Several articles have recently appeared in major media describing indiscretions, questionable ethics, and inappropriate surgical indications by various spine surgeons throughout the country. Whether it be a surgeons in Louisville, Minneapolis, or Portland, these articles cite a rampant profit motive and environment of inappropriate relationships with industry as causitive factors in inappropriate application of spinal fusion surgery.
Utilizing selected patient testimonials, testimony to which the surgeons are unable to respond due to confidentiality, and selective statistics, the articles attempt to construct a narrative of greedy physicians performing unnecessary procedures to the detriment of patients, and seemingly of greater importance to the reporters, of Medicare.
Despite noting reimbursement rates from Medicare of 10-20% of billing, and without reporting physician federal, state and local tax contributions from the implant royalities and income, the central thesis is that physicians are engaging in theft from Medicare via harmful procedures.
Without knowing the specifics of the clinical problems under discussion, it’s impossible to know if the procedures were indicated, but the unwritten details give one pause about the purpose of the articles. Divorce records are frequently utilized to outline the financial position of individual surgeons. The Bloomberg article shows a picture of a surgeon’s house and describes his other assets that were divided in his divorce, but fail to mention that his wife was one of the most successful plastic surgeons in the Twin Cities. The Twin Cities Spine group invited reporters to their clinics to show their contributions to medicine through prolific research projects, headed by one of the great names in orthopaedics, Dr. Robert Winter. None of this was reported.
Is the purpose of these expose’s to help reign in costs, a full frontal assault on waste? Not likely. As usual, it’s in the interest of powerful lobbies such as medical insurers and, yes, implant companies as well as those in government to call for ever greater regulation of physicians and medicine in general. While Medtronic provides excellent compensation in the form of royalties to physicians who help them design and test implants, it would be a massive boon to the company if the government stepped in to outlaw such payments. Further, small competitors would lose the ability to attract physician investors/innovators, removing the threat of competition from the concerns of Medtronic and other large companies. Republican Senator Charles Grassley’s personal crusade against physicians and the justice department’s attempt to force price controls shows that we have no friends in either party.
But the more the government attempts to throttle the livelihood of physicians, the less likely will it be for the best and brightest to enter the field, and the more early retirements or career changes will occur. Docs must start to push back against this tide of freedom crushing “reform.” SIA’s position – if you want to reduce costs and the incidence of unnecessary procedures, allow individuals to purchase catastrophic insurance and invest in tax-free Medical Savings accounts that make them financially responsible for their care. Pull apart the Ponzi schemes of HMOs, Medicare, and Medicaid, in which the well pay massive amounts of money to subsidize the care of the sick. Failure of these is as inevitable as the failure of social security.
Congress and the president have finally agreed on how to crash the medical airplane into the mountain. While the so-called benefit won’t take effect until 2014, the massive regulations and taxes will be upon the country in short order. The physician response will be interesting, since it is our unique field that is being reduced, in its essence, to another bloated federal bureaucracy. Some will fall pray to the siren song of employed positions. But many will try to find a way to maintain the level of independence superior patient care through physician owned practices and enterprises. A few observations about the bill:
The mandate for insurance, while unconstitional, will be beneficial to insurers, as 20-30 million will be placed in the insurance pool.
By forcing insurers to accept patients with pre-existing conditions, cover dependents until 26 years old, and with premium increases dependent upon the blessing of the HHS secretary, only those HMOs priveleged enough to peddle federal influence with long survive this legislation. The few remaining cartels will likely enjoy regional monopolies backed up by federal protection.
The newly insured will create a tremendous demand while other points in the legislation will put a crunch on supply, as many physicians will simply decide that it’s not worthwhile to practice in such a hostile environment.
The law of supply and demand will create pressure in the system, as patients must wait increasingly long periods of time to receive care. The free market will, as it always does, will find a release valve for this pressure – in physicians who opt out of 3rd party payers in order to provide timely and efficient service, free from requirements for privacy shredding electronic health records, restrictions on investing in portions of one’s practice, and the Orwellian pay-for-performance measures being enacted. SIA will help to guide the remaining docs through these changes.
