In some ways, those were the good old days. After my residency, I began my neurosurgical career in 1969 as a salaried member of the UCLA/Wadsworth VA program in Los Angeles. I did a small amount of private practice to supplement my income. I had no bookkeeper or secretary. So I asked someone else’s billing clerk to send out statements. When checks arrived, I put them in my personal checking account and I paid the billing clerk a few dollars a month. It was as simple as that.
Three years later I returned to East Tennessee and established a professional corporation with an established neurosurgeon in Knoxville. We had two employees, a bookkeeper/receptionist, and an office manager/transcriptionist, who also kept our hospital charts up-to-date. Two more neurosurgeons later joined us, and we opened a second office and hired two more employees.
In the 1970s and early ’80s we handwrote our charges and collections in a spiral notebook, a page per day for each side of the ledger. At the end of the day you could quickly add up the volume of business and the amount of revenue. At the end of each month, the bookkeeper and secretary took a day to type out bills and mail them. They did not enjoy this day, but it was only once a month.
Most patients in that era had some insurance. When the insurance did not pay our full fee, we were allowed to “balance bill” and the patient paid on a monthly basis. Occasionally, social agencies paid a reasonable fee for indigent patients.
Sometimes the local medical society asked me to review charges by other neurosurgeons that the patient or insurance companies protested as excessive. If it was significantly more than I charged, the medical society asked the other neurosurgeon to reduce the fee. This was the only form of “repricing” of which I was aware.
Pre-approval was never required. We could put patients into the hospital whenever and wherever we desired and do the tests and surgery we deemed necessary. Patients with back pain and/or radicular pain, for instance, were hospitalized for several days of physical therapy and a myelogram was done. We waited a day or two to operate and kept the patient in for another four or five days postoperative. The patients sometimes would even be given an overnight or weekend pass to go home while the hospital continued to bill and collect from the insurance companies.
The Past had Problems, Too
The downside of allowing physicians full authority was the opportunity for abuse. This was manifested by:
- Unnecessary hospitalization for the convenience of physician and patient. In my internship in the late ’50s, children were actually put into the hospital so that their parents could go on vacation.
- Unnecessary surgery was sometimes done.
- Excessive charges were billed and often collected.
- Diagnostic procedures, often unnecessary, were done on demand simply to avoid a confrontation with the patient.
I saw these abuses very clearly and I am sure most of my colleagues saw them. Most of us did not engage in these abuses, but we did see them happening and usually did little about them.
In the early ’80s I regularly attended the leadership conferences of the American Medical Association. I was then Chief of Staff at the University of Tennessee or president of the county medical society. Representatives of the Reagan administration told us that medical care costs were inflating at a rate more rapidly than other sectors of the economy and they would change this. Insurance companies had little incentive to keep costs down. They simply increased premiums to cover costs, which gave them more money to invest and thus improve their bottom line.
Thus the government’s goal to decrease medical costs and increase access to medical care and the abuses by physicians, patients and insurance companies led to progressive changes. And eventually to the current flawed system.
The problems began when Medicare required universal adherence totheir fee. Other third-party payers followed suit and became more careful about variations in fees. Employees demanded better medical benefits and employers balked at the rising premiums. To avoid increasing premiums, insurance companies lowered reimbursement schedules. In turn, crafty physicians (individually and in small groups) reacted by “gaming” the system. The growth of managed care groups brought thousands into the system who, while they provided no medical care, had to be supported out of the overall healthcare budget. The rest is history-and our present state.
The Impact of Managed Care
How has all of this impacted my practice?
- My collection rate, which from 1988 to 1996 averaged between 78 and 88 percent, plummeted. It now hovers near 45 percent. This occurred without any significant change in my charges.
- Our two-man practice requires five and a half employees to keep up with the extra phone calls and paperwork required for precertification scheduling and for documentation, in addition to bookkeeping, patient scheduling and transcription.
- Much of my time, and even more of my nurses’ and bookkeeper’s, is consumed justifying management decisions to case managers and insurance adjusters. We must patiently refute their arguments, no matter how ridiculous or trivial they may be. Just getting a human voice on the phone is often a frustrating undertaking.
- Hospitals have reacted to financial pressures by laying off personnel. It is increasingly difficult to schedule surgery and diagnostic studies. Hospital employees are overworked and frustrated.
Technological advances over the last 35 years have resulted in easier, more certain diagnosis and quicker, more technically satisfying operations. The medical and surgical aspects of the practice of neurosurgery are improved. However, the economic and management restraints have forced everyone to work harder, accomplishing less, earning less and obtaining less satisfaction.
Perhaps most distressing is the major part we physicians played in getting us here. Too many became obsessed with financial gratification and turned away from more noble goals. All of us are paying the price. Reversing the trend will be difficult. We must first dedicate ourselves to noble goals and then convince society of our dedication.
