Friday, December 27, 2013

Getting plugged in on "Linked-In"

Joan H has recommended your work as Scoliosis/Spine Surgeon / Epic Installation Exec Committee Member at Duke Raleigh Hospital.
Dear Lloyd,
I've written this recommendation of your work to share with other LinkedIn users.

Details of the Recommendation: "Dr. Hey is a great surgeon. After months of trying to get help we went to duke for help. Dr. Hey when he saw me in the waiting room, he knew my back was out of line! None of the other doctors noticed it. A dedicated man who asks for God's help before surgery! If you need him, he is great."
Service Category: Doctor
Year first hired: 2004
Top Qualities: Great Results, Personable, Expert

Wednesday, December 25, 2013

Seeking to Create a Movement of Surgeon Leadership in Stewardship & Sustainability by decreasing instrumentation costs

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.

As I have shared in my talks, my dad always taught me growing up that "IT IS TOUGH TO BE A LEADER."  There is no doubt that my dad is right.  Physicians, including surgeons are in this tough but essential role to lead, and make tough stewardship decisions from the ground up, even if you don't get "paid to do it" through a co-management agreement, etc. with your hospital.  The future for our children and grand-children is at stake.

I realize this blog isn't the perfect way to communicate the whole message, but it is a start.  
Maybe we can create a MOVEMENT of surgeons who can help us begin to slow the insane rate of cost growth in healthcare which is completely unsustainable.  We can all be more aware of how much things cost, and begin to work with our vendors to pay reasonable rates that allow them to make a reasonable margin but definitely do their part to "tighten their belt" with the rest of us.

I welcome your input and ideas.
Standing idly by is not a solution.
Like a patient in trouble, we need to take action, especially those of us who stand in the gap, where decisions are made daily that affect value and cost.

Lloyd A. Hey, MD MS

Fwd: For your "It Works" file. Can I run a marathon after spondylolisthesis instrumentation and fusion surgery?

---------- Forwarded message ----------
From: James D <j>
Date: Wed, Dec 25, 2013 at 3:31 PM
Subject: For your "It Works" file
To: Lloyd Hey <>
In July 2006 you did a L3-L5 fusion to fix my spondylolisthesis, so I wanted to send you this photo of me finishing my first marathon earlier this year as a way of saying thank you.

Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery

@drlloydhey on twitter

Fwd: The new me

Dr. Hey,  Here's a picture we took this past summer in the South Carolina mountains during my first kayaking trip since my Feb. 2012 surgery.
Best regards,  Joan  12/25/2013
We saw Joan and her husband Robert in clinic recently.  She is one of our adult scoliosis patients now postop from a thoracolumbar-sacral-iliac wing instrumentation and fusion with laminectomies and osteotomies.  She had shared that one of her goals for getting back to a good "quality of life" after her surgery was being able to kayak again -- a goal she has joyfully attained -- kayaking for over an hour and a half at a a time!  
--- Merry Christmas Joan and Robert, and all of our other Hey Clinic guests and family members.  -- Lloyd A. Hey MD MS, @drlloydhey.  Hey Clinic for Scoliosis and Spine Surgery

---------- Forwarded message ----------
From: Robert
Date: Wed, Dec 25, 2013 at 11:52 AM
Subject: The new me
To: Hey Lloyd <>

Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery

Monday, December 23, 2013

Can I get a nice correction of my rib hump and feel better with less pain after scoliosis surgery? Last clinic 2013.

More patients we saw in clinic just today!!   
Dr. Lloyd Hey -- Hey Clinic for Scoliosis and Spine Surgery.  

Amanda, in her low  20's, from Charleston, SC looking great, and doing well on her 1 year anniversary.
Amanda and her mom share their story, including referral from Dr. Steve Poletti, Charleston SC for scoliosis surgery

16 yo Tandra and her mom here about 6 months after her scoliosis surgery looking very straight and very happy!

