Predictably, surgeons protect their turf

in Uncategorized | 13 responses

Christian Shalgian, speaking for the ACS: “We as the surgical community don’t have a problem with increasing payments to primary care physicians . . . when MedPac is making a recommendation to do it in a budget-neutral manner, that means we as a surgical community will be cut in order to increase payments to primary care physicians. We have a fundamental problem with that.”

Comments

ERP
Ummmm. Hello, it is time to even the playing field guys. Subspecialist surgeons simply should not be paid what they are at the expense of other doctors who routinely make important decisions about their patients’ care.
Anonymous
Uhhh… actually if you think about it is the subspecialist surgeons who have a skill that is not easily reproduced whereas the primary care docs can be replaced by nurse pracs and people won’t know difference until a study comes out 20 years from now revealing how bad their care was. The point is is that it is easier to get people to pay for acute benefit (ie life saving hepatobiliary surgery) versus prevention for 20 years down the road. So if you cut services in the acute and tell people that you are helping them 20 years from now, they are going to scream bloody murder. That is why nothing will change.
Anonymous
I’m all for paying PCP’s EXACTLY the same amount I get as a specilaist for doing primary care on a day in day out basis. Same E & M code after all.
Anonymous
Kevin is continuing to foment class warfare between specialists and generalists. It is his achilles heel.
1) This argument serves the purpose of those wishing to drive down reimbursement in general and to gain further control over the entire field. It will be used to take money from the specialists, but most of those savings will not be redistributed to PCPs. It is incredibly naive of you to believe that it will be sent to the generalists. It will be given to the insurance industry.
2) “Protecting their turf” is exactly what the surgeons should be doing. It is what you should have done, too. As you know, there are those who would happily insist that we provide our services for free if they could. We need more advocacy for our interests. Kevin’s weak sarcasm is misguided.
3) I am tired of hearing from the generalists that they are the thinkers who make important decisions, while all I do is perform rote procedures. I am a neurosurgeon. Every day I make dozens of decisions that carry enormous risk. I also do quite a bit of thinking and counseling. I respect my PCP colleagues, but they do not do all of the workup, evaluation, consideration, and teaching that goes into treating these patients. Sometimes you act as if you do all of that and then tell me what surgery to perform, and all I do is cut. Sorry, that is false.
4) The work that I do is difficult. I have more risk and more stress. I have more uncertainty. I have less control over my schedule and my time. Furthermore, I trained longer and harder to do this. I do deserve to be paid more for it. There does not have to be a “level playing field.” We are not playing the same game.
5) When I was in medical school in the mid 1980′s we were all aware that primary care was under attack. The current state of the field is not new or sudden or unanticipated. If you are under the age of 50 and a PCP (like Kevin), you cannot claim that you didn’t know this was happening. You made your choice to go into primary care with full knowledge of the pay disparity. Please stop playing the victim.
6) Kevin, again carrying water for the insurance industry, fosters the impression that specialist pay is outrageously high. I cannot speak for other specialties, but in neurosurgery the pay for the common CPT codes is surprisingly low. For a Medicare patient undergoing a lumbar laminectomy (63047) the reimbursement is about $900. A craniotomy for brain tumor is about $1500. A craniotomy for acute subdural hematoma, even in the middle of the night, pays about $1200 (if the patient actually has insurance). All of our codes carry a 90 day exclusion period. In other words, all of our in hospital and other postoperative care is included in that fee. And the PCP’s are not asked to help with any of that.
My overhead expenses are about $500,000. This includes insurance, rent, and three employees. I have to do a lot of surgery at those prices just to break even. I would be curious as to the reimbursements for other specialty procedures. Most people are surprised when they see how little we are actually paid. They are misled by their bill into believing that their $20,000 expense for their back surgery is going to the doctor. It is not. The hospital is getting more than 90% of that.
Kevin knows better than that, but it serves his purpose to play into the myth and feign ignorance.
As a specialist, I am aware of the crisis in primary care. I want to fight for you. Stop making me the villian. It won’t fix your problem, and you will end up losing one of the only allies you have in this battle.
Anonymous
When the RVU system is dismantled, we will really find out how “necessary” all the volume of medical procedures really was. When everyone (except the cash only docs) is paid a salary, procedures will be done when necessary for the patient, not when they are necessary for the boat payment. How many normal heart caths get done every freaking day of the year? So, specialists, get it while you can because the train is coming off the tracks! Glad I got out.
Anonymous
Everyone likes to say that cardiac caths are over utilized, but from what I as a lowly medical student can tell they seem to the gold standard and an amazing tool to make sure nothing is wrong. And if something is wrong you can fix it right there. I really don’t see something that is the gold standard for diagnosis going down in volume. Maybe you should find a different example?
