Sunday, September 9, 2012

Inevitable

With the coming advent of Accountable Care Organizations and the re-branding of capitation under the banner of "cost containment", the Surgeon realizes his days as an independently practicing general/trauma surgeon are probably limited.  He understands that the only way to make the coming paradigm work (where health care spending is capped for specific inpatient admissions) is if all the doctors are employees.  The idea is to eliminate the stake for physicians.  If you are employed, then it doesn't matter to you if the employer stops getting reimbursed after a set spending limit during a long, complex admission.  You get paid the same no matter what.  A non-employed surgeon who gets asked to see a decrepit old ICU patient with free air at two in the morning when said patient has already gone past the reimbursement cap will be none too happy when he finds out he will get paid zilch for his troubles.  The employed surgeon couldn't give less of a shit. 

The Surgeon understands this "solution" as a quintessential deferral of responsibility.  The main issue (performing unnecessary surgeries, providing futile care, ordering unnecessary tests) is kicked down the road.  All that is addressed is the cost issue; to the extent that, mathematically, final hospital tallies will end up being reliably less than before.  It is so much easier to declare, by fiat, that all this unnecessary medical care that occurs in the USA, especially in the last 6 months of life, will henceforth be written off, a victim of capitation, rather than to delve into the dark quagmires of rationed medicine and recognizing the limits of modern science.  Much more difficult to catechize a generation of physicians who are not afraid of limits, of death, of the futility of efforts--- once a certain line has been crossed---- who are willing to see this calling as something far nobler than an income stream worked in shifts.  And even more difficult to inculcate such complexity of thought in the mind of the general American populace.       

It's pure cowardice.

6 comments:

Attorney Andy said...

If your days are numbered, it suggests that you are only a physician because you want to get paid. Aren't you going to make that 2am visit even if you're over the spending caps if you know that you can intervene in a meaningful way for the patient? It might burn your ass later to know you didn't get paid, but I'm guessing the paycheck isn't what gets you out of bed. If it was only about the paycheck, you'd be a dermatologist in Florida.

Joseph Sucher, MD FACS said...

The Surgeon has a good point. But his line of argument is built on shaky ground. Let's first start with agreeing that the future of healthcare is uncertain, at best.

Nonetheless - I take issue with the Surgeon's statement of "The employed surgeon couldn't give less of a shit". This divisive rhetoric has no proof or basis in reality. Employed, or not, surgeons remain distinctly individual. Employment, in and of itself, does not a bad surgeon make. In fact, it may just end up being the opposite. Yikes. I said it. But yes, being an employed surgeon might, in fact, place that surgeon under more scrutiny to do the "right thing". This goes past the grotesquely mediocre "peer review" panel / quality control committee that has proven to be less than effective on removing known "bad actors" from the hospital stage. But I agree that employed surgeons could find themselves in a "shift work" type of setting. Here is where the sticky wicket lies. The shift worker mentality is what we don't want to see in surgery. Once that line is breached, the profession will be in peril.

This is a very important topic. But there's much to praise AND bemoan about both sides (private practice versus employed practice). Despite the fact that I've been employed my entire career, I see the great positives of the private practitioner. The two have co-existed for many decades. I think it should remain that way. But alas, the tsunami approaches.

Buckeye Surgeon said...

Good points Joe. "couldn't give less of a shit" is poorly phrased. I was trying to convey the idea that an employed surgeon wont be affected by the relative status of the patient's spending cap. He/she gets compensated as per contract. A private surgeon who provides free care not because the patient is without insurance or adequate funds, but because of arbitrary government dictate, is going to grow disillusioned.

Further the "quarterback" is going to be less likely to consult a private surgeon \, knowing the responsibility for cost containment falls on her shoulders.

Andy- I get out of bed as it is now---- for the self pays who show up at 3 am.

Point is that we neglect to instill values into our physicians. As long as costs are contained no one cares if we train a generation of who are more accountable to the bottom line rather than to the patients.

Buckeye Surgeon said...

"Ambivalent" probably a better word choice, Joe.

Joseph Sucher, MD FACS said...

aI don't know.... "Inevitable" seems more correct...

Anonymous said...

Two surgeons walk into a bar...

-SCRN