My two cents

August 16, 2009 at 11:35 am | Posted in Uncategorized | Leave a comment

I’m not an active part of this policy debate, but here’s my take on health care reform.

1. The biggest problem I see is simply access to the system.  People go to the ER for a number of reasons.  The most obvious is because they don’t have insurance and can’t afford to pay at the time of service like you have to do at a doctor’s office.  But lots of people also go because they can’t get an appointment with their own doctor within a reasonable time frame.  And when they have a problem, most doctors are so well-buffered by their staff that you can’t even talk to them over the phone.

Seriously.  I am a doctor, and even I can’t get through to a doctor here to set up care unless I do an end run and page them directly. Otherwise I have to wait six months for a new patient appointment.  And it’s completely unacceptable that anyone would have to wait that long to address an urgent issue.  My other option would be to show up in the ER and make them see me now, which is a waste of everyone’s time and system resources.  But that’s one reason people go.  It’s not what the ER is for, but the system is broken even if you do have good insurance.

2. I do not believe that most doctors choose among treatment options according to their reimbursement rates.  Speaking for my own field, surgical morbidity is potentially so high that we don’t operate on anyone unless it’s clearly their best option.  And I don’t know many surgeons in other fields who would choose the big whack unless medical treatment has been or obviously will be inadequate.  In Surgery, although reimbursement is high, so is patient morbidity and professional liability.  This is as it should be, because it promotes good surgical decision-making.

3. The externalities that reimbursement does create for us are less obvious.   In neurosurgery, it is not the riskiest operations, or those requiring the greatest expertise, that are best reimbursed.  Simple spine surgeries are reimbursed better than craniotomies, yet spines are junior-level cases at most programs.

Also, I spend way too much time gathering patient data that has no impact on surgical decison-making, simply because it’s arbitrarily required for a consultation note to be billed at a level commensurate with the service we provide. These note-writing standards were developed for IM-based specialty billing, and are completely inappropriate for the surgical specialties.  And yet I spend the time, because our services are worth the higher billing, and there’s no other way to get it.

In addition, the medical specialists for whom these note-writing standards were designed have far fewer patients to see in a day than I do.  We have fifty patients on our service, and around 4 junior and mid-level residents to split between the ICU, ER, clinic, floor and OR.  The neurology service has twice as many residents for one-third as many, or fewer, patients.  AND they don’t operate.  AND we take care of their ICU patients for them.  Medicine residents are typically capped at 6 new patients per call day, and 10 total.  AND they don’t even deal with consults.  In neurosurgery, we have no cap; the resident handles every consultation and admission to our service.

The basic problem is that we don’t have enough training positions across the board, in both medicine AND surgery.  Frankly, the shortage is greater in surgery, but instead of complaining, we turn it up a notch and find a way to get it all done anyway.

I am for a single-payor system, for the sole reason that it’s far more efficient to have a single set of rules to follow.  In addition,  a single-payor system is far more transparent and accountable in day-to-day practice.  It will be much easier to see what works and what doesn’t, and I firmly believe that this will only serve to emphasize how singularly efficient surgeons are, and the dramatic difference that surgical solutions can make in overall quality of life.