Cost Analysis of Tele-Neurosurgery (T4A4)
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Cost Analysis of Tele-Neurosurgery (T4A4)

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  • I have a long way to go, but as long as my jugular veins are wide open and the stem cells continue to clean up the mess those narrowed veins left behind, and damaged nerves continue to regenerate, I believe the sky is truly the limit! My main focus at this point is not only to rebuild muscle but to get my legs to work together, which will restore my balance.

    Every day is a new gift that allows me more recovery. I can hardly wait for each morning to see the next improvement! There’s so much more happening in my body than I’ve even mentioned in this writing but I hope I’ve related the main message here...MS was my previous diagnosis.

    I will be starting a blog on my progress in a week or two if anyone wants to contact me or follow my improvement. I’m sure there are many of you out there who are skeptical or would want to know how this is going for me. I’ll post the site information back here once I have it up.For more information visit our site http://davidsmsstemcelljourney.blogspot.in/
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  • Since I returned, and after only one month, the positive changes have been happening regularly and most every day. Most significantly, I think, my incontinence has completely improved and I am now able to almost totally control my urinary and elimination functions. All other disabilities aside, I think that this is one of the most important deficits that anyone with MS wishes they could get back! Incontinence is so embarrassing and not having control of that particular function somehow makes you feel lesser as a person. So I’m very happy to see the improvements there. My speech is back to normal. Although I never slurred my words, the thought process was oh-so-slow. Now my words come so quickly that I sometimes find myself stumbling over them...trying to say too much at once. I can’t complain about that!

    I am convinced that CCSVI Clinic is on to important discoveries about MS. They have figured this out and are doing the sequence of therapies correctly and the addition of the stem cells completes the need to repair the nerve damage that’s been done by the disease. In retrospect what they are doing suddenly makes complete sense to me. It’s still early yet and I guess time will tell to what extent my motor functions will come back, but if the last month is any indication, it could be everything, which excites me so much. I don’t know if that’s too much to hope for, but it’s the first time in 10 years that I’ve even really allowed the thought to cross my mind. The first fleeting thoughts of this after the original liberation therapy 2 years ago weren’t realistic. The good changes didn’t last. And consider this; a few months ago, I was in a wheelchair, in a permanent brain fog losing more of my independence and quality of life on a daily basis. All I had to look forward to was a deteriorating condition where others would have to take care of my every bodily function. Now I can’t wait to wake up every morning to check myself out. If anything I’m too impatient and working out too hard. But at least I can! Given my current state of health and ability to live and function on my own, the thing that is very certain is that I have a much better quality of life back and that wouldn’t have even been possible if it hadn’t been for the lucky discovery of CCSVI Clinic through an Internet search. My family and I will be eternally grateful for what has happened no matter how this turns out. Thanks to Dr. Gupte, the other doctors, the medical team and staff at the Clinic who made this all happen for me, I’m looking forward to each day with new health and optimism! May God Bless them all!For more information visit our site http://davidsmsstemcelljourney.blogspot.in/
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  • Four days later I underwent a lower lumbar puncture, but this time not simply to gather information on whether I have MS. This time, stem cells cultured from my own body were on their way to do what God designed them to do, and that is to heal. For all of you that might be skeptical about this, I am here to tell you that is exactly what they are doing. The positive changes were noticed as soon as I returned to my suite in the clinic and anyone who is paralysed below the waist will understand this next part. To manoeuvre myself as I usually do, I went to pick my leg up from a sitting position and throw it in front of me. The hope here is that the ‘dead-weight’ of the leg will land just right and in a position where I can best situate myself to haul my body into a position where I can further awkwardly throw my whole body into my wheelchair. If you’ve ever seen a spinal patient do this or are unlucky enough to have to do this yourself, you know what an ugly, uncomfortable process this is. But this time the ‘throw’ of the leg proved to be an over-compensation. To my absolute shock and delight my leg lifted itself just as it’s supposed to work...without aid from my helpful hands and placed itself exactly where my brain told it go! At first I didn’t think much of it...this was a fluke, maybe my imagination, but it was something sure not to last. But it has to this day without any hint of regression as I work out and get stronger. This was the first sign of any recovery whatsoever that has occurred below the waist in over ten years, and it happened only hours after the stem cell transplant!

