Academic neurosurgery is currently facing perhaps its greatest challenge. In more than half a century of existence, many economic, political and social factors have converged on the academic environment, particularly for neurosurgery. The ability of academic neurosurgery to cope and succeed in this environment is mandatory. Many academic institutions are seeing an increased vulnerability to stresses in the medical environment. This is inextricably tied to an increased level of bureaucracy. Some of the factors affecting this process are addressed here.
Negative Factors Impacting Academic Neurosurgery
- Diminished Revenue. Many neurosurgical programs are facing deep financial trouble as a result of declining reimbursement for services. This, combined with the growth of managed care, soaring University taxes and cuts to Medicare funding, has caused many Program Directors to pull back the reigns on funding for resident education, capital equipment, travel and educational seminars.
- Contract Negotiations.Institutional fears regarding political and social issues have diminished the role of the neurosurgeon as a negotiator with third-party payers. In essence, the neurosurgeon’s hands are tied; he has no choice other than to enter into suboptimal contracts with suboptimal reimbursement and excessive clinical obligations.
- Billing and Collection Deficiencies. Institutions that are less privatized usually have less efficient billing and coding systems. Collection rates in University systems are notoriously less than other comparable systems. This, combined with the often exorbitant costs associated with reimbursement services, can result in an excessive overhead/reimbursement ratio.
- Taxation. Excessive taxation brought on by the Universities and state government can increase the overhead of an academic neurosurgical program to unacceptable levels. In some cases, the sum total of this taxation can reach fifty percent of collectible dollars.
- Lack of Empowerment. Department Chairmen are facing their jobs with an ever-decreasing ability to efficiently carry out their mission. In fact, their missions are often unclear. Division Chiefs also are often emasculated in their ability to seek funding for clinical or research endeavors and to function as faculty and resident advocates.
- Inefficient Operating Systems. The function of the inpatient, outpatient and operating room components of patient care become increasingly less efficient as the bureaucratic nature of a system increases. The time and effort required to compensate for the inefficiencies of neurosurgical faculty and residents can be excessive.
- Dwindling Research Dollars. Research and publication are becoming less fiscally rewarded, while the expectations for such are unchanged. This, combined with increasing revenue generation pressures, creates a situation where the time and energy available, as well as the reinforcements for research and creative thought, are diminishing.
- Decreased Resident Responsibilities. The clinical responsibility of neurosurgery residents has been reduced. They no longer can assume the complete care of the patient. This increases the faculty obligation to a greater role. In addition, it diminishes the reward of resident education, while increasing the work and effort required for such.
- Increasing Liability. Medico-legal liability is increasing, particularly in institutions where ancillary support is low. This exposes the neurosurgeon to increased responsibility and risk. Universities are usually the institutions that care for excessive and indigent patient loads. These patient populations tend to be more litigious.
- Fraud and Abuse Issues. Fraud and abuse issues raised by third-party payers, particularly federal reimbursement agencies, are oof great concern to neurosurgeons practicing in bureaucratic academic environments where the checks and balances are often inadequate. A neurosurgeon’s efforts to compensate for such, and the stresses that fraud and abuse accusations present, can be excessive.
Survival of the Fittest
Institutions and programs that can decrease the bureaucratic overhead and liability of clinical care, and also streamline basic science and clinical research productivity, will fare the best in years to come. Creativity regarding physician reimbursement is required. This will probably involve increasing a neurosurgeon’s independence in state institutions. Divisions of neurosurgery must become departments or increase autonomy to function as such. If this does not transpire, the stifling nature of academic medicine will put out the fire of academic neurosurgery.
New sources for neurosurgical basic science and clinical research must be sought. Industry support and partnerships must be developed and nurtured. Moreover, patient care and research performance should be streamlined and its efficiency increased. Institutions must dedicate increasing funds to the resident and faculty core that supports them. This includes, in particular, the funding of research and the provision of time for creative thought.
Edward C. Benzel, MD, a neurosurgeon in academic practice for nearly 20 years, is Professor of Neurosurgery at the Cleveland Clinic Foundation and Chair of the AANS Professional Development Program.