While those in power continue to squeeze the last vestiges of free market capitalism from this nation, the data in support of orthopaedic specialty hospitals continues to mount. Consider this from the British Medical Journal. Hospitals specializing in orthopaedic care have improved outcomes for a host of variables – including DVT/PE, infection, post-operative bleeding, myocardial infarction, and mortality. The degree of specialization correlated directly to reductions in these adverse events. Government has demanded pay for performance-type structures for medicine. It is therefore no wonder that specialty hospitals are in the crosshairs, as they would demand significantly higher pay under such a system. A request for our “representatives” – the free market has found a way to deliver superior care. Please inform your constituents that you wish to eliminate it.
The recent Senate election results in Massachusetts, with state senator Scott Brown emerging victorious, has seemingly stalled the plans to institute the mammoth health care bill being hashed out in the bowels of the federal behemoth. This is an excellent development for physicians who desire the ability to provide superior care to their patients, but it is unlikely that politicians will be willing to totally abandon the holy grail of federal control of the health system.
Interestingly, Mr. Brown was a supporter of Massachusetts’ disastrous health care plan. One can only feel grim amusement that turncoat physicians feel the failed plan simply didn’t go far enough in giving the state control over their practice. We only hope that Mr. Brown is listening to his constituents, who largely feel the plan has failed in its stated goals of expanding coverage and improving care. The Cato institute provides an interesting analysis of the MA debacle.
With passage of the Senate health care bill (H.R. 3590) on Christmas Eve, the differences in the House and Senate bills will need to be resolved in conference committee. While substantial differences exist, particularly with respect to establishment of a government-run option, it seems probable that a final bill will emerge that includes significant restrictions on physician investment, restricts expansion of existing physician-owned facilities, creates some form of public insurance to “compete” with private insurers, and empowers the Health and Human services secretary with unprecendented control of a large sector of the economy. The bill itself, as well as the Democrat and Republican summaries are now available for review. Each is educational.
Now, a few predictions.
The new bill will result in a significant number of departures from the medical profession due to retirement and decreased entry into the field – crippling physician supply. Expansion of insurance coverage to millions of additional individuals will cause a dramatic increase in demand for physicians. As a result, a two-tiered system of care will emerge, with access to medical care dictated by quality of coverage and ability to pay. Here is one potential scenario.
The damage to physician investment applies to Medicare-approved facilities, particularly with respect to physician owned hospitals. SIA predicts that a number of these such facilities will be viable in a new environment which further marginalizes Medicare beneficiaries through significant cuts to the program, as current hospitals under development that will not meet the Senate deadline may opt-out of the system. Several states will be unwilling to forego the additional tax revenue generated by these hospitals (over $2 million per hospital annually on average), particularly given numerous unfunded mandates for state programs in the legislation.
The gap in care providers will be met with expansion of the responsibilities of Nurse Practitioners and Physician Assistants, as well as further recruitment of internationally trained physicians. This also represents an opportunity for physicians trained in the best medical system in the world to compete for patients.
As physicians take advantage of opportunities unintentionally presented by the new healthcare environment, the federal government will move towards securing control of licensure and certification to dictate a minimum number of government-insured patients be seen prior to care for privately insured or fee-for-service patients.
Surgeon’s Independence is committed to helping practitioners navigate the tumultuous waters of healthcare reform. That’s why we’re planning to offer the most effective job search engine for physicians ever designed. The single most important factor in finding a great opportunity is who you know. Many jobs arise through serendipitous connections. Through SIA, you can expand your opportunities by finding connections with practitioners throughout the country. As we develop our job search engine, check back to see how we plan to make your first job a lasting and successful practice.
Check back to see our search engine develop. And remember, though we hold out hope that the current healthcare bills will be voted down, there will always be avenues of opportunity for motivated and savvy surgeons. SIA plans to show the way.
