Something I've been thinking about....(gov't consolidation)

Today's WSJ has an interesting article about how the governor of Michigan is pushing Michigan municipalities to consolidate. His point is that his state doesn't need 1,800 different units of government in the state. He isn't trying to consolidate the power in his office, but rather just trying to reduce the cost of government. (How many accounting departments are needed in Michigan, for example.)

(here comes a rant)

I've been thinking about this same thing since hearing that here in Virginia, county lines were originally drawn in the 1600's based on how far one could ride on a horse in one day. This makes for counties with ginormous populations (Fairfax, with 1.1M people) and tiny populations (Highland County, with just 2,510 people, which is adjacent to a county with only 4,500 people.) Now that we've drive cars instead of horses, shouldn't we reinvent the definition of a county?

I see the potential efficiencies, but it turns out they are overstated or illusory. (See the financial detail in the WSJ article.)

Local governance is always best, and highly appreciated by most, as the WSJ article describes that only 27 of 105 consolidation ballot initiatives have passed in the last 100 years.

I mention this issue as I think there's a lot of lessons for us to apply in other policy areas. In this era of progressivism, there are a never ending stream of new top-level (often Federal) policies, plans, or departments to instigate a desired change propelled by the efficiency argument. Two quick examples - among many - are the Obamacare iniitative and the entire Department of Education.

In both cases, local control is being subsumed by progressive programs, with the sponsors saying not only do they know what's best for you, but they can apply their brilliance more inexpensively than the local solution. Unfortunately, as the consolidation example illustrates, the reality is that the plans are rarely better, and seldom economicaly beneficial. Think about that the next time someone in a faraway place comes along with a plan to cure whatever ill is on the front page of the papers.

(rant over)

Knee surgery update

“When was your accident?”

I was in my 2-week post-surgical follow-up with my doctor (Dr. Grant)’s ace PA (physician assistant) Vince. He was reviewing pictures from my knee surgery, which was the first time that we had seen real images of my damaged knee.

“Accident? Huh?” I answered.

Vince explained that he was wondering what had happened to so colossally mess-up my knee. I realized what he meant because I had been asked it before. Nobody 40 years old should have this level of cartilage damage without being in some sort of accident.

“Oh, I wasn’t in an accident. But I played catcher for 30 years.”

Vince was startled, but managed to say “Really? That might do it.”

Vince did the 2-week post-op review, and I was lucky to receive rave reviews* – little swelling, good range of motion, and no infections or other complications. There is very little scaring and I’m allowed to resume normal activities “as tolerated,” except I must avoid high impact activities like running.

Though the surgery was a success, the reason for avoiding impact activities can be seen in some of the surgical pictures as seen through the arthroscope during surgery.

Originally, we thought that I had a simple meniscus tear prompting a couple of months of physical therapy to strengthen the surrounding muscles. A few months later, an MRI indicated a slight degradation of my articular cartilage. The pictures, though, showed twice as many areas of cartilage degradation, each many times larger than reported on my MRI.

 A little bit on articular cartilage, or chondyle: it’s the very slippery material on the front of the femur at the knee joint that allows smooth and easy bending of knees. How slippery? Cartilage on cartilage rubbing is 10X more slippery than ice rubbing on ice. The articular cartilage is ~4mm thick, and mine had worn to the bone, resulting in arthritis. Yes, I’m a 40 year old with arthritis, but hopefully not for long.

Knee parts: 

Copied from http://www.orthspec.com/articular_cartilage_injury.htm

Side view of a cartilage “divot:" (Click on any picture for a larger view).

 (Each white area is cartilage, each tan area is bone.)

To repair the “divots” in my knee cartilage, I’ll be going in for another knee surgery (autologous cartilage implantation) in a few months to have new cartilage laid into the gaps – like laying sod or filling a pothole. Just like after laying sod, I’m not allowed any movement for 6-7 weeks post-surgery that could rip up the newly laid cartilage.

Because the replacement cartilage will be frozen for shipment to Virginia, I can choose the schedule for the implantation surgery, so as to schedule when 6-7 weeks of downtime might be convenient. My two thoughts here are to either proceed as soon as possible (likely early June implantation, back on my feet by late July) or to delay until next winter, when I wouldn’t mind being couch-bound and unathletic for 2 months. What would you do?