    Upon returning home on April 14, 2012, I closely followed the Clinic’s physiotherapy program. Since then I have been working out at levels I had been told by my doctors here in the states would not be possible again. When exercising before I had stem cell therapy, I always had to be careful not to overdo it because I would get a sickness that sometimes lasted 2 days, completely wiping me out. This even occurred after the first liberation therapy, but no more. I’ve been working myself silly and have not yet felt sick. Real strength has returned and muscles have been popping out in places on my body where I haven’t seen them in many years. As of this writing today, and for about the last two weeks my right hand has been functioning normally in every respect. I’m not saying it has improved some, I’m saying it is now completely NORMAL! I can hardly believe it myself.For more information visit our site http://davidsmsstemcelljourney.blogspot.in/
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  • On Tuesday March 27

    , I once again had the liberation therapy followed by the harvesting of red bone marrow cells from my hip bone. The clinic has strict aftercare protocols around each type of procedure with regard to position control and movement. It didn’t much affect my activity because I was unable to move much anyway. I was supine positioned, tilted slightly head high for two days following my venoplasty and then laid out supine again, in just the opposite tilt...head-lower-than-the-body for several days following the transplants of the stem cells. I was told that this would allow the newly transplanted stem cells to filter through the full length of the nervous system and locate to the points of injury. A Doppler ultrasound of my neck veins was done every day for 10 days following my liberation procedure. This was to check for any clotting or re-narrowing of the veins which had been widened. If they clotted or restenosed at any time I was in the clinic, they would take me back into the cathlab for a re-do. Happily this wasn’t necessary.
    Following the liberation therapy, the changes within my body were just as immediate and dramatic as in my first procedure in 2010, hopefully without the fear of re-stenosis; but my ‘headspace’ almost didn’t accept it. The first time with my liberation therapy in the US, the IR found one narrowing in each jugular, the right side being more severe. This time around, two blockages were found on my right side, and again one on the left. I have heard that second and third procedures for venous angioplasty are more difficult for the surgeons because there is more build up of scar tissue in the interior of the veins, but the medical team took their time and did a perfect job. Words cannot express the emotional joy in getting the blood flowing again and getting those symptomatic improvements back a second time!
    For more information visit our site http://davidsmsstemcelljourney.blogspot.in/
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  • But it ended by the 90-day point and I was right back where I started. Immediately following the procedure I had dreams of rising from the wheelchair I’d been confined to for ten years and walking like a real man; but even with the incredible improvements overall, it seemed that the only healing occurred above the waist. Perhaps I would just have to accept that even if I could improve to what the full extent of the liberation therapy would allow, I would always be in a wheelchair. While researching the New York clinic and other places, my parents and I came upon CCSVI Clinic through a Google search. We discovered that they are essentially a research clinic operating under an IRB but with a major difference. For the past year, having seen even better results than just doing the liberation therapy alone, they have also been transplanting adult autologous stem cells, cultured and re-injected into the body shortly after the neck venoplasty. If I chose to go there instead of New York, the procedure would be done at CCSVI Clinic at Noble Hospital in Pune India and I would have to get there essentially as a partially paralyzed patient transported in a wheelchair. There would also be a requirement to stay in the hospital for 10-12 days. But after researching the improvements demonstrated in MS patients in stem cell clinical trials, I simply decided that as long as they would take me, nothing was going to stop me from making that trip. On calls with the clinic, it was also explained that stents were not necessary as the stem cells injected intravenously could be enough to keep my veins from restenosing. My confidence in their method increased when I discovered that Dr. Gupte, the neurosurgeon, had been transplanting autologous stem cells for 4 years for a number of different neurodegenerative conditions, including MS and based his therapies on completed stem cell trial methods done in a number of hospitals and universities outside of the US (to be absolutely sure, I confirmed this through searches on Google Scholar). He had already done over 2000 successful transplants! Regarding my communications with CCSVI Clinic, I need to confess here that we did not tell the doctors the truth originally. My mother, who arranged the treatments, told them that I was an EDSS 6.5 in order to qualify. Basically she knew that they wouldn’t accept me into the program if she said I was higher. But if they saw my actual physical condition could they refuse me on the clinic steps? I hoped not.

