the office. A very happy patient returned to see me three months after her arthroscopic rotator cuff repair. She was feeling great. She had no pain, normal function, and was back to doing all her activities.

She presented me with a  jar of honey from her farm, and said, "I saw your bills from Medicare. I can't believe that's all you get paid for these surgeries. I wanted to give you something extra!" We shared a laugh and I am now the proud owner of a fresh pound of honey.

The point of this is not to say that doctors don't make enough money. We do just fine, and are blessed to be in this profession. The real point is that physician fees make up a very small portion of health care expenditures. For instance, surgeon reimbursement for a medicare rotator cuff repair is roughly $1,000. The amount we are paid for a shoulder replacement is in the neighborhood of $1,500. On the other hand the total cost of a shoulder replacement surgery is $10,351 according to a study out of Johns Hopkins. Based on this math, 90% of the cost is not your surgeons fee. Does that seem right?

As health care costs continue to spiral out of control the American public should understand where these costs are coming from: hospital charges, device manufacturers, insurance companies. Of course, these entities have powerful lobbyist, who ensure that money continues to flow to these industries. As a result, it is easy for politicians to cut reimbursement to physicians instead of tackling the real problems.

What is a frozen shoulder?

Frozen shoulder is one of the most common conditions that I treat in my practice. There are a lot of misconceptions about this common problem. The first thing that patients should know is that most people will get better without surgery, and will regain normal function. Unfortunately, the recovery process can take a very long time and is often frustrating. I have found that many patients simply want to know what is happening with their shoulder. Once they understand the process their recovery goes better.
Here is a webpage that I have written to provide basic information on this topic.

Planning your Ream and Run Shoulder Replacement

The Ream and Run shoulder replacement is a new type of shoulder replacement that has advantages for patients who wish to remain active. Dr. Carofino is one of a few shoulder surgeons in the country with extensive experience with this operation, and is commonly contacted by patients interested in traveling to Virginia for this procedure.

This is a description of how you can arrange to visit Virginia Beach for a Ream and Run Shoulder Replacement

Step 1. Determine if you are a candidate for this surgery:

Dr. Carofino will review your records, x-rays, MRI, etc. to determine if you may be a candidate for this operation. If you would like to start this process you may send an email to carofinob@atlanticortho.com. After the records have been reviewed he will discuss his finding with you by phone.

At that point if you are interested in visiting Virginia Beach to have surgery further arrangement will be made.

Step 2: Planning Your Trip

You should plan to arrive in Virginia Beach on the Saturday or Sunday prior to your surgery.

Monday: Office consultation with Dr. Carofino to review x-rays and perform physical examination. The surgical procedure and recovery process will be reviewed. All additional questions will be answered at this point. Pre-operative lab work is completed.

Tuesday:  Surgery is performed at the Sentara Princess Anne Hospital. The surgical procedure takes approximately 1.5 hours. Post operatively patients are admitted to the hospital for pain control and initiation of physical therapy. Most patients will be discharged from the hospital in one to two days.

Post Hospital Course: (Wednesday until departure)

After discharge from the hospital you will stay in a nearby hotel until your departure. During this time physical therapy will be performed at our office on a daily basis to ensure you are stretching the shoulder properly. We recommend that you plan to stay in Virginia Beach until Saturday at the least. This will allow plenty of time to ensure that you are comfortable after surgery, and progressing with physical therapy.

Step 3: Planning your follow up care

You will need to continue with your physical therapy at home. We will coordinate this with a therapist of your choosing and provide them detailed instructions. It is encouraged that you send us pictures of you doing your stretching exercises so that we may monitor your progress.

You will need to have stitches removed two weeks after your surgery. A local doctor or physical therapist can perform this.

Ideally, you will return to Virginia Beach at three months after your surgery so that we can check your progress. However, if you are doing well we can monitor your recovery by sending a video, and phone discussion.

Miscellaneous

Travel

If you are flying the Norfolk Airport is 30 minutes from the office and hospital.

Insurance Coverage

Shoulder replacements are common procedures and typically covered under insurance. If you are from outside of Virginia then Dr. Carofino is most likely considered an “out of network” physician by your insurance. Therefore, you will need pre-authorization from your insurer prior to treatment. Our billing department can assist you with this process.

The Truth about Tommy John Surgery

The Truth About Tommy John Surgery

If you watch any professional baseball there is a good chance that at least one pitcher on the roster has had a “Tommy John Surgery”.  This is a surgical procedure to rebuild the ulnar collateral ligament of the elbow, which can be torn due to repetitive throwing. The number of these surgeries being performed is increasing each year, but not just in professional athletes. In fact, more and more of these operations are being performed on youth baseball players as young as twelve years old. This is partly a product of the shear amount of baseball that kids are playing at a young age. Many high-level youth baseball players compete year round, and often play on more thane one team at a time. Their young arms never get a chance to rest and heal.

Another possible reason for the increase in this operation is that kids believe it will make them better pitchers. I have had several young patients tell me that they think they will throw harder and come back stronger if they have a Tommy John procedure. There also is a perception that the surgery works every time. Its understandable that people would think this because there are so many major leaguers who have had the operation and returned to competition.