* For the great 2-week review I have to thank my parents for taking care of me post-surgery and Move Better physical therapy for the post-op rehab.

MJH Outpatient Surgery & Dr. Grant: two thumbs up!

Last week I had arthroscopic surgery performed on my left knee by Dr. Grant of Albemarle Orthopaedics at the Martha Jefferson Outpatient Surgery Center. I am now 5 days post-surgery and stunned at the ease and quality of the surgery, care, and facilities.

I first went to Dr. Grant in early fall 2010, though the injury was noticeable months before (I stupidly ran three triathlons on it before giving in to the pain.) I found Dr. Grant's practice through blind luck: I had been calling for an appointment at UVA's Sports Medicine practice, but after three days without a callback to schedule an appointment, I did a search online for local orthopaedists and stumbled onto Dr. Grant's web site.

My initial diagnosis last fall was a torn meniscus - a straighforward injury with non-surgical therapy - and was prescribed a cortisone shot and physical therapy at Move Better Physical Therapy in order to strengthen muscles near the meniscus to compensate.

The knee pain continued and a January cortisone shot had almost no effect. This lead to an MRI for my knee, and the finding that I had a chondral displacement, specifically that I had a roughly 10mm x 10mm area of my chondral cartilage completely missing, with significant deterioration of the remaining cartilage. This injury is typical only in the elderly - it's an accumulated injury. At one point, I was asked if I had an injury that precipitated this, as I was very, very young for this diagnosis. I answered no, but that I had played catcher in baseball for approximately 30 years. The response: "That'll do it."

So I had an osteoarthritic condition which would only get worse with time, severely limiting my mobility, fitness, and quality of life. (No more running or biking for me.) Treatment options were 1) treatment with euflexxa (an injectable acid) to artificially lubricate my knee, 2) simple chondral debridement (arthroscopic clean-up of the messy cartilage. No  permanent improvement resulting, but likely less pain and greater mobility), 3) surgical procedures to regrow/replace cartilage (more on this later), or 4) full knee replacement.

I immediately ruled out the full knee replacement, and began researching option#1. Euflexxa was appealing, but had 2 problems: it only treated the symptoms (i.e. the knee problem never went away - it would just hurt less frequently), and each injection provided benefit for only 2-4 months at a time, meaning that I would become a Euflexxa junkie - also bad because Euflexxa is expensive.

So surgery was the answer. The options, were simple clean-up (chondral debridement - a clear preference, though it's long term benefits are debatable), micro-fracture surgery to encourage growth of new cartilage, the "OATS Procedure" (another, more intense way to encourage cartilage growth), or
autologous chondrocyte implantation (ACI).

ACI is an amazing surgery - a portion of the injured cartilage is collected then sent to a lab in Boston to be grown into a larger piece of cartilage for re-implantation. This procedure is still new and quite expensive, but ideal for "young, healthy patients with medium to large sized damage to cartilage."


An indication of my extreme interest in my knee health is that even though ACI and the other knee procedures are expensive, I never blinked an eye at the financial commitment. (ACI alone is $20-35,000k. I'm pretty sure that I'll end up paying 20% of the final bill, but it is definitely worth it.)

The unnerving thing about surgery is that the most effective treatment option can't be determined until the surgeon sees the injury up close - in surgery. Surgery involves general anesthesia, so I could not participate in choosing the treatment while Dr. Grant was operating on my knee. I was more freaked out by this than the notion of undergoing surgery (with all of its' risks) or being knocked out. I guess I like to be in control.

The day of surgery came, and while I was nervous, it was a fantastic experience from start to finish.

To begin with, I was instructed to mark which knee was NOT to be operated on - a low tech, but effective step. I also had to go 12 hours without food or water, which was darn hard.

Martha Jefferson's outpatient facility is just a few years old and modern in every way. Given the lobby receptionist, my intake felt more like was visiting someone's business offices than I was about to undergo a medical procedure.

The day unfolded as I had been told to expect - except where MJH and the team exceeded expectations. For example, I had been told that the recovery from anesthesia would take 2-3 hours. However, I was conscious and eating animal crackers 45 minutes post-surgery. Dr. Don Mathes - my anesthetist - was an absolute maestro - verbally walking me thru the procedure, then delivering me on the other side quickly and with absolutely no nausea or side effects.

Dr. Grant was fantastic (as expected) on the day of surgery, and received high marks from someone who would know - my Mom.

