Biology Reference
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surgeons, physically, emotionally, in their marriages, and with their children. Surgeons placed
a high personal investment in doing the procedures, not entirely altruistically, although they did
not hesitate to do procedures for free. CMS/ Medicare do not allow pro bono free surgery on
Medicare patients although Crawford would waive the co pay fees or professional fees if
elderly patients were not covered. One can argue whether all these high risk patients should
have had surgery, even if the mortality risk was 5% to 10%. The flip side of the coin is that
90% to 95% did have improved quality of life and prolonged life if they survived. As surgical
reimbursement fell for cardiac surgeons, by about two thirds, surgeons were increasingly
employed by institutions and paid a salary. Furthermore, institutions are increasingly driven by
government pressure to require better outcomes from their employed surgeons (so called better
quality of care with fewer complications) and many surgeons feel pressure to accept less of the
high risk, barely operable patients. Apart from no financial reward, potential censure, and
personal cost, the potential downside is that the high risk patients will not get as aggressive
treatment. In essence, it is a way to deny the high risk expensive patients care, and spend less
money. Should these patients be denied care just because they have greater risk and there is a
lesser likelihood to a successful outcome? Society needs to debate this. Back in 2004 I was
fortunate to work with two friends, Mike and Todd, on developing a new approach to remotely
insert new aortic valves in patients with diseased valves using sheep and pigs. The research,
and previous research by others and the company involved, led to a highly successful remotely
inserted valve that we expect will obtain FDA approval for commercial use in inoperable
patients. We, including with my friend and colleague Murat, have performed a number of
studies at the national level with the new device and showed a most impressive marked
improvement quality of life and survival in the inoperable patients. The cost, however, was
$78,000 per procedure and average survival in these elderly patients (average age 83 years)
was 1.59 years. In medical terms, the cost per year of life gained was $50,000.
CMS/Medicare has made the assessment that as long as these patients are followed in a
registry, the cost is justified. Since the studies were undertaken primarily in centers with
physicians on salaries, there was not a strong incentive for accepting high risk patients. As a
result, in some centers, more and more patients are considered “inoperable or prohibitive
risk” and thus get the remotely inserted valves. In the case of aortic aneurysms, more and more
so called endovascular procedures are being done whereby an aneurysm is lined from the
inside by a stent graft inserted through the groin. The effect on young surgeons then has been the
further loss of skills and experience with high risk operations. Ultimately, the skill to perform
high risk procedures will be lost. (I am board certified in vascular surgery also so I have seen
the marked change over 15 years). Consequently fewer options are available for high risk
patients and less end up being treated. The same will probably happen for the new
experimental percutaneous aortic valves. This is not surprising if one looks at the hunter-
gatherers, because the less they hunted mastodons or whatever high risk animals there were,
the less likely they were able to deal with the challenges when they arose, particularly if they
did not also get a reward for their labor. The point is, denying professions just reimbursement
for the risks they take, whether it is surgeons, fire fighters, police, teachers, or military, will
result in a less experienced and skilled workforce.
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