The End of Delayed Gratification

Perhaps no greater stimulus for performing difficult tasks exists that are to become a person's vocation is that of delayed gratification. Successful lawyers, financial analysts and business people know this. But few are more a master of delayed gratification than a physician with their long, poorly-paid residencies - even more: surgeons.

The profession of surgery, after all, is a hands-on endeavor, involves countless hours at the patient's bedside and even more in the operating room to perfect the craft. The weeding process of individuals to find those with the "right stuff" to become a surgeon is remarkable: only the strong survive. Admittedly, that "worth" to some is just to have a nascissitic "bragging right" to calling themselves "surgeon" or the altruistic and admiral goal of being skilled at helping one's fellow man. But in the end to many, it is the hope that some day their efforts will pay off personally and financially. To this end delayed gratification, the hope that some day it will all be worth it, plays a significant role is helping an individual complete the training gauntlet.

But these times are difficult for anyone contemplating becoming a physician, let alone a surgeon. The commoditization of the profession, the ever-increasing regulatory environment, the decline of revenue, and the rise of liability - all serve to remove the carrot of delayed gratification dangling before the horse.

Josef Fischer, MD's excellent commentary appearing in the Journal of the American Medical Association last week illuminates the issues:

In the United States, approximately 1000 general surgeons complete their residency training each year. These surgeons have completed 4 years of medical school and 5 clinical years of residency, and during residency many also have spent 1 or 2 years in a research laboratory. Thus, these physicians enter the workforce between the ages of 33 and 35 and usually have $150 000 to $250 000 in educational debt. (editor's comment: some have suggested this number is MUCH higher) The training of surgeons has been stable since the early 1970s, and the number of general surgery residency training programs will not likely increase. Even if new medical schools were established the number of surgeons trained would not likely increase much, because many medical students have lost interest in pursuing a career in surgery.

In small urban or rural hospitals, which care for approximately 54 million patients, general surgeons care for emergencies and trauma and perform a variety of operations. They are essential to the provision of adequate health care and often are the most well-rounded surgical clinicians in the area. Therefore, training only 1000 general surgeons per year will not meet demands. Specialization also affects the general surgical workforce. Presently, approximately 70% of graduating surgical residents pursue specialized surgery training, and this percentage may be increasing. Thus, only about 300 to 400 of the 1000 general surgeons completing residency each year will choose general surgery practice.

But the historical and future impacts of reimbursement for surgical services is articulated nicely by Dr. Fischer and spells the end of any hope of delayed gratification for surgeons:

In 1993, Congress declared a redistribution of funds from proceduralists to primary care physicians.10 Initially there were 2 conversion factors—1 for medicine and 1 for surgery. The conversion factor, ie, the multiple of the RVU for payment, had the added advantage of demonstrating where costs were increasing. The 2 conversion factors demonstrated conclusively that surgeons did not increase their utilization when reimbursement decreased (because, for example, patients have only 1 gallbladder, and the indications for its removal remain constant). Other specialties increased their utilization, a process that continues to this day.11 In a refining effort to shift money to primary care, a third and separate conversion factor was developed in 1995. By 1997, it was clear that separate conversion factors were not controlling utilization of primary care and medicine services, causing these 2 conversion factors to decrease. The 3 separate conversion factors were eliminated in 1998, resulting in a decrease for surgery and an increase for medicine and primary care. In addition, more surgeons' practice expense reimbursements are included under the indirect category, now reimbursed at 35% of cost; internists and primary care physicians have a higher percentage included as direct expenses, which are reimbursed at 66%.

A recent Medicare Program review focused on concern about patients with chronic conditions and on compensating the physicians who care for them, not on the technical aspects of Current Procedural Terminology. Seventy-eight percent of Medicare beneficiaries have 1 chronic condition. By contrast, 63% of beneficiaries have 2 or more chronic illnesses; caring for such patients accounts for 96% of Centers for Medicare & Medicaid Services expenditures. It was proposed that patients with chronic disease were not receiving care because physicians were underpaid. The most frequently billed code in the physician fee schedule was revalued upward, and payment was increased by 37%. This year, the estimated $4 billion impact of the proposed changes in work RVUs resulting from the 5-year refinement will require that a budget neutrality adjustment be made.16 Fees for certain procedures, specifically for malignancies in women such as hysterectomy (–4.7%), partial mastectomy (–5%), and resection of ovarian carcinoma (–2.9%), decreased between 2006 and 2007.

In addition, the 90-day global period means that no additional payments will be made for any physician services that can be associated with the initial procedure, regardless of how much work the follow-up entails. Other physicians can see patients daily for the same illness or situation and can bill and collect each time.

No other profession or situation apart from medicine experiences denial of payment for services already performed. (ed: emphasis mine) At times, it seems that health insurance companies employ staff whose only goal appears to be to deny payment for services already performed.

These sequential decreases in reimbursement provide a substantial disincentive to enter these branches of surgery and may have profound future consequences. The self-designated specialties of internal medicine, medicine, and pediatrics have substantially increased members since 1985, while general surgery membership has remained level.

While I appreciate all of the new health care proposals to provide univeral health care (and certainly our system is broken), unless we address the shortages of physicians in general, we won't have professionals where the rubber meets the road: that is, physicians capable of performing the remarkable skills to which we and our health care system have become accustomed. Without them, the final policy enacted won't be worth the pile of paper upon which it is penned.

-Wes

Reference: Josef E. Fischer, MD. "The Impending Disappearance of the General Surgeon." JAMA. 2007;298(18):2191-2193.

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