2. Boise State University, Boise, Idaho, USA
The American healthcare system is in a state of crisis, and through it, the ethical protocols of the medical profession have been called into question. The 50.7 million uninsured Americans,14,24 the rising cost of insurance for individuals and small businesses, hospital inefficiencies and scandals, and the ambiguous relationship shared by the legal and medical professions have made healthcare delivery increasingly difficult for neurosurgeons and other medical professionals to perform their jobs. By scrutinizing the current status of the healthcare system with an understanding of ideals, ethics and the realities of America’s healthcare crisis, adjustments can be made and the integrity of the medical profession can be maintained.
A Critique of the Healthcare Reform: The Search for Unification of Ideals and Realities
Healthcare in America has become balkanized — spread among those who receive it, those who provide it and those who pay for it. The antecedent tenets of healthcare have always been to provide the best care possible. Unfortunately, these principles are becoming obscured by the prevailing and escalating barriers to delivering an affordable healthcare system that functions ethically and effectively. Indeed, the United States is currently immersed in an intense and bitter partisan battle regarding healthcare reform. This debate affects all who provide and receive healthcare. Neurosurgeons are no exception. Every aspect of neurosurgical practice is potentially affected by what Apuzzo referenced as the “upward spiraling of healthcare costs.”2 Accordingly, we will address three of the primary obstacles to achieving the best possible healthcare system: 1) the vast number of uninsured and the insufficiencies of the current insurance system, 2) the erosion of physician trust in a litigious society, 3) and the pervasive, conflicting goals of business and medicine.
The Insurance Entanglement
Historically, the ideology of insurance helped to establish a model for a reasonably well-functioning healthcare system. The insurance industry was created on the premise that within a large group of people, the majority will be healthy (requiring only periodic checkups and medical assistance) and the minority will experience chronic illness or catastrophic injury. Thus, it follows that a large insurance pool should maintain low costs for its clientele while delivering adequate care for those who need it. Nevertheless, the insurance industry in America has become insufficient, antiquated, unreliable and widely criticized. The assumption that medical care is affordable if the consumer has appropriate insurance and is relatively healthy has been corroded. The current industry's dysfunction is exemplified by the fact that even though insured, people who are chronically ill or have suffered catastrophic injury may reach the limits of what their insurance companies will provide, leaving them with unanticipated and often excessive medical charges and restricted healthcare options.15
The number of insured people is split between approximately 850 companies multiplying costs.11 With this system, small businesses and the self-employed make up small groups and pose challenges to insurance companies. Because insurance pool size has a significant effect on the quality and cost of coverage, health insurance places an inordinate burden on small rather than on large companies.10 Insurance companies and businesses have found innovative ways of addressing small insurance pools, but these solutions ultimately regress to one of two forms: increase cost to their clientele or reduce coverage benefits.10 One way insurance companies can reduce coverage benefits is by deeming surgeries and other medical procedures unnecessary or cost ineffective, denying part or all of payment for services.4 Neurosurgical procedures that have gained recent scrutiny from third-party payors include spinal fusion procedures for spinal stabilization, in part due to the increase in the number of procedures performed.17, 3, 21
The Centers for Medicare and Medicaid Services (CMS) suggest that there is a lack of evidence supporting the effective use of lumbar fusion for degenerative disc disease, 7, 3, 21 which affects coverage for some of the procedures.17 In fact, the private insurance Blue Cross and Blue Shield of North Carolina discontinued reimbursement for spinal fusion as a treatment for degenerative disc disease beginning January 2011.5 Moreover, CMS may deny reimbursement if procedures do not follow their pre-set guidelines.