    So in late March it was off to India with my father who is a strong man, and my capable assistant. We arrived on March 26, 2012, and met Surjo Banerjee, CCSVI Clinic’s Managing Director at the airport. He drove us from the airport to Pune, a surprisingly modern city just south of Mumbai. I was amazed to see that the hospital and the CCSVI Clinic itself, (a full wing of suites within the hospital complex) was as clean and modern as any hospital here in the States. After checking in with a number of other patients, I was triaged for the procedures. However, based on my new assessment, it was determined that I would need about twice the amount of stem cells that they had originally programmed, figuring my EDSS scale requirement of 6.5. But paying more was out of the question. We are not rich and had basically ‘sold the farm’ to get here in the first place, and the recommended additional stem cells were going to cost another $12,000 that we had not planned for. Not their fault...I didn’t tell them the extent of my condition in the first place. So the first miracle happened when CCSVI Clinic management offered to personally cover these additional costs. I had never even met some of them, but as a result of their generosity, I received an additional 50,000,000 mesenchymal stem cells and I cannot thank them enough for the difference they have made to my life.For more information visit our site http://davidsmsstemcelljourney.blogspot.in/
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  • 1. Samuel S. Lyness, MD, FACS Director, Tele-Neurosurgery Program Wendy Baynard, MSW Program Manager, Tele-Neurosurgery Program The Walter Reed Tele-Neurosurgery Program American Telemedicine Association 2007 Annual Meeting Nashville, Tennessee
  • 2.
    • James M. Ecklund, MD, FACS, COL, MC, USA
    • Professor/Chairman, National Capital Consortium Neurosurgery Program
    • Walter Reed Army Medical Center, National Naval Medical Center and
    • Uniformed Services University of the Health Sciences
    • Leon E. Moores, MD, FACS, COL, MC, USA
    • Chief, Department of Surgery
    • Walter Reed Army Medical Center
    • John Posey, MD
    • Associate Professor of Neurosurgery
    • Tulane University
    • New Orleans, Louisiana
    • Alan Anderson
    • Clinical Business Analyst, Resource Management
    • North Atlantic Regional Medical Command
    Tele-Neurosurgery Program Contributors
  • 3. Tele-Neurosurgery Program Agenda
    • Objectives
    • Scope of Care
    • Clinical Process
    • Case Management
    • Consult and Referral Sites
    • Consult Site Team/Functions
    • Referral Site Team/Functions
    • Resource analysis (earnings)
  • 4. Tele-Neurosurgery Program Walter Reed --- Ft Bragg
  • 5. Tele-Neurosurgery Program Afghanistan ---- Walter Reed
  • 6. Tele-Neurosurgery Program Objectives
    • Optimize Specialty Care Delivery
    • Neurosurgeon focuses on surgical candidates
    • PA and PT evaluate patients for treatment options
    • Nurse case manager and LPN support providers
    • Increase Access-to-Care with Neurosurgeon VTC
    • Improve Clinical Outcomes with Treatment Options
    • Physical therapy
    • Anesthesiologist pain management
    • Surgical care
    • Ensure Continuity-of-Care from PC Referral to PC F/U
    • PA and LPN manage evaluation and conservative care
    • Nurse case manager coordinates all surgery-related care
    • Patient documentation stored in single electronic record
    •  
  • 7. Tele-Neurosurgery Scope of Care
    • Not Robotic Surgery
  • 8. Tele-Neurosurgery Program Scope of Care
    • All Ages
    • Routine and Urgent Care
    • Intracranial and Spinal Conditions
    • Vascular Lesions
    • Tumors
    • Congenital Malformations and Deformities
    • Degenerative Diseases
    • Acute Brain and Spinal Injuries?