However, the truth is that not all baseball players return to their desired level of function. In fact, a study published this year in the Journal of Shoulder and Elbow Surgery found that nearly 20% of athletes undergoing an ulnar collateral reconstruction failed to return to their prior level of competition. We should discuss this openly with young athletes who are weighing their options and considering Tommy John surgery, and remind them that surgery is never a sure thing.

Dr. Carofino is an orthopaedic surgeon who specializes in shoulder and elbow surgery. He has expertise in Tommy John surgery, and treatment of baseball injuries. Dr. Carofino sees patients in Virginia Beach and Chesapeake, and is a team physician for the Norfolk Tides. If you have questions Dr. Carofino can be contacted at carofinob@atlanticortho.com

“I’m Having a Rotator Cuff Repair…….what could possibly go wrong?”

“I’m Having a Rotator Cuff Repair…….what could possibly go wrong?”

Rotator cuff repair surgery is one of the most common and successful orthopaedic operations. Most patients tell me that they feel that their shoulder is at least 90% of normal after they have recovered. However, as with any surgery things can go wrong. Thankfully that is not common but if you are having a rotator cuff repair surgery you should be aware of the potential complications. Here is a list of the most common ones.

1.     Stiffness: Most patients will have some mild stiffness after a rotator cuff repair, and this will gradually loosen up with physical therapy. This stiffness is normal and is caused by scar tissue that forms around the shoulder. Unfortunately, some patients will have severe stiffness that can be very bothersome, and prevent them from regaining normal motion. This is referred to as a “frozen shoulder”. I would estimate that approximately 5% of patients encounter this problem after a rotator cuff repair. It tends to occur more commonly in younger patients (less than 55) and patients who have a small tear repaired.

If a patient does have a post-operative frozen shoulder the first step is try to address the problem with physical therapy and stretching. Sometimes a cortisone injection can also help. If the shoulder does not “loosen up” after at least 3 months of therapy and stretching  your surgeon might consider a second procedure to break up the scar tissue in your shoulder and improve your motion.

2.     Re-tear of the rotator cuff: During a rotator cuff repair the tendon is reattached to the bone. Unfortunately, in some instances the tendon may re-tear. When this happens it is usually because of “biologic” reasons meaning that the patient’s rotator cuff tissue was not strong or of good quality. A re-tear is more common in patients who are over 65 years old, patients with massive tears, and smokers.

The good news about re-tears is that even if this occurs most patients can still get a very good result and benefit greatly from their surgery. In fact, some studies have shown that patients who have a re-tear do just as well as those who do not! However, if a re-tear causes pain and weakness a revision surgery could be considered.

3.     Nerve Injuries: Thankfully, this is a very rare complication following shoulder surgery. But when it does occur it can be disastrous for the patient. I have published a paper on this topic from the Mayo Clinic’s experience. If you have suffered a nerve injury following a shoulder surgery a surgeon with knowledge of these problems should evaluate you as soon as possible.

4.     Infection: As with any surgery infections can happen following rotator cuff repair. It is not common. Symptoms include fever, persistent redness or drainage from your incision sites. This might require antibiotics and  a surgery to clean out the shoulder.

If you would like a consultation regarding your rotator cuff tear, nerve injury, shoulder replacement or other shoulder diagnosis you can contact Dr. Brad Carofino at carofinob@atlanticortho.com.

Dr. Carofino sees patients in Virginia Beach and Chesapeake, Virginia.

How to prepare for your rotator cuff repair surgery

Rotator Cuff repair surgery is one of the most commonly performed orthopaedic surgeries. In general, this operation has excellent results with most patients regaining shoulder function of 90% or better. However, rotator cuff surgery also includes a long recovery, and the first few weeks after surgery can be difficult.

Here is a list of recommendations that may make your post-operative recovery more comfortable.

1.     Find a comfortable Recliner: Patients find it difficult to sleep in their bed after surgery. This is partly because you will be wearing a sling, and partly because it may hurt your shoulder to lay flat.  Most patients sleep in their recliner for several weeks after surgery.

2.     Ask about your pain medications and physical therapy before surgery. Your doctor may be able to prescribe your pain medications before your surgery. If so, you can fill the prescription a day in advance so that you have one less thing to worry about on the day of surgery. The same is true for your physical therapy. Most patients start their therapy the week of surgery, you may ask your doctor to set up these appointments for you in advance.

3.     Find shirts that are easy to take on and off. After surgery it will hurt to move your shoulder. You will want to have some shirts, jackets, etc. that are easy to put on without having to move the arm too much. Men often find that button down shirts and zip up sweatshirts are easy to work with.  Women may have success with similar style clothes. There are even some specific shirts for after shoulder surgery that can be bought on-line (although I don’t think that's really necessary)

4.     Have a support plan: You should have someone stay with you for 24 hours after surgery to make sure everything goes well.

5.     Think about transportation. You will not be able to drive while taking narcotic pain medications. For many patients that is at least two weeks. You will most likely be wearing a sling for six weeks after surgery. It is possible to drive with a sling on, but you will have to consider your particular situation and make sure you are safe to drive.

Good luck with your upcoming rotator cuff repair!

Brad Carofino MD

Virginia Beach, VA