-Harvey Cushing
Whatever the exact type of practice, neurosurgeons work hard to ensure payment for professional services. After all, the Talmud states that “a physician who does not demand to be paid does not deserve to be paid.” There are coding courses, books, software, consultants, billing managers, and so on, all part of the third-party reimbursement system. We do our best to eke out the maximum we can under the rules while insurers do their best to pay us the minimum possible. If only we could return to a kinder, gentler time….
Doctors used to provide a fee schedule to prospective patients. For emergency care, payments were collected when possible from patients or families. The Newark Medical Association published such a schedule in 1853. It recommended $1 for a consultation, $2 for leeching, and between $20 and $100 for (yes) trephination. When a family could not afford the full amount, they paid what they could, provided something as barter, or the surgeon waived his fee (working pro bono, “for the good”).
Harvey Cushing benefited from the system of private practice in place at Johns Hopkins Hospital as he began his career in brain surgery. But he certainly was not immune to the vagaries of practice, noting in 1907 that “people are slow in paying their bills these days.” This required him to seek a handout from his obstetrician father.
R.M. Peardon (Pete) Donaghy was a pioneer in microneurosurgical technique at the University of Vermont. His online biography (www.med.uvm.edu/neurosurgery/donaghy.html) notes how he survived medical school in part by free access to milk from the UV dairy school. Years later, upon his appointment as chair of the new neurosurgery department, the dean suggested that vegetables from the school of agriculture could defray part of his salary.
Managing a practice has always been a part of medicine and of neurosurgery. Neurosurgeons’ income increased as a result of the modern insurance system and now is threatened by it. “Boutique” practices that charge well-heeled patients to pay as they go may satisfy certain medical groups, but it is doubtful that this solution would work for most neurosurgeons. Fresh milk and vegetables, anyone?
Michael Schulder, MD, is associate professor in the Department of Neurological Surgery and director of image-guided neurosurgery at UMDNJ-New Jersey Medical School.