Tandra and her mom share their scoliosis story

Teen Olivia "graduates" from Hey Clinic with a great posture.  

18 yo Corey, now 1 year postop from AIS scoliosis surgery doing great lifting weights, doing well in college, and no pain.  Family thankful as shown in video below.

New 13 yo scoliosis I saw today with progressive thoracolumbar curve and trunk shift.  No brace.  Will observe.

She's got a very large thoracolumbar hump on scoliometer, and her hip is "sticking out" quite a bit with trunk shift.

David's preop MRI showing his pinched spinal cord.  He could barely stand out of his wheelchair.  

David now walking and standing up straight 3 months after having pressure taken off his spinal cord.
David shares his story of thoracic disc herniations and progressive leg weakness, surgery and recovery

This new 13 yo patient has small lumbar curve, but it is causing a large trunk shift to the left, and quite a bit of back pain. Treating it conservatively for now.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery
Twitter @drlloydhey

Last clinic for 2013. Thanksgivings. Rachel's family shares how they found a scoliosis center they could trust.

December 17, 2013
Dr. Hey and the Hey Clinic Team,
It has been 6 months since Rachel had scoliosis surgery in June.  We wanted to let you know that her recovery has gone very well.  She has no pain and her back is nice and straight now!  In August, Rachel started her busy junior year at Enloe High School and besides having too much homework, is doing just fine.

You all have our sincere thanks for making the transition to the Hey Clinic so easy.  Earlier this year when we needed to find a specialist, the staff at your clinic quickly arranged the initial consultation.  We were immediately impressed with the knowledge and expertise shown and reassured that we could proceed with surgery.  
We are so grateful for the excellent level of care Rachel received at Duke Raleigh Hospital and from the Hey Clinic staff.   All the people who helped were skilled and showed much compassion to our family.  
We would like to extend our sincere best wishes to all of you for a wonderful holiday season.  Please enjoy these Southern Seasons treats.
Warmest regards, Carol and Paul M.  

Friday, December 20, 2013

Long-Term Outcome from Kyphosis Surgery as an adult? Art from Michigan gives us his report

Art is 33 from Michigan, and is 2.8 years s/p kyphosis surgery still doing very well after suffering many years with severe pain.
Still doing great now, following up with us remotely by getting x-rays done locally, and phone/email.  
Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery

On 12/20/13 6:58 AM, "> wrote:

  I just wanted to let doctor Hey, and all of his staff, know that I'm doing great, and the back surgery was the best thing I ever did.  I now walk perfectly straight and continue to do all the physical therapy exercises which has made me really well toned.  I jog everyday, play tennis, and work-out on a regular basis with no problems.  I really appreciate how Dr. Hey prayed with me before the surgery and I'm so appreciative that he did such a great job on me.  I want to wish Dr. Hey, and all of his staff, a very happy holiday season!  God bless, Art

Lots of Scoliosis Experience this Week and over last 9 years at Hey Clinic. Today's Clinic on Twitter @DrLloydHey Realtime.

Went home yesterday after her AIS Surgery, mom and patient thankful
"Thank you for everything, Dr. Hey!"

We have 2 more AIS scoliosis patients going home today, after 2 nights in hospital, no ICU stay, no blood transfusions.  Both families very happy with nursing and physical and occupational therapy care.  

Surgical, as well as clinic and institution/hospital experience and focus on quality control and compassion all add up to a wonderful experience and outcome for patient and family in large majority of families served.

We are just about to celebrate our 9th year as Hey Clinic, plus my nearly 10 years before that at Duke University Medical Center, serving on teaching faculty in the Division of Orthopaedic Surgery.  With over 300 spine surgeries per year, the majority of which being deformity-reltated surgeries, we have built a wealth of experience and learning that has enabled us to continue to improve the quality and safety of the care that we deliver.  This has led to many families traveling to see us for the care of their children and adolescents, as well as adult patients with scoliosis, kyphosis, spondylolisthesis and other conditions including revision deformity surgery.  This is definitely a "team sport" and we continually seek to improve our team delivery of excellent care.  The smiles at the end of the day tell the story, as well as the improved posture which changes lives.

