In the Spring 2005 Bulletin, Education Editor Deborah L. Benzil, MD, related two cases of patient transfers, one necessary and one probably unnecessary, to her New York academic medical center, opening a dialogue concerning patient transfers and the tensions they often generate between community and academic neurosurgeons. In the same issue, William T. Couldwell, MD, offered his views on the positive and negative consequences of patient transfers to his Utah AMC. In this issue, Thomas C. Origitano, MD, continues the discussion, sharing his experience at an Illinois AMC.
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| Data Source: Department of Neurlogical Surgery, Loyola University Medical Center, Maywood, Ill. |
Academic medical centers in Cook County, Ill., including Loyola University Medical Center where I practice, have received a significantly increased number of transferred high acuity neurosurgical patients who represent a disproportionately poor payer mix. This situation has stressed the system of neurosurgical care delivery, threatening the viability of AMCs, where tomorrow’s neurosurgeons are trained, and imposing formidable barriers for patients needing neurosurgical care.
Among the factors underlying the increase in transfers are unfunded mandates such as the Emergency Medical Treatment and Labor Act, residents restricted to an 80-hour workweek, the medical liability crisis, and the neurosurgical community’s survival responses to these influences. Defining a problem is the first step in solving it, and in the interest of fostering discussion and proposing possible solutions, the issue of patient transfers to academic medical centers will be discussed not in the context of good or evil, but rather in terms of driving forces, consequences and the effects on patient outcomes.
My perspective is shaped by the neurosurgical environment in Illinois, a medical liability crisis state which in May passed modest tort reform that for doctors included a $500,000 limit on noneconomic damages. Medical malpractice insurance premiums in uncapped states are increasing yearly by double digits, and academic medical centers are not immune to these increases. My faculty paid $195,000 per person for malpractice premiums in 2003 with a 20 percent increase for 2004. The increase in premiums and the declining collection rate related to the shift toward a population with a low-reimbursement payer mix is shown in the table above, which also expresses malpractice premiums as a percentage of collections. Academic medical centers in the Chicago area pay a range of 21 percent to 35 percent of collections for malpractice premiums.
The demographics of the area of Illinois where I practice, Chicago and Cook County, fuel the increase of transferred patients. The area harbors five academic medical centers where approximately 40 faculty neurosurgeons and 33 residents practice. The greater metropolitan Chicago area (including northwest Indiana and southeast Wisconsin) has approximately 14 million people. Indigent residents of Cook County or those injured within its bounds are served by Stroger Hospital. However, the fastest growing populations are in the counties surrounding Cook, where the driving force for this growth is the availability of factory jobs which typically do not provide benefits such as health insurance.
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| Data Source: Department of Neurlogical Surgery, Loyola University Medical Center, Maywood, Ill. |
Compounding the issue of a rapidly growing uninsured or underinsured population is a concomitant decline of neurosurgical services in community hospitals for head injury, pediatrics, stroke and hydrocephalus.Within the collar counties, greater than 25 community hospitals no longer have cranial neurosurgery coverage. Conservative estimates for neurosurgical coverage in the greater Chicago area are 150 neurosurgeons or one neurosurgeon per 93,000 people. The impact of some neurosurgeons restricting their privileges to spinal cases redefines this ratio to one neurosurgeon per 100,000 people for spinal cases and one neurosurgeon per 350,000 people for cranial cases.
The New Town and Gown
This voluntary limitation of privileges exclusively to spinal cases can decrease malpractice premiums, remove obligation for emergency room coverage at “high risk” hospitals, permit transfers of elective cranial cases to “safe haven” hospitals where surgery can be performed without the consequences related to trauma, and shift responsibilities for urgent and emergent care to academic medical centers by evoking EMTALA. Community hospitals are complicit with this practice because it allows retention of low acuity, short stay, high margin cases, while transferring high acuity, high resource consuming, poorly reimbursing cases.
