Lots of great feedback from everyone regarding my post on the MedPac/general surgeon controversy. Shadowfax submitted an interesting response in the comments section about the idea of certain procedures being "over-reimbursed". Why should an ankle fracture be reimbursed far more than the hour he spends sifting through the critical care complexities of a patient in the ICU?
It's a good point but not an entirely fair one. First of all, let me back up for a second. There is a tendency to group all physicians who perform procedures together under one banner. GI, general surgery, ortho, vascular, dermatology, plastics, cardiology, etc. But they aren't all the same. Far from it. I see two distinct categories of "proceduralists".
1) The "Hit and Run Bandits": You're the PCP. You consult Specialist X. Specialist X sees the patient, books the case for the next day, does the case, says thank you very much, and signs off as soon as the patient gets wheeled out of the procedure room. Ortho is quite good at this. As is GI. In and out. No hassles. Easy billing.
2) The "You Operate, You Own It Crew": These poor saps (general surgeons) tend to get sucked into being the primary care provider for all the patient's needs as soon as the scalpel is unsheathed. Patient admitted to internist from ER with "nausea". CT shows volvulus. Surgeon consulted. Emergent, life saving operation. Patient to ICU, attending physician changed to "Dr. Buckeye".
Now I wouldn't have it any other way. I operate, I own it. That's the way I was trained. I run the show. I correct the electrolytes. I manage post op hypertension and pain. I write my own TPN. I order my own insulin drips. I make most of the critical care decisions for my sick patinets in the ICU. That's the way it is. My part doesn't end when I take off my mask. Often, it's only just beginning.
So what does this have to do with Shadowfax' point about the overcompensation of proceduralists? Well, there's this little thing called the 90 day global period in medical billing. Basically that fee you collect for the cholecystectomy or the cataract or the Whipple is supposed to include the cost of all the post operative care (with a few exceptions) that the patient receives for 90 days. If you're the GI guy and you do a negative colonoscopy for anemia, you could care less; you'll never see the patient again once the procedure is done. You collect your fee and that's the end of it. But imagine a perforated diverticulitis that comes into the ER and you do the left colectomy/end colostomy routine but the patient is septic and limps along in the ICU for a week and you're writing TPN and managing hyperglycemia ruling out pulmonary embolisms and your pager is always going off and its three and a half weeks until she/he finally leaves the hospital. Suddenly, that fat fee for the intial procedure doesn't look so great when you add up all the hours of work and stress you've put into the patient's recovery.....
Perhaps general surgeons are being dumb about the whole thing. Maybe we ought to just be like the orthopods and refuse to have anything to do with the care of patients outside the operating room. Just dump it all on the internists/hospitalists.
I don't see it happening though. The problem is I kinda like what I do. I actually like being, you know, a doctor. I don't see myself as a "proceduralist". Maybe I'm a dying breed. Maybe the concept of the "general surgeon" is becoming an anachronism. But until it actually happens, I'm going to continue doing things the only way I know how.
Let's assume for a minute that we are dealing with a zero sum game. There's only so many dollars to go around and the PCP's are scrambling to pay their bills and it's apparent some redistribution of funding is necessary. Should general surgeons be the first target? Really? We're ok with radiologists and dermatologists raking in half a million bucks a year? Maybe if these hit and run proceduralists weren't so "overly compensated", more of our bright medical students would opt to go into primary care and alleviate the growing shortages in that area.....