Archive | July 2010

Heart Surgeons Not Immune to Private Practice Squeeze

A thoracic surgeon performs a mitral valve rep...

Mitral Valve Surgery

The Detroit News discussed private practice trends in a recent article.  Unsurprisingly, the number of physicians operating solo or small practices is dwindling.  Many new residency graduates in most specialties are opting for the security of an immediate paycheck, rather than taking on the financial risk associated with opening a private business.  There is little to no useful business training provided in medical school or residency.  Furthermore, the fee-schedule based mode of reimbursement has not kept up with inflation for quite a while, leading to more than a 20% decrease in net earnings since 2001.  What this means is that the room for error is very small for private practices.  This has been true for a long time with non-procedural doctors, but now is also true for surgical subspecialties.

An amazing fact in the article is that the percentage of cardiothoracic (CT) surgeons in private practice has decreased from 80% to 30% in the last three years.   I find that to be both sad, and as noted above, unsurprising.

CT surgeons are among the most technically skilled of all surgeons, which is only my opinion but one forged by watching them and almost all other types of surgeons over a few years now.   But reimbursement schemes do not take that into account, nor do they take into account that three hours of surgery operating on a heart is one heck of a lot more stressful than operating on almost anything else, with a few exceptions.*

CT has faced difficulty for a variety of reasons.  Here are three of them.

1) The rise of interventional cardiology procedures.

When interventional cardiology was getting started, things were largely great for CT.  Understandably, they did not want to fool around learning how to thread tubes into arteries and to do closed procedures on an x-ray screen.  It was far better to stay within their comfort zone, getting better and better at open surgeries. But the success of stenting meant that fewer patients needed to have open surgery, and those that did were often older and sicker.  Often they had stents in place from prior interventional procedures, making for a harder open operation.  Notably, many vascular surgeons paid attention to this lesson, learned endovascular procedures and added them to their repertoire.

2) Severe downgrades in the Medicare fee schedule.

Cardiac surgical procedures suffered fee schedule downgrades of around 40%, which doesn’t factor in increases in practice overhead.  When that is taken into account, the picture is much worse.

3) Decreased demand for open surgical procedures (directly attributable to item #1)

Interventional cardiology is an important advancement in cardiac care.  Like all new and disruptive technologies, it has shaken up the market for cardiac care.  The good thing is that many people can avoid open heart surgery, and recover faster from revascularization.  The consequences are smaller caseloads for surgeons and less experience for surgical trainees.  Add in a lowered fee schedule and the effect on the field has been significant.  Interventional cardiology has also been significantly impacted by schedule cuts, and they have been joining hospital staffs in increasing numbers.

*: certain neurosurgery procedures, liver transplants, thoracic aortic aneurysms, and neonatal surgery are those which come to mind.

Saying Goodbye to “The Boss”

George Steinbrenner has left the stadium, and he goes out as a winner.  Its a sad time for baseball fans in general, and Yankee fans in particular.  The Boss is the second Yankee icon to depart this week, following the long-tenured announcer, Bob Sheppard.  George applied his considerable skills to the Yankees, serving as a major catalyst in the tranformation of the sports business.  Despite some underachieving 1980’s teams, by 1996 he had established a dynasty that is still going strong fifteen seasons later.  The Yankees were just one of his many successes, but the one for which he will be most remembered.

New Medicare Chief Termed “Rationer”: Is This Fair?

The Centers for Medicare and Medicaid Services (CMS) has a new chief.  Donald M. Berwick M.D. was appointed by the president to take over CMS.  A “recess appointment” was made during the absence of Congress, as there was concern that the formal hearing process would be used to stall or delay the nomination.

Dr. Berwick is a pediatrician with decades of experience, the CEO of the Institute for Healthcare Improvement, and a professor at Harvard.  He is well qualified for this challenging post. 

The emerging backlash is centered on his views concering utilization of healthcare resources.  One comment noted in many news items  is the following, made by Dr. Berwick during an interview in the June 2009 issue of Biotechnology Healthcare.  He said this:

We make those decisions all the time.  The decision is not whether or not we will ration care – the decision is whether we will ration with our eyes open.  And right now, we are doing it blindly.

The complete interview is here

Most criticism has focused on taking pieces of the above comment, usually sentence two, and honing in on the issue of “rationing”.  Naturally, lawmakers do not like recess appointments, which is part of the reason for the criticism.  Other groups have opposed his appointment, using terms I will not repeat.  Is this justified? 

There is no doubt that the healthcare system is under significant stress.  It suffers from imperfect competition, and costs are rising beyond our ability to contain them.  Something has to change, and forces are underway to that effect.  But terming Dr. Berwick a “rationer” makes little sense.  What he and most sensible observers advocate is for care options to make clinical and financial sense. 

Considering this quote in full, there is all sorts of rationing in healthcare just in reaction to the economic forces that shape the system.  And since this is imperfect competition, that sort of rationing doesn’t always help patients.

The system simply cannot provide everything to everyone, and one way or another, decisions will have to be made.  The medical education system has chosen to largely ignore considering the cost of care when training doctors and other providers.  This is because taking on the cost issue is very difficult and brings up many ethical conflicts.  Ignoring it is far easier.  But the problem has never gone away.  Now, with costs out of control, it must be tackled.

“Blind rationing” is not an appropriate way to reduce cost.  Improving the system requires considering incremental benefit and cost of new treatments, confirming that new treatments are effective, and reducing the moral hazard issues prevalent throughout the system.  Leading CMS is a big challenge, moreso now than at any time in the recent past.  Dr. Berwick doesn’t need accusations of being a “rationer”, he needs support and best wishes.