For example, CMS will deny payment if a minimum of a 24 hour admission is not followed after certain spinal surgeries, however, in some circumstances this length of admission is not required for optimum recovery.19 This lack of reimbursement from CMS has been attributed to a lack of evidence in research and corresponding lack of consensus as to what constitutes best practices in neurosurgery.4
Another way that insurance companies can reduce their expenses is by decreasing the amount they reimburse for procedures, which has notably affected neurosurgery. For example, the reimbursement for lumbar laminectomy declined by 30 percent between 1992 and 2003.27 Although the expectation is for increasing reimbursement as the cost of living increases, as of 2011 the payment is still 20 percent lower than in 1992.6 This is not an isolated case: in 1997 the reimbursement was $1,705 for posterior lumbar interbody fusion, $1,205 for lumbar discectomy and $1,662 for anterior cervical fusion.16 In early 2011, reimbursement for these procedures was approximately $1,561, $981 and $1,284, respectively.6 This is a decrease of 8 percent for posterior lumbar interbody fusion, 18 percent for lumbar discectomy, and 23 percent for anterior cervical fusion. While the reimbursement to neurosurgeons is lower, the payment to hospitals for these procedures has increased annually, meaning that the neurosurgeons are receiving a smaller percent of the payment.16
Insurance companies can increase cost to their clientele through administrative expenses, which represent as much as 11 percent of the price of an insurance plan or as little as 0.5 percent.10 The discrepancy among rates has been attributed to differences in risk management and negotiating costs.10 However, if this were true, it follows that the bulk of administrative costs should be one-time fees paid when insurance coverage is purchased.
The rising numbers of the uninsured (estimated 15 percent of Americans) has further complicated healthcare delivery. These Americans are more likely than their insured counterparts to forego regular visits to a healthcare provider, sacrifice basic and preventive treatment options, and to die in the emergency department.10 Moreover, when those who are uninsured receive medical treatment the costs inequitably burden an already overburdened system.10
The Image of the Physician: To Trust or Not to Trust
As an integral member of the scientific establishment, neurosurgeons have a well-founded credence in empiricism, and as healthcare professionals they are bound by established codes of ethics. Physicians have long been trusted to diagnose and treat patients accurately. However, this faith has been tarnished by non-medical entities such as the legal and business edifices that intrude into the medical sphere.22
The progressively litigious American society has focused on arbitrary and capricious determination of medical negligence.22 In reaction, malpractice insurance rates have radically escalated. This legal turmoil diminishes public trust in healthcare by adding a new element: defensive medicine; which may be one of the most troubling results of the erosion of public faith in healthcare. This practice is not to ensure the health of the patient, but rather is performed to safeguard against legal liability.26 There are three main ways in which the practice of defensive medicine harms the healthcare system: 1) it compromises the physician’s reliance on his or her instincts;23 2) diminishes public perception of the medical establishment; and 3) places emphasis on potential legal repercussions in the case of failure instead of the well-being of the patient. 22, 26
One area of neurosurgery that has been notably affected by defensive medicine is the disincentive for surgeons to be available for on-call emergencies. It is well established that with emergency cases comes an added risk for medical liability, especially in pediatric neurosurgery, along with an often low reimbursement for services.9,12,25 This financial environment has discouraged some neurosurgeons from taking emergency calls. A survey of neurosurgeons estimated that emergency pediatric calls were not taken in up to two-thirds of those polled.9
The shortage of specialists willing to be on call for emergencies has been partially attributed to medical liability, with one study reporting that exiting surgical residents are less likely to practice in areas with higher malpractice insurance premiums.8 Defensive medicine not only contributes to specialist shortages, it reflects poorly on the ability of an individual physician and on the medical establishment itself. Moreover, it undermines physicians' efforts to promote equitable access to healthcare and denigrates the doctor-patient relationship — the very ideal medical reform intends to protect.26
The Hospital Setting: Marriage of Business and Medicine
The rising costs of healthcare, insurance coverage and dwindling tax revenues have made it increasingly difficult for states, churches, and schools to maintain funding for hospitals. As the expense of healthcare skyrockets, the potential for hospital privatization also increases. The amalgamation of business and medicine has facilitated the development of new technologies; however, it has raised numerous ethical questions and conflicts of interest. Potential conflicts of interest may arise in the seemingly insignificant gifts and samples from pharmaceutical and device companies, or may be extensive, including physician ownership in stock or even business ownership.18
Many argue that financial incentives to use a specific company's product over another, equally effective product may create biases and interfere with the physician-patient relationship.18 More importantly, physicians have developed innovative ways to make a profit, despite declining reimbursement, in the form of physician-owned hospitals. Through self-ownership, physicians have the flexibility to set their own reimbursement schedules and choose which companies to purchase medical devices and technology from.16 Allowing physician ownership of hospitals raises concern for the potential to have unethical conflicts of interest from increased profits through self-referrals and bias in selection of which corporation to purchase equipment from.13 One study, conducted in Florida, showed a greater utilization of five common procedures in physician-owned outpatient centers than in hospitals with outside ownership.13 This situation raises questions regarding the justifications and requisite for the variance in procedures.
