AANS Neurosurgeon | Volume 28, Number 4, 2019

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Neurosurgery: Is Our Specialty Becoming a Commodity?

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In affiliation with the Council of State Neurosurgical Societies (CSNS)

How often have we all heard the phrase “it’s not brain surgery?” Our profession has always been held in the highest respect by the general public. Like a rocket scientist, an accomplished neurosurgeon signifies the pinnacle of professional accomplishment. Over the last decade, the U.S. has seen a rapid increase in the number of health-system mergers and hospital acquisitions (1). The pressure felt by many neurosurgeons because of this evolution in the health-system structure, has led many neurosurgeons to feel as if they are being treated like a commodity, fulfilling the service requirements of the health system(s) with which they are aligned, employed or affiliated. Many neurosurgeons now see their function as a role defined by the health system rather than having self-determination in many aspects of their practice. Changes in the scope of a medical specialty are not unique to neurosurgery. For example, internists now turn over in-patient care of their patients to hospitalists.

Inverse Value
In the past, neurosurgeons have been valued as highly productive and profitable members of health-care teams. Their presence on hospital staff equated to more revenue and prestige for each institution. In capitated systems, the value proposition for neurosurgeons is largely inverse — provision of neurosurgical care is an operational expense for the organization. In this context, neurosurgeons perceive their new status as undervalued, given the high-acuity services many neurosurgeons provide, such as neurotrauma and support for stroke programs.

Health-care systems recognize they need a calculated number of neurosurgeons to meet the needs of their covered lives. The number of neurosurgeons is, therefore, now largely determined by the health-care system. Once that number of neurosurgeons has been recruited, further hiring may not be considered. The traditional neurosurgical guidance for career success, to be “able, available and affable”, is no longer the overriding factor to assure a neurosurgeon’s success in their referral-based practice. The health-care system has increased influence and authority, controlling which neurosurgeons have access to referrals within a community.

The Corporatized Medical Workforce
This has put enormous pressure on the individual neurosurgeon to fit into the more corporatized medical workforce. Based on 2014 data from the Neurosurgery Executives’ Resource Value and Education Society (NERVES), more than 60 percent of neurosurgeons are now employed (2). The employed neurosurgeon often has less control over his or her work environment and cares for those patients whom the hospital system is contractually able to cover — based on the hospital’s negotiations with various insurance panels — often including the hospital’s self-insurance product and their commercial insurance offering.

Several academic neurosurgeons may have recognized a decrease in referrals, since insurance alignments now play a more significant role in directing referrals than individual patients and long established physician-referral relationships. Gaining access to a larger referral pool for tertiary and quaternary services may be limited by the contractual relationships their health-care system has pursued for access to covered lives. In addition, academic neurosurgeons, like his or her private-practice counterparts, are also being measured on productivity and quality- and patient-satisfaction data, which is often viewed as nebulous data. In many centers, this is increasingly replacing traditional academic goals of research, publication and education.

Creating a Perfect Storm
In this era of health-care system consolidation and physician employment, the private practice neurosurgeon may no longer have the ability to attract patients if he or she is not part of a large patient-referral network. This, in addition to decreased remuneration and increased practice expenses, has led many neurosurgeons to hire mid-level practitioners or simply increase their individual workload, rather than bring a new neurosurgeon into their practice. These factors in combination can be viewed as a perfect storm, creating a fixed demand for the total number of neurosurgeons practicing in a given community, leading to decreased opportunity for mobility and new graduate opportunities.

A climate survey was recently done in the northwest region of the U.S. Through aggressive alignment of health-care systems and the creation of hub and spoke models of care, the suburban and rural areas are being staffed often as gateway referral centers to larger institutions. This requires local doctors in smaller areas to either align with larger health-care systems or be excluded entirely from patient-care panels.

Academic subspecialty programs in the region reported struggling to maintain sufficient referrals due to insurance limitations. With both the academic and private neurosurgical practices describing cautious financial conditions, this northwest area has relatively few opportunities for new neurosurgeons who may want to enter practice. New graduates and fellows seeking positions in this region lamented their limited opportunities. These factors also limit patient choice in selecting their neurosurgeon. The climate survey found that health-care panels in this desired geographic area were already filled, and filled panels also impact the negotiating leverage for the current neurosurgeons.

Addressing the Challenges
Patients are losing the capacity to see the neurosurgeon they or their primary doctor choose, and neurosurgeons are losing choice in their practice opportunities. A measurable impact of the commoditization of neurosurgery includes the observation that senior neurosurgeons are choosing to retire earlier in their careers. The most recent NERVES socioeconomic report shows a decrease in neurosurgeons’ salaries for the first time in many years (2).

Addressing these challenges is not an easy issue. It is important to be aware that as a result of mergers and acquisitions and the national trends toward the commoditization of neurosurgery, opportunities for new neurosurgical practices may be more limited and defined by health-care systems, rather than the golden desires of an individual neurosurgeon.

Becoming involved in hospital and health-care system leadership and strategically positioning neurosurgeons on influential committees, such as finance and strategic planning — where decisions are made — should become a focus for each neurosurgical practice (3). Analyzing workforce issues and defining new practice models should become a priority of our national organizations. Neurosurgeons will benefit from closer alliance with other neurosurgeons in their community, which may yield greater benefits than competition when negotiating with health-care systems. Recognizing that neurosurgery has become a commodity is an important first step in looking at solutions for ways to preserve and advance the specialty.

Disclosure: Edie E. Zusman, MD, FAANS, MBA, is a partner of Benzil Zusman, LLC; Healthcare Strategy Consulting

References

1.Kutscher, B. Expect more not-for-profit hospital mergers and acquisitions. Modern Healthcare, October 21, 2014.

2. NERVES 2015 Socio-Economic Survey

3. Zusman, EE. The Neurosurgeon’s role in Integrated Health Systems. Neurosurgery 20 (4): N13-16, April 2012.

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