Anonymous
How dumb can docs be to keep taking the RVS bait and tearing into each other–as it’s original supporters dreamed. You are like a bunch of slaves baited into keeping each other in servitude when you fall for the ploy to get you attacking each other. Fools!
Anonymous
Of course cardiac caths are the gold standard. They are also invasive with a 1/1000 risk of death on the table. They are also extremely expensive. Unless you are a diabetic with CHF, then stenting does not add one year to your life. Statins do however. So, what problems are you fixing “medical student”. I will grant you acute MI. I will grant you intractable angina not responsive to maximal medical therapy. Those are the easy ones. However, so many caths are done on the 22 year old anxious MVPs, it would blow your mind. Reminder, as you get out into practice, don’t recommend a potenitally lethal procedure to one of YOUR patients unless you can back up the reasons with the literature. So, if you look through the data and see the astounding number of “normal caths” and “caths that need no intervention” compared to the caths that actually found something very serious, I think you might change your tune. It is not called the “cash lab” by chance.
Anonymous
I think when people look at “unnecesary procedures” from a distance they say that it is wasteful. But when it is you who has the angina just believing that their is a 95 percent chance that it was just a benign vasopasm or something is difficult to swallow. We should all walk a mile in someone else’s shoes before we decide what should be deemed unnecessary.
Anonymous
As a villified specialist cardiologist raking in a massive $240 for a cath that is always normal, please stop calling me from the ER for bogus chestpain so that you can cover your ass. This website has always been about attacking specialists!
That same specialist attacked on these pages is profusely thanked in the middle of the night when an acute MI arrives and has a door to balloon time of 45 minutes. So how much is a life worth…$~750 for the stent, half of the $240 for the cath, and the admission. Saving a life for around $1100, that’s not exorbitant pay for a specialist. All the while, the not-for-your-profit hospital collects $100,000. The hospital CEO laughs all the way to the bank while we fight on these pages.
Kevin, stop bashing specialists. You play right into the hands of the insurance companies and the administrators seeking to divide and conquer physicians.
Anonymous
The reason that I am a cardiologist is because I completed four more years of training and passed two more board exams. You are dreadfully wrong regarding your assertion that stenting adds longevity if you are a diabetic or in CHF.
Anonymous
I am a second year med student at a public university. I will most likely go into primary care (partly depending on my USMLE step 1 board score I take in one month). I also wholeheartedly agree that specialists should be well compensated.
Although my decision is probably premature and may change during my 3rd year, a small part of my decision will involve the consideration that I unfortunately forsee specialists losing in the reimbursement battle. The general public seems to adore their primary care physician, weather a FP, IM or a pediatrician. I not sure if the general public has the same adoration for their specialist that they may see less frequently.
I hope I will be wrong, but I think reimbursement will ultimately be left to politicians and the general public who will determine where the funding comes from and that will most likely favor their “doc”. So, for med students like myself, if financial considerations are a deciding factor, then I would be willing to wager that primary care will be a better decision in the next ten years as the tide shifts increasing reimbursement.
When all the baby boomers are eligible for medicare and can’t find a doctor who takes their insurance because it pays so little, then the public outcry will drive a policy change….and it won’t favor specialists.
Anonymous
“As a villified specialist cardiologist raking in a massive $240 for a cath that is always normal, please stop calling me from the ER for bogus chestpain . . .”
How can you expect the ER doc or PCP to make a judgment call that it doesn’t warrant a cath when you, the specialist, don’t have the guts or aren’t able to make that call? What warrants higher fees is the extra responsibility and risk involved is making those decisions–not the manual skill which any neurologically intact person can master with practice.
It isn’t only proceduralists who are highly trained specialists with years of added residency. The subspecialist with years of extra residency asked to make high risk judgement calls with his hands in his pocket is also deserving of a higher fee which the RVS system doesn’t recognize. Nor does it recognize the value of years of experience vs green behind the ears new grads. In short the system is a frankly immoral holdover from communism–but it isn’t in Russia and it is supposedly “land of the free and brave” American physicians who are not only putting up with it but destroying the independence and solidarity of an ancient profession in greedily milking it for personal benefit instead of subverting it, shunning, and attacking it as they are morally bound to do.
I have seen this fracturing bear fruit in a severe decline in quality of care and professionalism in the last 15 years.
Kevin, you are part of the problem in this area.

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