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.

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