Markian Hawryluk
The Bulletin

Local hand surgeon Dr. James Verheyden has treated patients with Dupuytren’s contracture from as far away as Hawaii and North Carolina. They travel such distances for a nonsurgical alternative, an injectable enzyme that’s been available nationwide for more than 18 months.

So why do they come to Bend when there are hand surgeons in their own towns?

“I call this the ugly side of medicine,” Verheyden said. “Surgeons don’t make money doing injections. I think there’s been a very slow uptake to do this because of that.”

Treating patients with Dupuytren’s accounts only a minuscule part of the trillions of dollars spent on health care in the U.S. each year. But the financial incentives influencing treatment options are a prime example of why the nation is struggling to clamp down its behemoth medical bills.

Dupuytren’s is an inherited disease that causes an excess build-up of collagen in the hand, creating tight cords that pull the fingers toward the palm. As the disease progresses, patients can’t straighten affected fingers, oftentime losing effective use of their hands. Traditionally, the condition has been treated with hand surgery, cutting away the cords and releasing the fingers. But in February 2010, Auxilium Pharmaceuticals won approval to market Xiaflex, an injectable enzyme that eats away at the cord and allows the fingers to be straightened the next day. It avoids the risks of surgery and anesthesia, provides a faster recovery and does not build up scar tissue. Yet, only one in three hand surgeons in the U.S. are using Xiaflex.

“I’ve done 80 (patients) and have 20 in the pipeline getting authorized,” Verheyden said.

That represents nearly 1 percent of the more than 10,000 patients treated with Xiaflex since its approval.

“There’s been a resistance here. I shouldn’t be doing this many,” he said. “I should not be the capital of the world for this.”

Verheyden believes the reluctance on the part of hand surgeons has to do with the way they are paid. The cost of the enzyme runs about $3,400 for a third of a milliliter and Verheyden receives another roughly $200 for the injection and the manipulation the next day. The costs for an hourlong hand surgery is $3,000 to $5,000 depending on the insurance plan, of which $2,000 is the surgeon’s fee. Choosing Xiaflex over surgery cuts the surgeon’s income by $1,800.

“If you look at the total cost — the anesthesia cost, the surgery costs, almost everyone after surgery needs hand therapy — that’s going to cost significantly more than the cost of the injection,” he said.

Laurel Solum, an Oregon State University employee from Corvallis, had hand surgery four years ago, but last year one finger on each hand started to bend again. This time she was looking for a nonsurgical alternative and was referred to Verheyden.

“I would really like to get it fixed,” she said. “It’s really starting to interfere with my life. I can’t sew, I can’t quilt. And I do fishing, hunting and golfing.”

Solum traveled to Bend for two days last month. Verheyden injected two fingers with enzyme from a single vial of Xiaflex the first day and then straightened out her fingers the next.

“They’re on opposite hands, so I’d have to do surgery twice, two separate charges, (a total of) $11,600,” Verheyden said. “I’m going to take care of this with one visit. It will be less than half the cost.”

There was less recovery time and no need for therapy. Solum described her previous surgery as “wicked.”

“That was slicing open your hand and you skin. I was on Hydrocodone for the pain. It was like six weeks and therapy on top of it,” she said. “It was not debilitating, but it was pretty rough.”

Other options

Not all hand surgeons agree that Xiaflex always represents a better option than surgery. Dr. Joel Solomon, a hand surgeon at Oregon Health&Science University, is trained in the use of Xiaflex and offers it as an option to his patients. But he favors a surgical approach and so far none of his Dupuytren’s patients have opted for the injection.

“So far my impression is that it’s not a major step forward,” he said. “It’s certainly a new and exciting avenue and it’s so categorically different.”

Solomon feels the surgical approach provides a longer lasting treatment and is more effective for many more severe cases. A third alternative, needle aponeurotomy, involves placing a needle through the skin and using it to break up the cord. Like the Xiaflex injection, it is a “blind procedure” where doctors are working by feel and knowledge of hand anatomy rather than sight.

As an OHSU employee, Solomon isn’t paid on a per-procedure basis and so has no financial incentive to choose one procedure over the other. But he acknowledges that for hand surgeons in other settings, the difference in fees may have an impact.

“I don’t want to make it sound like the incentives are strong enough to sway someone to do something inappropriate,” he said. “But if you think that for all groups everything is equal, and on one I’m going to make a lot of money and on one I’m not going to make any, I’d probably do the one where I make a lot of money.”

‘Misaligned incentives’

Convincing more doctors to choose a less-profitable procedure, however, is easier said than done.

“Instead of sending somebody for a $10,000 surgery, you can use a $3,000 medication, and everybody benefits from the savings,” said Dr. Sean Rogers, medical director of Bend Memorial Clinic. “It’s a classic example of misaligned incentives. The fee-for-service model in the current system basically incentivizes people to do the wrong thing.”

The current health care payment system, known as fee-for-service, is built around procedures. Public and private insurers set out fee schedules that list the payments for each procedure. The more complex and time-intensive the procedure, the more money the doctor receives.

“Physicians have the incentive to provide more care when it’s on a fee-for-service basis, and the amount of care they provide is really not at all controlled with the fee-for-service payment system,” said Stephen Zuckerman, a health economist with the Urban Institute. “But when you have a trade-off like this, you hope that the professional ethics will take over and that the physician will provide clinically appropriate care and provide the patients with enough information to make an appropriate choice.”

Managed care companies tried a different approach in the 1980s and 1990s offering to provide all the health care services a patient requires for a fixed payment. If the company could keep spending below that rate, they would keep the savings. That provided the opposite incentive from a fee-for-service approach. The less care provided, the higher the profits.

“That’s one of the dilemmas that policymakers and payers are going to have,” Zuckerman said. “They can provide incentives for the physician to provide less care. But in many cases the patient may feel that they don’t want the provider to have that kind of incentive.”

Many of the current health reform strategies are focusing on changing the current incentives, offering payment structures that reward physicians for keeping patients healthy, rather than treating them after they get sick.

In the meantime, Auxilium is trying to bring more hand surgeons into the Xiaflex fold by arguing that doctors can do multiple injections in the same time it takes to do a single surgery, thus offsetting the difference in payments.

“The one-to-one ratio is going to be different, but it really comes down to a balance of time. You can treat a lot more patients with Xiaflex,” said Will Sargeant, the company’s vice president of communications. “But it’s a paradigm shift.”