The senate voted over the week-end to begin debate on the Senate version of the health care bill. Now more than ever, efforts such as SIA will be critical to maintaining the level of medical excellence practiced in the United States. While passage is not inevitable, it is clear that the administration and both houses of Congress will manage some form of this legislation that “cuts” costs by targeting physician salaries. What kind of physicians can Americans expect if we continue downward pressure on reimbursement in a hostile legal environment? How will the projected shortages be solved by crushing physician opportunities for entrepreneurial endeavors? Our goal will be to give surgeons the tools required to maintain their profitability and navigate the coming bureaucratic behemoth.
A few parting questions.
How much do you think the surgeon responsible for your spine surgery be paid?
How much is the improvement to your function from a knee replacement worth?
How much is a lifesaving appendectomy worth to you?
And – who should decide these values? Government? Insurers? Or patients and and their doctors?
There is increasing demand in government circles for adoption of Electronic Medical Records that will be used for national data purposes. The claims of improved patient care and efficiency are largely unsupported, but this did not stop Congress from dumping $20 billion into implementing health information technology in medical practice. Initially, the Centers for Medicare and Medicaid services (CMS) will provide modest benefits to physicians who adopt EMR prior to 2011, followed by a 3% cut in reimbursement after that point for failing to comply.
This is in light of a new study which finds no real benefit to patient quality or cost of care from use of EHR, despite significant costs to implementation. With an initial cost of over $32000 per physician and an additional $1500/month cost of maintenance, one would expect significant benefits to a practice.
The federal government reply? More funds and more rapid adoption of EHR will assuredly demonstrate savings and better care. It is unlikely that the benefits will offset the cost of implementation, and that the penalties will be trivial to a surgical practice which wants to protect the integrity of its patient data. Consider Dr. Silverstein’s take in the Journal of American Physicians and Surgeons.
HR 3962, the Affordable Healthcare for America Act, passed by a vote of 220-215 in the House in a late session Saturday 11/7/09. The anticipated tally is well over $1 trillion dollars.
Despite the tacit endorsement by those organizations reputedly representing physician interests, the passage of this bill is yet another step towards centralized control of the medical profession. Read carefully the text of 3962 linked from our resources page. The language is impressively vague, and instills unprecedented power in the office of Health and Human Services. The Secretary is given the ability to broadly interpret the bill and given authority over what “qualified” health plans will cover. All Americans are required to participate, and the ability of physicians to opt out is likewise invested in the authority at HHS.
Here is representative Paul Ryan, R-Wisconsin, on the floor:
The process now moves to the Senate. Contact your senators to express your opinion about this unprecedented step towards centralized control of medical practice.
The American College of Surgeons has joined with several other specialty societies in opposing the Senate Health Care Reform Bill. While SIA agrees that the reforms proposed will limit patient access to care and cause significant problems with the delivery of care, we believe that continued focus on the Medicare Sustainable Growth Rate Formula is flawed.
The SGR was established in 1997 to control Medicare expenditures. Total outlays and growth in payments, number of beneficiaries, and other economic indicators are utilized to calculate growth in Medicare and compare that to growth in Gross Domestic Product (GDP). Reimbursement is then cut in a scheduled fashion in the hopes of maintaining Medicare’s solvency. Each year since the SGR’s inception, the scheduled cut has been delayed, and Medicare outlays have increased.
The American Medical Association (AMA) has hinged its support of reform on elimination of the SGR, and the ACS has stated that their support would be contingent on the same. The fact remains that Medicare’s insolvency looms large, and that implementation of the SGR as written would simply result in many physicians opting out of Medicare. This naturally leads to rationed care for America’s seniors, and reduced benefits for most non-life threatening conditions. No doubt a free market would be able to step in and fill the gap, while Medicare would take a necessarily reduced role in the delivery of care. It is clear that Medicare is unsustainable, as will be any public option passed by the Senate. With the economy still in dire straights, federal revenues will be insufficient to cover either the elimination of the SGR or the massive new entitlement currently under consideration in the House.
Tell your specialty societies that elimination of the SGR will not change your mind about the current health reforms proposed in the House and Senate. Contact your congressmen to do the same.