Here are some highlights from today's clinic so far today , including some YouTube testimonials.  We are Tweeting through clinic for those who wish to follow us real-time @drlloydhey.  We only share photos and video with folk's permission, but our guests are usually very willing to share and give thanks.

Dr. Lloyd Hey
Hey Clinic for Scoliosis and Spine Surgery
Twitter @drlloydhey

Sunday, December 15, 2013

How much of a difference will scoliosis surgery make to my posture / appearance as a young adult?

Nikki, our 22 yo scoliosis patient who had adolescent idiopathic scoliosis that we straightened up last week sent me this email tonight with her own before and after picture.  She is doing well at home now, and is already showering with a plastic surgery subcuticular closure which will have a very nice appearing incision.  

Nikki  <>
1:23 PM (8 hours ago)
to me
Thank you so much Dr. Hey! 

We finished up a busy scoliosis week last week on Saturday, which also included an ACDF 2 level surgery with microsurgery, and a revision microdiscectomy surgery on Sarah, a young lady from Virginia Beach, Virginia.  Her story is told on this YouTube video and on Twitter @drlloydhey.

Our week finished up with our Hey Clinic end of year Christmas party --- we all had a nice time together, thankful for our team which works so hard to go the extra mile to deliver compassionate, high-quality care that we are constantly striving to improve.  We really missed Sarah who was out caring for her husband and are keeping him in our prayers for full healing.

We have 8 kyphosis and scoliosis surgeries planned for this coming week on 7 adolescents and one young adult, and then a lumbar microdiscectomy on Friday on a Division 1 lacrosse  player who plays LAX up in the northeast.  Will be busy on Twitter for those who wish to join us for play by play action from our wonderful world of scoliosis here at Hey Clinic and Duke Raleigh Hospital, Raleigh, NC.

Have a good week!  Dr. Lloyd Hey  Hey Clinic for Scoliosis and Spine Surgery
Follow us on Twitter @drlloydhey

Saturday, December 14, 2013

Can I become a body builder and lift heavy weights after adolescent or adult scoliosis surgery? What about Cross-Fit?

Is it better to continue to wait to have your scoliosis fixed if you are an extreme athlete with body building, weight lifting, cross-fit, etc?  Obviously there is no simple answer, but one thing is true:  it IS possible for many patients to return to a very active, athletic life after scoliosis surgery.

Jillian is a good example.  She is a DPT, or doctor of physical therapy who had an adolescent idiopathic scoliosis never treated as a teenager, except for possibly some bracing.  As a young adult, she definitely was affected by the scoliosis appearance and her posture, and even when it appeared that her curve was progressing up to 60+ degrees, she kept avoiding surgery because she was so active.  Then, however, she started to have more and more back pain, which is when I met her about 8 years ago.

After quite a few visits and much thought, and one canceled surgery due to "cold feet", she eventually had her scoliosis fixed here at Hey Clinic / Duke Raleigh Hospital about 8 years ago.  You can see that JILLIAN'S SCOLIOSIS SURGERY BLOG POST HERE.

Jillian has done great after surgery, and actually been the physical therapist for MANY of my scoliosis patients both here in Raleigh and also in Greensboro, NC.

She has become a phenomenal body builder and fitness guru, competing regularly.
She emailed me yesterday as her anniversary approaches for her surgery this January, showing her ability to lift heavy weights and do all sorts of aggressive physical activity which she loves.

Yes, you can be quite active, and look and feel good after scoliosis surgery -- even years later.

Keep going Jillian!!!

Dr. Lloyd Hey -- Hey Clinic for Scoliosis and Spine Surgery --
Follow us on Twitter @drlloydhey