We have heard that neurosurgeons are key economic drivers within a hospital, not only because neurosurgical procedures tend to reimburse the hospital more favorably than other fields’ procedures but also because of the downstream revenue incurred due to neurosurgical care (follow-up imaging, physical therapy, occupational therapy, rehabilitation, etc.). Subspecialization within neurosurgery can have a financial impact on the individual neurosurgeon and the hospital or group.
The Generalist Neurosurgeon
Historically, given how small the field of neurosurgery has been, the training philosophy had favored more broad-based expertise without attention to subspecialization. If the already small field of neurosurgery branched into multiple subspecialties, the fear was that there would be too few practitioners to meet patient demand and that each subspecialty function would be absorbed within other disciplines, such as general surgery or orthopaedics. However, over time, there has been a growing appreciation that subspecialty training deepens specific areas of expertise and does not necessarily have to compromise the ability of a neurosurgeon to remain cognizant of and proficient in providing broad neurosurgical care.
Supply and Demand
When the financial potential of subspecialization is considered, it is important to contemplate supply and demand. For instance, in recent years, pediatric neurosurgeons were in short supply. Subsequently, as more trainees gravitated towards pediatric fellowship training, there was a glut in the market making it difficult for newly minted pediatric neurosurgeons to find a position, especially in academics (1).
Salaries and Reimbursement
Salaries are driven by revenue generated for the practice or the hospital. The revenue generated is correlated with reimbursement for the procedures performed. There are several considerations regarding this. First, reimbursement for some types of surgeries (e.g. instrumented spine) is much higher than for other types of surgeries (e.g. carotid endarterectomies). This has to do with the current procedural terminology (CPT) coding infrastructure and the physician fee schedule. Second, the payor mix of the patient population treated by a certain intervention also influences the revenue generated. Among pediatric patients, Medicaid is a notoriously poor payor compared to private insurance. Thus, pediatric neurosurgeons tend to net less for a hospital than other subspecialists. Third, net hospital or practice revenue can be negatively affected within subspecialties relying on device implantation. For instance, among Deep Brain Stimulation (DBS) patients who may be treated for Parkinson’s disease, many tend to be over 65 years of age and are therefore Medicare patients. Medicare’s payment to a hospital for implantation will not provide extra for implantation costs related to the lead and battery. Many hospitals negotiate on a six to 12 month basis with device makers to obtain competitive pricing on implantable devices. These costs can also negatively impact the net revenue generated for a hospital or practice, and thus, impact the salary of individual neurosurgeons.
Practice Type
In a fee for service world, private practices lend themselves well to subspecialists who focus on surgical interventions without much multi-disciplinary involvement and with relatively short operative times to generate increased volume. For instance, instrumented and non-instrumented spine, endovascular interventions and radiation therapies, such as Gamma Knife, are considered profitable through this framework. Subspecialties that require the involvement of other disciplines, such as neurology for many functional neurosurgical programming applications, neuro-oncology and pathology for tumor neurosurgery and pediatricians and pediatric intensivists for pediatric neurosurgery, lend themselves well to large group practices or academic practices. Practice type is related to earning potential, since academic practices tend to pay less than private practices, due to compensated time for less lucrative activities such as research and teaching.
Your Career
None of us lives or works in a vacuum. You have to consider the practical realities of the marketplace and your work environment as these relate to your degree of subspecialization (ranging from none to max). In the end, though, as in all other aspects of neurosurgery and life, success will flow from your passion and commitment to your daily activities.
References
1. Darves, B. 2015. Tracking the neurosurgery subspecialties. Neurosurgery market watch, 5(1).
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