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Information
Surgical Manpower USA
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ROM SURGERY NEWS: OVERTRIAGE
RAISES COSTS AT TRAUMA CENTER
A third of patients transferred to a Level
1
regional trauma center were sent there
unnecessarily and at substantial cost to
the center, and most of this “secondary
overtriage” could be attributed to nonmedical
reasons rather than severity of injury, report
staff of Surgery News, the official newspaper
of the American College of Surgeons (ACS).
Of 2,486 patients transferred, 374 who were
admitted to the trauma center had injuries
that could have been safely handled by the
referring institutions, and 582 were seen and
released from the emergency department, Eric
A. Toschlog, MD, FACS, said at the annual meeting
of the American Association for the Surgery
of Trauma
in Boston, where he discussed the results of
a retrospective study.
From 2007 through 2009, secondary overtriage
resulted
in an estimated $570,000 loss for the center,
whereas
appropriate transfers, after adjustment for
Medicaid payments,
resulted in an estimated $1.5 million gain.
Dr. Toschlog, of the Brody School of Medicine
at
East Carolina
University, Greenville, NC, said the study
results are in
agreement with the American College of Surgeons’
Resources for Optimal Care of the Injured Patient
(Green Book), which
states that overtriage has no or, at most,
minimal
consequences for patients, but results
in “excessive
costs and burden for higher level trauma centers
in
the routine care of injured patients.” |
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Two nationally prominent surgeons
expressed alarm about young surgeons' work ethic in 1990. The authors refer to "the yuppie mentality" and the "perceived attributes
of less arduous postgraduate education, a lucrative future, and limited patient responsibility; in short, one in which lifestyle
is controllable."[5] In a survey of British surgeons reported the same year, practitioners demonstrated higher scores than the general population
on validated measures of stress– specially job interference with personal life, general administrative duties, and the
number of patients seen in clinic.[6] A 2009 report on burnout among surgeons stated, "Increasing evidence suggests that physician burnout can adversely
affect patient safety and quality of patient care and contribute to medical errors."[7] Burnout occurs among trainees as well, and is not a new phenomenon.[8,9]
Among general surgeons (as well
as all surgical specialties), burnout is characterized by depersonalization, exhaustion, and a low sense of personal accomplishment,
and ranges from 30 to 38%.[7–9] Burnout leads to early retirement for an estimated 10–15% of surgeons at their peak. Morale is currently low
in some practice sectors; manpower issues are becoming urgent.[10] As a result, the surgical workforce is experiencing a numbers crisis. Other reasons have been proposed to explain the
emerging US surgeon shortage, including the Balanced Budget Act of 1997 that froze the number of federally funded residency
slots. This is linked to the failure of the Residency Review Committee to expand the number of positions for chief residents
(fixed at about 1000 positions a year for decades). Surgical leaders in the past did not anticipate a quantitative problem
with the American surgical workforce as reflected in this 1999 remark: "We are not overdoctored in general surgery–the
workload and the workforce are reasonably in balance. Distribution is a problem, but not the number of practitioners."[2] Added to this is the rapid expansion of the elderly segment of the US population, especially those over the age of
85, requiring surgical care.[11]
Recruiting tomorrow's surgeons currently
suffers from issues that seem to defy solution: diminished reimbursement, unrelieved medical student debt, increased surgical
work volume, more complex patients, the unresolved malpractice mess, and third party and federal regulatory oversight. The
reduced attractiveness of surgery as a desirable profession and the consequent surgeon shortage is further aggravated by sustained
attrition rates (junior residents leaving their training) of about 20% and the expressed need by 80% of our graduates to do
additional fellowship training to be competitive in practice.[12,13] More attention today is being placed on remediating surgical residents who might otherwise have floundered and been
dismissed in the past. Remediation involves not only behavioral issues, but also academic performance problems. These concerns
– both remediation and attrition - challenge general surgery residency programs and leave them struggling to meet the
future surgical needs of the country.