Ethical questions have been raised when spinal surgeons in America continue to receive research and administrative funding for procedures propelled by implant companies, even though the literature outlines abuses observed with physician ownership. A recent example is the focus on the hospital in Kentucky that was ranked third in the nation for number of spinal fusions performed between 2004 and 2008 on people with Medicare.5 During this time the national average for spinal fusions performed on those with degenerative disc disease was 17 percent of all spinal fusion surgeries, but that amount was 24 percent at this hospital in Kentucky.5
In addition to the scrutiny on the sheer number of surgeries conducted, the spine surgeons received criticism for the royalties they earned from the device company, totaling over $7 million for five physicians. However, the physicians state these earnings were related to new product design and did not influence their treatment decisions.5 This is a complex situation because physicians do not typically have the resources to independently design new devices.1 Utilization of medical technology is important in establishing best practice standards; however, safeguards are essential to discriminate business’s influence on treatment decisions.4
Further complicating the relationship between business and medicine, federal law requires hospitals to provide treatment to the ill and injured regardless of ability to pay. At the same time, hospitals (regardless of whether designated nonprofit) must be constantly cognizant of the economic bottom line. There are direct and significant losses every time an uninsured person presents for treatment. Hospital profit margins provide a clear disincentive to admit people without insurance and some hospitals are responding to this problem in a variety of ways. For example, is it is becoming increasingly common for hospitals to deport illegal immigrants with chronic illnesses and massive injuries to their homelands where adequate medical facilities and opportunities for treatment may be limited.20 The symbiosis of business and medicine in these instances has saved businesses money but has not enhanced the practice of medicine and its basic tenets.
Finding a Course of Action
As physicians, we have a commitment to maintain the integrity of the medical profession and uphold the tenets the profession was built on in order to provide the best care possible. There have been a number of proposals for healthcare reform in recent years to address the number of uninsured, the rising costs and the ethics of healthcare delivery, yet none have gained full support by all medical professionals.
One proposal, by Dr. E Emanuel, gives Americans a variety of options to choose from, including the maintenance of one's current insurance policy, and reduces the overpriced administrative costs subscribers currently pay. The proposal frees business from the obligation to provide healthcare plans to employees; however, the model is unlikely to actualize in the current political climate without the advent of complete healthcare reform and government intervention.
Complete healthcare reform makes ethical sense in that it could encourage the physician-patient relationship under the auspices of medicine, liken to the tutorials of neurosurgery. Under a national insurance program, the question of who would pay for medical care would cease to play a significant role in the treatment of patients. However, this approach bounds with ideology and less with practicality and pragmatism. We believe neurosurgeons need to play a significant role in healthcare reform. With the rising costs of care related to advancements in medical technology, neurosurgeons are poised to focus on providing an example of assessment of their own practices to develop best treatment standards to keep costs affordable.
Predicting the endpoint of healthcare policy may be just conjecture, and gain little attention. Presenting the facts of declining reimbursements, increased scrutiny, and a system based on merit is much more accepting to patients and physicians alike. Reminding neurosurgeons of their duties is always good. Our prediction could be that there will be a separation of wheat and chaff, and a return to patient emphasis and mindedness.
Author Biography: Christian G. Zimmerman, MD, MBA, FACS, is System Executive Director of Research, Health Policy, and Quality Recognition at Saint Alphonsus Regional Medical Center in Boise, Idaho. Pennie S. Seibert, PhD, is Chief Research Scientist at Physician Research Services, Saint Alphonsus Regional Medical Center in Boise Idaho, and professor at Boise State University, Boise, Idaho.
