AANS Neurosurgeon | Volume 26, Number 2, 2017

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The Financial Impact of Concurrent Surgeries

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The topic of overlapping surgeries –  two surgeries that are ongoing on two different patients at the same time — is challenging for the surgical field. Patient advocacy groups suggest that overlapping surgeries place patients at risk, given the need for the attending surgeon of record to split time between multiple operating rooms, leaving portions of the surgery in the hands of a trainee or mid-level. Surgeons and hospitals contend that the practice is safe and is meant to ensure that the critical portion of the case is performed directly or through supervision by the attending surgeon of record.

The financial impact of concurrent surgeries, and most specifically banning the practice of overlapping surgeries, has not been quantified. The Senate Finance Committee, in a report on the subject published on Dec. 6, 2016, stated “a number of patient advocates… raised concerns to the Committee that the primary motivation for a surgeon to conduct concurrent surgeries was financial, enriching surgeons at the expense of patient care.” Allowing more than one operating room at a time would theoretically increase throughput and generate increased revenue. However, enhancing throughput can also be seen as a way to improve productivity and efficiency and reduce patient delays accessing care.

Given publicly reported data, there were approximately 26 million surgeries done in American hospitals in 2014. During their investigation, the U.S. Senate Finance Committee requested data from 20 teaching hospitals; of the hospitals that reported estimates of the percentage of overlapping surgeries performed from January 2015 through March 2016 hospital-wide, those percentages ranged from less than 1 percent to 33 percent of all surgeries.

Interestingly, it seems that surgeons who perform overlapping surgeries tend to be concentrated. Data from one hospital reviewed by the Senate Finance Committee showed that 9 percent of all surgeries were overlapping but among the subset of surgeons that performed overlapping surgeries, 46 percent of surgeries were overlapping. According to publicly reported data, patients are sharing their surgeon for some part of the case 15 percent of the time at Massachusetts General Hospital (MGH) and Cleveland Clinic, less than 10 percent at the University of California San Francisco and roughly 4 percent at Tufts Medical Center.

According to the Senate Finance Committee, of the hospitals that had processes to authorize surgeons to schedule surgeries in two operating rooms at the same time, only a fraction of surgeons were so authorized by their hospital. Given this information, it is difficult to express the financial burden limiting this practice. At a hospital, if a certain proportion of surgeons are currently performing overlapping surgeries, then restriction of this practice will lead to halving or perhaps decreasing by two-thirds the volume of surgeries performed depending on whether two or three rooms are utilized. This translates into lost revenue for the hospital and, for the patient, would mean further delays in scheduling surgery.

Part of the intent of the Finance Committee’s hearing was to determine whether there should be revisions to the way in which overlapping surgeries were reimbursed. Specifically, Finance Committee staff had concerns as to whether the Centers for Medicare & Medicaid Services (CMS) had taken steps to determine whether the existing billing requirements applicable to teaching physicians in hospitals are or are not being followed. Additionally, they were concerned that CMS’s billing requirements are applicable only to teaching physicians operating in hospitals. At present, there are no billing stipulations preventing a surgeon from billing for two or more concurrent surgeries in non-teaching hospitals or in ambulatory surgery centers. Given these concerns, the Finance Committee staff recommended first that the Health and Human Service Office of the Inspector General undertake an evaluation to review the controls in place to ensure that hospitals and physicians are appropriately billing for physician services provided by teaching physicians. Second, that the Administrator of CMS review the agency’s billing requirements for services performed by teaching physicians to determine if those requirements should be established for non-teaching hospitals and other types of surgical centers.

Since the practice of overlapping surgeries occurs across many Medicare-reimbursed institutions across the country, the surgical community will have to continue to follow a vigilant “wait and see” mindset in response to these challenges as they arise. 

References
1. United States Senate Finance Committee. Overlapping surgeries: Additional measures warranted a senate finance committee staff report. Dec. 6, 2016.

2. Abelson, J., Saltzman, J., Kowalczyk, L., & Allen, S. (2015). Clash in the name of care. Boston Globe.

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