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No
I'm sorry to say this but the days when it was reasonable to attempt to build a solo private practice of general surgery
are long gone. Solo general surgeons do indeed exist but it tends to be more of a subsistence greatly dependent on part-time
hospital employment via ER contracts or indigent care contracts from hospitals who have a direct tax base. The vast major
of newly minted general surgeons are becoming hospital employees.
In the recent past, say 10 to 15 years ago, solo
surgeons were able to compensate for a continually declining fee schedule based on Medicare price controls by generating high
case volumes. The insurance industry unfortunately has developed very effective means of interfering with this approach and
have succeeded in driving up practice overheads faster than practice income. The main approach is to impede the referral mechanisms
of private practice by forcing primary physicians and hospital based treating physicians into warring camps. The animosity
has now resulted in a complete separation of acute hospital practice and chronic outpatient practice to the point where office
based referring physicians no longer visit their hospitalized patients and most hospital admissions are generated by emergency
rooms not primary care offices.
In addition, hospital OR staffs currently are unable to maintain the high case turnovers
required by the making it up with case volume approach, mostly because of nursing lifestyle issues combined with declining
hospital revenues and increased financial burdens from uncompensated care. Federal mandates which force hospitals to provide
uncompensated care are chiefly the cause of this.
Surgeons who practice their trade in outpatient facilities and practice
owned operating theaters outside of the purview of public hospitals and government entities can hope to maintain some form
of lucrative practice, but this kind of protected environment where the patient and surgeon negotiate healthcare and fees
without third party interference is rare, and definitely not applicable to Medicare or Medicaid recipients.
It's not a good game plan nowadays to avoid ER call if you're an old guy. Most
hospital admissions now come through the ER. If the ER doc and hospitalist have already diagnosed the patient for you, it's
pretty easy to call in orders and meet the patient in the OR in the morning. Even if the odds ratio of dealing with uninsured
patients are unfavorable in your locale, you can negotiate call pay with your hospitals to overcome this problem and maintain
an easy income stream, provided that your malpractice carrier doesn't bump up your rates. Remember I'm talking about general
surgery call not level II trauma call. That's definitely for young guys.
"Training in the 80 hour work week has nothing to do with
what surgical practice is becoming for the young surgeon. It still takes about 3-5 years, hopefully with affable mentors,
for a new surgeon to make his bones, i.e. feel comfortable as an independent practitioner in the operating room, office, hospital
and community. Unfortunately the economics of the present era are pushing for shift workers and a 48 hour work week for individual
surgeons who are mostly being forced into hospital employment. This is an unstable situation which leads to increased surgical
job turnover not enhanced surgical productivity.
The hospitals aren't looking for the Renaissance man general surgeon,
who can do anything, just for enough shift workers to keep their emergency rooms open. Nor are the hospitals looking for high
volume individual surgeons, just enough surgeons to do enough work to keep their beds filled and their nurses working at steady
state staffing levels which satisfy their lifestyles and their unions. Use the state of Massachusetts as a benchmark for this.
The general surgeon is falling from professional grace and notoriety and becoming a faceless commodity.
As for the
concept of a surgeon shortage, believe me, insurance companies and the federal government find this quite desirable. After
all, major surgeons are walking cost centers to third party payers and are to be beaten down at all costs in order to save
the nation's health care budget. As tertiary practitioners surgeons must necessarily be replaced by preventive medicine specialists
and public health authorities to keep from further bankrupting the federal and state budgets for Medicare and Medicaid.
If
CMS really wanted surgeons to perform Whipples, and esophagogastrectomies and intrapericardial pneumonectomies as treatments
for advanced cancer they wouldn't have dropped their fee schedule to the point where it is ludicrous to perform these procedures
for the amount of unreimbursable post-operative grief entailed unless the surgeon is aspiring to sainthood. CMS would much
rather reimburse the outpatient care of these malignancies as a cost containment measure to be shared by medical and radiation
oncologists and outpatient interventionalists with a speedy and acceptable, if less than ideal, outcome."
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