My Mom just retired from a 40+ year career as an OR nurse in an outpatient surgery center very similar to MJH and was able to appraise the MJH facility and team (excellent), and got her peer's appraisal of Dr. Grant prior to my surgery. (From one nurse to another, my Mom was pulled aside and told that Dr. Grant was excellent. (You'd be surprised how often the nurse appraisal is "that Doc isn't very good," or "Dr. ______ is the one you want to see." A nurse's appraisal is worth any 100 other reviews.)

I have nothing but high praise for everyone else who worked on me that day. I wish I had a full list of the team that worked on me, but unfortunately I can only go by memory (hazy, due to the anesthesia). The two additional names that standout are Maggie Lebo (who prepped me for surgery), and Judy, an R.N. who screened me and walked me through the procedures.

I'm now 5 days post-surgery and feeling great. I used crutches and pain killers for the first 4 days post-surgery, but I am fully ambulatory (though tender) and have already had 2 physical therapy sessions.

I am under orders to take it easy for the next month. (I haven't even tried to climb a flight of stairs yet) and won't be allowed to bike or swim for about three weeks. In about 10 days I will see Dr. Grant for the post-surgery analysis. My hope is that the chondral debridement (clean-up) will be enough to get me back to pre-injury health, but it is probably 75% certain that I will undergo an additional surgery in 2-3 months to re-implant the replacement cartilage (ACI.) Unfortunately this is going to mess with my cycling and baseball goals this spring/summer, but I know that I will appreciate my improved knee health in the long term.

I'll also increase my appreciation for the US health care system. Politicians keep creating one-size fits all healthcare solutions, but my improved knee health (and overall experience) is only possible (and available at a reasonable price) through specialization. Instead of an expensive hospital stay, I was in and out in ~2 hours, and was able to benefit from the expertise of an orthopedics specialist.

Political solutions like Obamacare are firmly aligned against specialist practices. For example, there are all kinds of regulations against physician-ownership of outpatient facilities, and intense regulation of outpatient competition through things like "certificate of need" legislation. (In Florida, for example, you can not open a new hospital or surgical facility unless the nearby hospitals sign-off that there is a need for additional surgical capacity. In practice, this squishes competition.)

This most often takes the form of a big hospital lobbying to stop the permitting of a specialized center, such as for heart surgery. Heart surgery is fairly profitable for a large hospital, but a specialized (focused) center will deliver better results at a lower price. The big hospital fears that eventually the focused heart center will take customers away, raising the fixed price of all of the healthcare they deliver (e.g. still paying for the costs of establishing their heart center.)

In much the same spirit, my therapy was only possible due to R&D incented by the American healthcare system and profit motive. Only ~10,000 patients have had my surgery so far, and this would not be possible without clinicians mindful of adopting new, advanced procedures (due to the pressure of market competition, rather than the status quo of nationalized healthcare), and my ACI therapy would not be possible without the R&D and regulatory effort by Genzyme (an American biotech company.)

The regulatory pressures (as from Obamacare) combine to make our healthcare more expensive and less effective as possible. There are additional dimensions to the US system that I experienced that will make for another post (for example, I was ~3 weeks from decision to surgery. In Canada or the UK, I'd be lucky to experience 3 months from decision to surgery), but suffice to say, I had an excellent experience with Dr. Grant, his team, MJH, and the US healthcare system.

Return of Hillarycare?

From Cato, a timely reminder of Hillary Clinton's previous take on healthcare. (Remember that she chaired a commission, along with Ira Magaziner, to remake the US healthcare system during her husband's first term?)

Here's the impartial Wikipedia description of the Clinton effort.

Cato reminds us that Hillary's plan was, in a word, communist, with firm state ownership of healthcare delivery (through comprehensive rules and price controls) and control over every aspect of care, to the point that patients could be fined for deviating from the plan.

At the time, the opposition said that the Clinton plan was akin to letting the Post Office deliver healthcare, but I think the Cato author is right - it's like putting FEMA in charge of health care delivery.

I hope that Clinton's health care ideas have moderated over time, but even if so, I would guess that this is more a factor of sagely centrist advisors than an old dog learning a new trick.
We'll see with the next Congress. In some ways, this could be a positive, as with Congress under the control of the Democrats, there's no reason not to submit the party's best health care reform ideas, thus exposing them prior to the '08 Presidential election.