“It’s a huge issue for everyone,” said Clark Allen, MD, referring to neurosurgical emergency coverage. Dr. Allen is one partner of a two-neurosurgeon practice in Pocatello, Idaho. The city of about 70,000 in southeastern Idaho is home to Idaho State University and the Portneuf Medical Center, a level 3 trauma center. For five years Dr. Allen and Scott Huneycutt, MD, provided the facility with continuous neurosurgical emergency coverage, but in October 2004 the duo made the difficult decision to discontinue on-call services.
“We were covering neurosurgical emergencies 24/7, so each of us was on call every other night,” Dr. Allen said. “Beyond the significant pressure this schedule places on one’s personal life, it also effectively destroys an elective practice.”
He noted that emergency services, particularly trauma, are reimbursed at low rates if at all. “To survive, we have to generate income from our elective practice,” he said. However, when emergency cases run long, elective cases must be rescheduled, creating a situation in which a neurosurgeon might operate all night on a trauma case for which no payment will be received, and then be forced to reschedule a surgery that would have been fully compensated.
“A neurosurgeon in private practice is a business owner,” said Dr. Allen. “If we don’t make enough to cover overhead and meet payroll, we can’t keep the practice open and that means no neurosurgical service for anyone in our area.”
To compensate specialists for financial losses resulting from on-call responsibilities, some facilities offer a per diem stipend. Dr. Allen’s practice had received a stipend for two years, and while he thinks that reaching an agreement with the hospital on a stipend would help with reestablishment of on-call coverage, he also believes that stipends represent a short-term solution to a complex problem.
“Overhead costs keep rising while our reimbursement for services is declining,” he said. “This means that stipends would need to increase each year in order to even come close to adequate reimbursement for on-call services. Few, if any, facilities can continue these increases indefinitely.”
Into this conundrum, enter the medical liability crisis.
“Idaho is a tort reform state with a $250,000 cap on pain and suffering damages, but even so my medical liability premiums have increased 20 percent to 25 percent each year,” Dr. Allen related. “If the situation is this bad here, I can’t imagine what my colleagues in other areas are going through.”
He believes that liability related to trauma, particularly for head and spine cases, is the driving force behind the premium increases, and further, that liability exposure at a community facility may be greater for specialists like neurosurgeons because many neurosurgical procedures rely on the availability of state-of-the-art technology.
“A community facility just can’t afford to keep up with the ‘whiz bang’ technology available at the level 1 trauma centers, which usually are located at major academic centers,” he said. “We grapple with the pressure to provide a service that sometimes may be beyond the reach of our facility.”
Dr. Allen and his partner are expanding their practice into the surrounding rural areas, mindful that the population base of 150,000 to 200,000 is barely enough to support two neurosurgeons. “There is economic pressure for one of us to leave, but it would make life difficult for the one who remains and it would be nearly impossible for one person to provide continuous neurosurgical emergency coverage.”
The irony is that Dr. Allen and his partner were recruited by Portneuf Medical Center to bring neurosurgical care and emergency coverage to Pocatello. Dr. Allen, who just received his certification from the American Board of Neurological Surgery in 2004, knew he wanted to live in the West and made the move from Virginia to Idaho especially for the opportunity in Pocatello.
“In a community like this, you see your patients at the Wal-Mart,” he said. “You feel an obligation to provide a service to the community.”
For the present, neurosurgical emergency cases are stabilized at Portneuf and transported by Life Flight helicopter to the University of Utah Medical Center’s level 1 trauma center in Salt Lake City, about 150 miles away.
Manda J. Seaver is staff editor of the Bulletin.