  • 9. Tele-Neurosurgery Scope of Care
    • Works well in sub-acute conditions in which a large
    • proportion of patients recover without surgery
  • 10. Tele-Neurosurgery Program Clinical Process
    • Referral guidance for primary care providers
    • Patient evaluation and diagnostic imaging/lab tests
    • Non-operative treatment as first tier intervention
    • Neurosurgeon VTC consult and surgery assessment
    • Patients come to Walter Reed if surgery is needed
    • Pre-operative assessment and surgery
    • Post-op care and primary care F/U
    • Return to duty
  • 11. Tele-Neurosurgery Program Case Management
    • PA Conducts Referral Screening
    • Guide primary care provider on referral guidelines
    • Evaluate referrals for neurosurgical conditions
  • 12. Tele-Neurosurgery Program Case Management
    • PA Performs Patient Evaluation
    • Obtain comprehensive problem-focused history
    • Perform neurological examination
    • Order imaging studies and labs tests
    • Make diagnosis
    • Non-Operative Conservative Care as First Tier Intervention
    • Develop treatment plan with neurosurgeon input as needed
    • Prescribe PT and/or pain management interventions
    • Assess treatment results periodically
    • Request neurosurgeon VTC consult if conservative care fails
  • 13. Tele-Neurosurgery Program Case Management
    • PA/LPN Manages Neurosurgeon VTC Consult Process
    • Schedule VTC consult and obtain patient consent
    • Forward digitized radiology images to neurosurgeon
    • Manage VTC session between patient and neurosurgeon
    • Neurosurgeon discusses surgical options vs continued non-operative management
  • 14. Tele-Neurosurgery Program Case Management
    • PA/LPN and Nurse Case Manager Coordinate Surgery
    • Schedule and manage pre-op evaluation and care
    • Schedule surgery at WRAMC
    • Neurosurgeon-led surgical team performs surgery
    • PA Manages Post-Surgery Follow-up Care
    • Direct follow-up treatment and VTC specialist F/U
    • Refer patient to other health care providers as needed
    • Return patient to primary care with follow-up guidance
  • 15. Tele-Neurosurgery Program Consult and Referral Sites
    • Consult Site: Walter Reed Army Medical Center
    • All neurosurgical subspecialties represented on faculty
    • Center of Excellence for:
      • Comprehensive clinical care and resident training
      • Academic research on head and spinal cord/column injuries
    • Referral Sites: FT Bragg, FT Knox, Andrews AFB, Quantico
    • MRI and PT services available or in vicinity
    • Reasonable travel to Walter Reed if surgery is required
    • Current/projected enrollment to sustain service demand
    Fort Bragg Walter Reed Fort Knox
  • 16. Tele-Neurosurgery Program Consult Site Team/Functions
    • Neurosurgeon Performs Consults and Surgery
    • Neurosurgery PA Conducts Screening Clinics
    • Walter Reed three days per week
    • Andrews AFB and Quantico on-site one day/week each
    • Nurse Case Manager Supports Neurosurgeon
    • Coordinates VTC clinics and neurosurgeon clinical support
    • Provides case management for surgical patients
    • Surgical Team Supports Surgery (late afternoon )
    • Operating Room Nurse and tech
    • Anesthesiologist (runs pain management clinic 3 days/wk)
  • 17. Tele-Neurosurgery Program Referral Site Team/Functions