The concept of these transfers as “great resident cases” in the face of the resident workweek restriction to 80 hours is errant. Resident exposure has been cut by 20 percent to 25 percent and today many academic centers run operating rooms without resident involvement, especially after 6 p.m. Further, at my facility the restriction has resulted in a minimum expenditure of $400,000 per year on the neurosurgical service alone for nurse practitioners to replace resident caregivers.
The Consequences
The economic realities are harsh. Academic centers often function on small margins of 1 percent to 2 percent. Emergent and urgent transfers tend to have a higher acuity, poorer payer mix, longer length of stay (secondarily affecting hospital report cards) and a higher resource utilization. Failure to comply with EMTALA carries a $50,000 per violation fine to the hospital and can lead to physician fines and Medicare sanctions.
The overall impact of this environment on academic neurosurgery has severe consequences. The ability to obtain and grow state-of-the-art technology and facilities is limited due to reduction in margin. Faculty retention and growth is threatened, especially in areas of poor reimbursement and growing need such as pediatrics, functional and trauma. Academic neurosurgery faculty salaries in Chicago are experiencing declines of between 10 percent and 30 percent. These economic pressures further impose on the ability to retain high earning academic spine surgeons and foster the maturation of junior to mid-level faculty. This ultimately could result in teaching centers that have a single senior professor and the rest junior assistant professors.
My institution has experienced an increase in trauma admissions of 39 percent to 55 percent since 2003, primarily due to nonoperative head trauma. This population has an extended length of stay, higher acuity and poorer payer mix. “Code Red: No Beds Available” now occurs 90 percent to 95 percent of the time Monday through Friday. As a consequence, patients with aneurysms or brain tumors cannot be accepted or their transfer is delayed. Emergent and urgent transfers take priority over elective schedules, forcing elective surgeries to be postponed due to lack of bed availability. Patients who develop intracranial pathology while at outside hospitals, even with board-certified neurosurgeons on staff, must be transferred. Average transfer times, which are directly related to bed availability, now are approximately six hours and increasing.
Further, the above graph represents cranial and spinal volumes at my institution from 2000 to 2004. While poorly reimbursed cranial procedures have continued to increase, higher reimbursed spinal surgery has flattened in part due to retention of these cases in the community. Exacerbating this flattening has been a payeer mix shift from commercial and worker compensation to low-reimbursing Medicare, Medicaid, health maintenance organizations, and self-payers.
All neurosurgeons do not bear the same weight of either the transfer crisis or its consequences. Neurosurgeons must come to recognize the consequences of their survival tactics on academic training centers and patients. Academic neurosurgical centers, where tomorrow’s neurosurgeons are trained, are threatened. Patient access to care is jeopardized. Patient outcomes are being compromised.
The primary issue that must be resolved is patient access to care, which directly affects patient outcomes. It is doubtful that even with medical liability reform community practitioners would revert to previous lifestyles and practice patterns. Furthermore, it would be imprudent to resume procedures and patient management that one has not practiced for several years. Therefore, the solutions must be linked directly to the access to care issue:
- Link access to care to caps on liability damages, rewarding neurosurgeons and institutions that care for patients regardless of payer mix, case mix or acuity.
- Mandate transfer of all cranial cases to centers that manage all aspects of cranial surgery, linking margin to mission.
- Make unrestricted provision of neurosurgical services a requirement of maintenance of certification.
- Increase reimbursement to reflect the intensity of work associated with cranial surgery and the cost of high malpractice premiums associated with high risk surgery.
- Change neurosurgical training to reflect social need (for example, institute a four-year course with emphasis on trauma, critical care and basic spine).
- Discontinue holding neurosurgical meetings in states that do not have substantial medical liability reform, thereby linking reform to potent economic consequences.
Poor patient outcomes cannot and should not be the price paid for a stressed neurosurgical delivery system. The neurosurgery community must come together to forge solutions based on those things we hold in common, creating a new paradigm while holding to our old ideals.
Thomas C. Origitano, MD, PhD, FACS, is professor and chair of the Department of Neurological Surgery at Loyola University Medical Center, Maywood, Ill.
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