Some critical issues have come to my attention in relationship to the delivery of trauma care in Nebraska, a mostly rural state. An issue I was able to bring to the attention of one of our senators at the 2001 Neurosurgical Leadership Development Conference (NLDC), I think with some success, was the consequences resulting from a request by a hospital in one of our modest-sized cities to go from a level-three to a level-two trauma center. If the request were granted, the only neurosurgeon in town would then be required to be on call 24 hours a day, seven days a week, 365 days a year. Both he and I tried to explain to the hospital that this was an impossible task. The hospital wanted to require this effort of the neurosurgeon without any additional reimbursement. After negotiations failed over a considerable period of time, the neurosurgeon decided to move to another community because he did not think he could manage the obligations the hospital was requiring of him without getting into legal jeopardy, not to mention the arduous burden the requirement would put on his family and practice.
EMTALA Consequences Affect Rural Areas
This situation exemplifies the unintended consequences of the Emergency Medical Treatment and Labor Act. John Kusske, MD, and others in California have told me this legislation has placed a burden even on neurosurgeons serving urban areas. If neurosurgeons are going to be required to provide these on-call services, then we need to aggressively convince federal, state and local officials that adequate reimbursement is needed. This issue should continue to be at the top of the AANS/CNS Washington Committee’s agenda.
Another example is a case I recently reviewed in which a family had brought a lawsuit in response to a lack of neurosurgical coverage. The family member had sustained a head injury and was to be taken to a level-two trauma center that had two neurosurgeons, one of whom was away on vacation. But because the hospital and ICU were full, the patient was flown to a facility that was much farther away. The patient arrived there, received neurosurgical treatment and survived, but in a compromised state. Was there a problem with the trauma system or neglect by the physicians in this community of less than 10,000 people in taking care of this patient?
I was able to review the case and found that there was no negligence, but nonetheless here is another situation in a less densely populated area where there is not an adequate amount of neurosurgeons to provide services. Patients need to be able to access neurosurgical care quickly, and we cannot have regulations driving neurosurgeons out of smaller communities. There must be a way to reimburse neurosurgeons for all the time they are spending taking care of these complex and time-consuming trauma cases. I would also point out the patient in this case was self-pay. Most neurosurgeons would understand what the reimbursement level for that effort is going to turn out to be.
Malpractice Premiums Threaten Rural States, Too
A medical liability crisis is arising, much as it did in the 1960s, with neurosurgeons facing steeply increasing insurance premiums. In Nebraska a cap law has limited payments in professional liability cases. When I first moved to Nebraska in 1978 the cap was $1 million, and a few years ago it was raised to $1.25 million to account for inflation. There may be a move to make it $1.5 million, also based on inflation, but the individual physician only has to pay the first $200,000 and then the state superfund will pay the remainder. The Nebraska Supreme Court is now considering a case in which a family was awarded between $5 and $6 million, but the cap law would only allow the distribution of $1.25 million. The court’s decision, expected in the summer of 2002, may throw out the cap law. I harken to the Pennsylvania area, where, as in many other states, rising malpractice insurance premiums place an onerous burden on neurosurgeons.
The neurosurgiical community must be vigilant about these issues so they can be addressed before they harm the delivery of neurosurgical care. Resolving these problems requires good attendance at the NLDC July 19-23, 2002, in Washington, D.C., to develop advocates for neurosurgery in every state because many of these issues are decided at the state, not national, level.
Lyal G. Leibrock, MD, FACS, is immediate past chairman of the Council of State Neurosurgical Societies and chairman of neurosurgery at the University of Nebraska Medical Center.