    • Physician Assistant Manages Neurosurgery Care
    • LPN Supports and Optimizes Physician Assistant
    • Physical Therapist Provides Non-Operative Care
    • Pain Management if Available
  • 18. Tele-Neurosurgery Program Resource Requirements 0 0 0 0 1,500 4,200 6,000 2,000 Level 6 0 0 0 0 1,500 3,600 4,500 2,000 Level 5 0 0 0 0 1,000 3,000 4,500 2,000 level 4 0 0 0 0 1,000 2,400 4,500 1,600 Level 3 0 0 0 0 500 1,500 3,000 1,200 Level 2 0 0 0 0 0 0 1,500 800 Level 1 OR Techs OR Nurse NCMs LPNs Anesthesiologists PTs PAs Neurosurgeons Effort RVUs by Clinical Projected FTEs ( est. $85 per RVU) Level of 0.6 0.6 1.2 3.0 0.6 3.0 4.0 1.0 Level 6 0.4 0.4 1.0 3.0 0.6 2.4 3.0 1.0 Level 5 0.4 0.4 1.0 2.4 0.4 2.0 3.0 1.0 level 4 0.2 0.2 0.8 2.0 0.4 1.6 3.0 0.8 Level 3 0.2 0.2 0.6 1.6 0.2 1.0 2.0 0.6 Level 2 0.0 0.0 0.4 1.0 0.0 0.0 1.0 0.4 Level 1 OR Tech OR Nurse NCM LPNs Anesthesiologists PTs PAs Neurosurgeons Effort         $3,718,800 $309,900 $10,330 30 Level 6         $3,099,000 $258,250 $10,330 25 Level 5         $2,479,200 $206,600 $10,330 20 level 4         $1,859,400 $154,950 $10,330 15 Level 3         $1,239,600 $103,300 $10,330 10 Level 2         $619,800 $51,650 $10,330 5 Level 1         Surgery Earnings Earnings per Surgery per Month Effort         Annual DRG Monthly DRG Earnings Surgeries Level of
  • 19. Tele-Neurosurgery Program Resource Requirements
    • TEAM: 20 spinal operations per month
    • 1.0 Full-Time neurosurgeon
    • 3.0 Physicians Assistants
    • 2.0 Physical Therapists
    • 1.0 Anesthesiologist 0.4 OR/0.6 Pain Mgt
    • 2.4 LPN
    • 1.0 Nurse case manager
    • 1.0 OR Nurse 0.4 OR/0.6 Pain MGT
    • 1.0 OR Tech 0.4 OR/0.6 Admin. Assist.
  • 20.
    • 1 Neurosurgeon $170,000
    • 3 Physician Assistants 382,500
    • 2 Physical Therapists 255,000
    • 0.6 Anesthesiologists 125,500
    • TOTAL $933,000
    • Generated for Hospital
    Tele-Neurosurgery Program Annual Projected Earnings Outpatient Visits Only
  • 21. Tele-Neurosurgery Program Annual Projected Earnings Surgery
    • Neurosurgeon (240 cases/yr) $2,470,200
    • Generated for hospital
  • 22. Tele-Neurosurgery Program Annual Projected Earnings Outpatient visits +Surgery
    • Total: $3,472,220/yr
    • Generated for Hospital
  • 23. Tele-Neurosurgery Program Startup Costs Equipment
    • POLYCOMs x 6
    • COMPUTERS x8
    • BLACKBERRYs x4
    • About $60,000
  • 24. Tele-Neurosurgery Program Fixed Costs
    • Personnel per/yr $1,800,000
    • Blackberrys per yr 10,000
    • TOTAL $1,810,000
  • 25. Tele-Neurosurgery Program Net Annual Revenue
    • Income $3,472,200
    • Fixed costs 1,810,000
    • NET + $1,662,200
  • 26. The Walter Reed Tele-Neurosurgery Program Summary
    • Patient care objectives are being met
    • Financial objectives are being met
    • Travel burden to and from WRAMC has, thus far, not been a problem nor increased the complication rate
    • Enhanced resident exposure to the “bread and butter” cases
  • 27. The Walter Reed Tele-Neurosurgery Program
    • Plan:
    • Resume svc to AAFB and Quantico
    • Market the program to other remote
    • sites (Aberdeen, Carlisle)
    • Tele-mentoring link to acute care sites
    • that lack a neurosurgeon
    • Recruit personnel as needed
  • 28. POC: Dr. Samuel Lyness Phone: 202-782-5123 Email: [email_address] POC: Wendy Baynard Phone: 202-782-6416 Email: [email_address] Tele-Neurosurgery Program Questions?