Monday, June 9, 2008

One more thing....the global period

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.....

14 comments:

The Happy Hospitalist said...

"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."

You are a dead breed. For everyone else, there's hospitalists.

rlbates said...

Buckeye, I wanted to write about this global period. It would seem we surgeons often get paid too much for a procedure until you factor in all the postop visits (with dressing supplies), rounds, etc and then maybe not. I have always been somewhat baffled about how charges for anything medical/surgical should be set. Just what is an appropriate amount for an office consultation, for repair of a complex laceration on a 16 yr girl, for an appendectomy, etc.

Luiz said...

It's not a dead breed yet, as a 1st year med student, I am more attracted to the general surgery route because you can still treat the patient. My opinion might change once I finish rotations, but if I were to choose the surgery path, general surgery gets the call.

Buckeye Surgeon said...

HH-
That hurts.

The Happy Hospitalist said...

Buckeye. It was a compliment. It is a rare surgeon in private practice that doesn't turn over all the medical post of stuff to the internist (vent/dm/bp/infection/etc...). I commend you. But, I also know as you get busier and busier that you will likely go the way of the rest. Give me a ring in 5 years and we shall compare notes.

Happy

Sid Schwab said...

I'm with you, Buck. But as trends go, HH is right. And reimbursement continues to fall, it looks more and more like folly for general surgeons to be the fabled "internist who can operate." I was. You are. Next generation? Doubt it. Heck, the whole concept of general surgeon is pretty much gone. Breast surgeon. Biliary surgeon, colorectal. Pecked to death by ducks.

Anonymous said...

Tell me sid. Where did you do your internal medicine residency? How many years did you spend in practice as an internist? Because you managed your own patients post op, it doesn't make you an internist. Your misplaced arrogance is amazing. Just because you say "I am an internist who can operate" doesn't make it so.

Buckeye Surgeon said...

HH- I do see the writing on the wall... it depresses the hell out of me.

Anon-
Ignorance comes in many flavors, even anonymous ones. Clearly you have no idea what you're talking about. What do you think happens during a five year surgical residency? That we all show up in the OR every day and start chopping? We put as many ICU hours in as a fancy pulmonary/critical care fellow. We manage diabetes and hypertension and pain and respiratory distress. We initiate the management of post op MI's. We give diuretics to patients in failure. We know how to titrate heparin drips for acute DVT's. The list goes on and on. Maybe I'm mistaken, but that sounds a lot like what an internal medicine resident does on a good day. It isn't arrogance. That's what we're trained and expected to do. You want to resort to tired old cliches about the "arrogant asshole surgeon" go ahead, but aim them at me; not someone who's spent a career actually doing it for thousands of patients like Doc Schwab..

halfmd said...

There's a saying that goes "What do you call an internist who's finished his training? A general surgeon."

I'm a fan of surgeons that can manage a hospitalized patient. Unfortunately, I see so few of them. Most consult the internists the moment there's a fever or high glucose reading. What's worse are the dinosaurs that think they can manage patients, only to do more harm than good. One of my attendings will automatically put all of his patients on Zosyn, Vanco, and fluconazole the moment a patient appears as if he has an infection. Then he wonders why antibiotic-resistant organisms and diarrhea are so rampant on his floor.

The field would be so much more appealing if not for lack of hospitalist skills and the paltry reimbursements. $300 for a lap chole and 90 days of followup? You've got to be kidding.

Anonymous said...

My group of hospitalists get at least one consult a week (400 bed hospital) for "hypotension post-op."

51 weeks out of the year it's post op bleeding and we have to argue with the surgeon who did the case.

The concept of "owning the patient" will be dead in one generation.

As for surgeons being internists - both they and their patients are fools. Who goes to an internist for an operation? Same logic applies. Never use an internist who never wants to see you again!

Stalwart Hospitalist said...

Like HalfMD, I also am a fan of surgeons who can manage a hospitalized patient. Not those who do but can't, but those who want to and can.

As Happy says, we'll be here for the rest. As I watch surgical trainees go through year after year, there is definitely a move toward general surgery residents focusing more on the surgery, and less on the other medical issues, which get farmed out to consultant services. Whether this is due to duty hour changes or just the evolution of the culture is anybody's guess.

Anonymous said...

Buckeye:
You correct, ignorance does come in many flavors, and you have just shown how ignorant you are. Do you really think that placing a diabetic on a post op sliding scale/insulin gtt is managing diabetes? Do you really think fiddling with a heparin gtt in the setting of an acute DVT is "managing a DVT"? Do you really think throwing a patient on a PRN BP med is "managing blood pressure"? Do you really think fiddling with a vent/pressors overnight is the same thing as what a critical care doc does? Do you really think thowing an MI patient on a heparin gtt/lovenox, ASA, beta blocker, then calling cards is "managing an MI"? All you have simply done is shown me what any god damn intern in ANY SPECIALTY SHOULD KNOW HOW TO DO after 3 months. That's not IM, that is medicine 101 for dummies. If you really think that is all what IM is, then you really are a fool.

Buckeye Surgeon said...

Anon-
During a patient's post operative stay in the hospital, a good general surgeon ought to be able to manage most of the typical medical issues that arise. That's what we do. If a patient has a MI, I intiate the standard treatment and call cardiology. I believe that's what a good internist would do. It's called taking care of your patients. I'm not sure why that is so outrageous to you. What I don't do is manage diabetes, hypertension, heart failure over the long haul, over the course of a person's life. So yes, we are definitiely not internists in that sense.

The point of the post was to emphasize the difference in one breed of proceduralist from another. If a post op hip replacement develops shortness of breath, the orthopod won't even give the nurse any orders other than "call medicine!" You need to relax a bit. General surgeons aren't looking to get board certified in internal medicine; we just happen to have a training program in place that places responsibility for the identification and treatment of a wide range of complications that develop after surgery that would ordinarily be designated as "medical issues" on our own shoulders. And most of us are fine with that. Youre right that "any goddamn intern should be able to do it after three months", but most proceduralists don't. Not sure what else to tell you pal.

And your comments about critical care are amusing. I don't "fiddle with vents" and call myself an intensivist. I spend a lot of time taking care of patients in the ICU. Critical care comprises a big component of general surgery residency. Close to 20% of the board exams are on critical care issues. Again, no bragging or arrogance here. That's the way it is...

Anonymous said...

Im not sure how this global 90 day thing works maybe someone could tell me..my husband had colonostaphy and had his colon sticking out his side for 2 months then he had a reversal and had to be open up again right down the middle and put colon back together had bag taken off stitched up were bag was removed. month later we went to family doc and surgeon saying he has a incisional hernia they both told us no he didnt now we went back after the 90 days was over to say that hernia has gotten worse so now they say oh ya you have a hernia. time to operate. so i said we came to both of you a month after saying I had a incesional hernia and you said no. so should that be coverd under the 90 day global because we came to you one month after surgery and told you we had one but you said lets just keep a eye on it..I had ins. at the time of surgery and now I lost my surgery..so i asked if the global will cover this because it happen 1 month later. they said no it only coverd the surgery..well this is the insicion from the surgery..she said that different..is she right dont understand ??