Helping People Amid Piles of Paperwork
James A. Killeffer, MD
My neurosurgical career has been entirely within the era of managed care. Thus the impact of managed care on the profession is somewhat difficult for me to appreciate. What I can understand is how managed care affects the reality of the practice of neurosurgery, in contrast to my expectations on entering the field. What I think is important to keep in perspective is that changes in the business management of healthcare should have very little effect on what being a neurosurgeon means.
I chose medicine and neurosurgery as a career for reasons that I am sure are common to many physicians and neurosurgeons. Medicine was a good way to cultivate my interest in science while providing a service to others. Growing up, I saw that my father and grandfather, a general practitioner, worked very hard. Yet they appeared to enjoy practicing medicine, held the respect of their patients and the community and found satisfaction with their role as hard-working but well-appreciated physicians. Although they shared their experiences about practicing medicine with me, business and financial concerns were seldom mentioned. I entered medicine expecting to work harder than most people but also to enjoy the intellectual stimulation and sense of accomplishment that I thought came with being a good doctor.
Although I observed some neurosurgical procedures by spending time with my father prior to medical school, I first experienced it directly on a fourth-year medical school rotation. The logical sequence of neurosurgical diagnosis, the graatification of being able to treat problems effectively and the intellectual challenge of neurosurgical science appealed to me.
Residency training was not a disappointment. The primary challenges were to learn to effectively diagnose problems, learn neuroanatomy and surgical techniques, participate in research and learn the art of effective doctor-patient interaction. Although residency was very hard work, learning these skills and applying them was in line with what I had expected entering the field. Interestingly, in retrospect, I was exposed to very little about the socioeconomic aspects of neurosurgery during residency, and as I entered practice I looked forward to a challenging career practicing the science and art of neurosurgery.
Impact Painfully Clear
The reality of managed care and its impact on neurosurgery have become painfully evident to me in private practice. Diagnosing neurological problems, treating them correctly and helping patients and families understand and deal with difficult situations often seems only a minor part of my job. Demanding a great deal of time and effort are documentation beyond what is reasonably necessary, seemingly arbitrary roadblocks to necessary care and difficulty securing appropriate reimbursement.
Many neurosurgeons who I expected to be colleagues and competitors at providing superior care instead appear to often focus on vying to secure patient populations with the best reimbursement. They avoid challenging clinical situations because they reduce practice efficiency and increase liability.
I have found it necessary to devote considerable time and effort to learn to properly bill for my work, to avoid mistakes that could cost thousands of dollars or even be considered criminal. Courses and publications encourage neurosurgeons to reduce their workload by hiring physician extenders to take medical history, do physical exams, explain surgical procedures, make daily rounds, perform parts of operations and even completely perform some simple procedures. In short, I sometimes seem to be more of a businessman than a physician.
It makes sense to me that third-party payers, politicians and the public regard physicians as merely part of the supply chain of healthcare delivery rather than those most responsible for healthcare delivery. I can understand why many patients, whose health insurance is part of an employment benefit or government program, often demand superfluous tests, unnecessary procedures and overly expensive medications rather than trusting the judgement of their physician. Physicians, feeling pressure to produce revenue and please their consumers, too often oblige.
Third-party payers, on the other hand, have as their primary goal limiting the flow of resources. They show minimal consideration for the welfare of patients or doctors. As a neurosurgeon in this environment, I am frequently disappointed that I cannot simply formulate a diagnosis, order confirmatory tests, treat problems as necessary and follow up appropriately. The logical intellectual process and human interaction that attracted me to neurosurgery are often hopelessly diluted by the Byzantine architecture of managed healthcare and lack of trust among doctors, patients and payers.
Away from Managed Care
One of my few experiences away from managed care is through a local clinic for people who can neither afford private insurance nor are eligible for government supported coverage. Patients pay a small percentage of the cost of their care; private contributions and donations of time and resources from physicians and hospitals account for the rest. Since the patients are of limited means and pay some percentage of the cost out of their own pockets, providers are directly responsible to them to provide good care as inexpensively as possible. The patients are generally cooperative, undemanding and appreciative. The primary care providers tend to refer patients only after a thorough primary work-up and delineation of a clear reason forr neurosurgical referral. Documentation is limited to what is medically prudent.
Although the neurosurgical problems are often challenging, there are no third parties standing between the physician and the patient. I interview and examine patients, order only the most necessary tests and perform only the most necessary procedures. Although there is little financial gain, caring for patients in this environment is as close as my practice comes to approaching the expectations that I had entering neurosurgery.
Realistically, I expect that the majority of my neurosurgical career will remain within the superstructure of some form of managed care. I believe that through most of his career my father focused on what I consider the essence of neurosurgery-careful clinical diagnosis, judicious diagnostic testing and conscientious application of surgical therapy. My generation is encumbered with the burdens of dealing with third-party payers, healthcare management systems and dubious patients.
Even though we don’t hear a lot about it, my guess is that my father’s generation had their own set of frustrations encumbering their practices. I imagine that permutations of managed care will continue to create new burdens in the practice of neurosurgery as time goes by. The real challenges and rewards of being a neurosurgeon, however, will remain in diagnosing and treating people with neurosurgical disease.