CMS: Centers for Medicare and Medicaid Services
Conflict of Interest/Investment/Financial Disclosure: The authors report no conflict of interest that may influence the content of the article being submitted.
Key Words: Healthcare; Reform; CMS; Neurosurgical Reimbursement; Neurosurgery; Ethics
1. AANS Neurosurgeons and industry policy statement. AANS Position Statement: 2007 Aug 24
2. Apuzzo MLJ: Healthcare reform in the United States 2010: An academic neurosurgeon's perspective. World Neurosurg. (1)74: 1-2, 2010
3. Ault A: Spinal fusion for back pain retains CMS coverage. Internal Med News. March 1, 2007
4. Barker FG: Pursuing excellence in healthcare delivery: American neurosurgery. Clin Neur. Volume 57:60-68, 2010
5. Carreyrou J & McgGinty T: Top spine surgeons reap royalties, Medicare bounty. The Wall Street Journal. December 20, 2010
6. Centers for Medicare and Medicaid Services: 2011 National Physician Fee Schedule [RVU11AR]. Released 12/21/2010. https://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4
7. Centers for Medicare and Medicaid Services: Potential NCD topics. http://cms.gov/medicare-coverage-database/details/medicare-coverage-documents-details. September 30, 2008
8. Chou CF & Lo Sasso AT: Practice location choice by new physicians: The importance of malpractice premiums, damage caps, and health professional shortage area designation. HSR: Health Serv Res. 44:4, 2009
9. Couldwell WT & Seaver MJ: Practicing neurosurgery in the United States. AANS Neurosurgeon: Issue 17(3), 2008
10. Emanuel E: Healthcare, Guaranteed. New York: Public Affairs, 2008
11. Enthoven AC & Fuchs VR: Employment-based health insurance: Past, present, and future. Health Affairs, 25(6):1538-1547, 2006
12. Fischman J: Get me a neurosurgeon, stat! U.S. News & World Report. 142.4 (2007): 38
13. Hollingsworth JM, Zaojun Y, Strope SA, Krein SL, Hollenbeck AT, and Hollenbeck BK: Physician-ownership of ambulatory surgery centers linked to higher volume of surgeries. Health Affairs, 29(4):683-689, 2010
14. Johnson A: Recession swells number of uninsured to 50.7 million. The Wall Street Journal. September 17, 2010
15. Jones EC & Amery M: Health care reform: What it may mean for your practice. Neurology Clinical Practice. 75(Suppl 1): S52-S55, 2010
16. Pelofsky S. Neurosurgeons should create and own spine hospitals. AANS Bulletin: Issue 16(2), 2007
17. Przybylski GJ: Concurrent spinal procedures - Coding frequently changes for established procedures too. AANS Bulletin: Issue 15 (2), 2006
18. Robertson JH: Neurosurgery and industry. J Neurosurg 109:979-988, 2008
19. Schuler TC: Conflicting forces impact the future of spinal health care. J Spinal Res Found. 5(1):3-4, 2010
20. Sontag D: Immigrants facing deportation by U.S. hospitals. The New York Times. August 3,2008
21. Spinal fusion under the microscope. OR Manager. 23(3):5-6, 2007
22. Studdert DM, Mello MM, Brennan TA: Medical malpractice. New Engl J Med. 350(3):283, 2004
23. Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, Brennan T: Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. Am Med Assoc. 293 (21):2609-2617, 2005
24. U.S. Census Bureau. Income, poverty and health insurance coverage in the United State: 2009. September 16, 2010
25. Watts C: Are payments for neurosurgical on-call services legal? Surg Neur. 71:725-726, 2009
26. Weinstein SL: The cost of defensive medicine. AAOS Now Issue November 2008.
27. Wohns RNW: When neurosurgeons drop cranial surgery privileges - what role might microeconomics play in their decisions. AANS Bulletin: Issue 4(4), 2005