Just a few updates before I get coffee.
First an interesting paper looking at surgical performance as a function of concentration on certain procedures instead of sheer volume of procedures**:
For all four cardiovascular procedures and two out of four cancer resections, a surgeon’s degree of specialization was a significant predictor of operative mortality independent of the number of times he or she performed that procedure: carotid endarterectomy (relative risk reduction between bottom and top quarter of surgeons 28%, 95% confidence interval 0% to 48%); coronary artery bypass grafting (15%, 4% to 25%); valve replacement (46%, 37% to 53%); abdominal aortic aneurysm repair (42%, 29% to 53%); lung resection (28%, 5% to 46%); and cystectomy (41%, 8% to 63%). In five procedures (carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy), the relative risk reduction from surgeon specialization was greater than that from surgeon volume for that specific procedure. Furthermore, surgeon specialization accounted for 9% (coronary artery bypass grafting) to 100% (cystectomy) of the relative risk reduction otherwise attributable to volume in that specific procedure.
The argument this paper makes is that surgeons who are mainly doing one thing are better at that one thing than if they are doing lots of different things even if the total volume count on a given surgery is the same.
Intuitively, this makes sense. A surgeon who is only doing one thing can recognize at an intuitive level when something is odd and adjust or correct before there is a crisis.
Now the other payment reform piece is the Medicare bundles for cardiac care and extending hip fracture bundles:
During a conference call with members of the media, Patrick Conway, MD, Acting Principal Deputy Administrator and Chief Medical Officer at the Centers for Medicare and Medicaid Services (CMS), described three policies included in the proposal:
New bundled payment models for cardiac care and the extension of the joint model to include treatment for hip and femur fractures A new model to increase cardiac rehabilitation A proposed pathway for clinicians and physicians in bundled payment models to qualify for payment incentives under the Medicare Access and CHIP Reauthorization Act
Under the proposed cardiac-care bundled payments, hospitals would receive quality-adjusted pricing for heart attack and bypass episodes of care, including 90 days after a hospital inpatient stay, according to a CMS factsheet.
What this is telling me is that the combination of bundled payments and quality accrual due to specialization is that the general surgeon and the general specialist will be declining in importance. Instead, hospitals will have emergency departments that can handle stabilization of patients and then they’ll ship the patients out to county or regional centers of excellence. If someone has a broken hip, there will be two or three hospitals in a metro area with a dozen surgeons who just do hips and nothing else. If there is a need to do a bypass, a hospital will have two bypass surgeons who do 90% of those procedures between the two of them.
If thees results hold and if these policy changes continue to accumulate where payments are based on quality of the entire episode of care, I don’t know what the general community hospital looks like in fifteen years. It won’t be a one stop shop for 90% of a town’s needs. The quality and two sided risk arrangements won’t allow that financially.
** BMJ 2016;354:i3571 accessed 7/27/2016
I hope the dude that is doing my hernia fit the bill!
@raven: ask him/her how often he does hernias and what else he does…
@Richard Mayhew: OK, he get’s great reviews and my GP thinks very highly of him.
It will be a free-standing Emergency Department with condo developments on the upper floors where patients used to be treated. A community hospital can’t stay open if they’re not doing anything besides stabilizing patients with pneumonia.
As my BIL likes to say, it’s minor surgery when it’s happening to someone else. And once you’ve gotten to (ahem) -a certain age- some kinds of surgery, e.g., cataract surgery and various other kinds of eye surgery, become very common. Cataract surgery is done at an overall rate of a few million a year and an active eye surgeon will do hundreds of procedures in a year. No one dies from a botched eye procedure– but mistakes do happen.
And you have to make some choices– younger surgeon vs. older surgeon, specialist vs. generalist, large practice vs. small practice. I’ve been through it and (I think) made good choices– but a lot of it is just luck.
When I did an internship in internal medicine in Lansing, Michigan (1989-90) this was sort of the way it was. Michigan had a strong certificate of need law so the only hospital in Lansing that did bypass surgery was Ingham Medical Center. The only hospital that did neurosurgery was Sparrow Hospital. I have no idea what it is like now in Lansing and I think that Ingham Medical Center is now closed.
@dr. bloor: and that is a definite possibility of where some of the community hospitals are going (actually, that is where some of them have gone as my brother, his wife and Chunky Monkey of a nephew live in an old hospital now) .
Hospitals in the middle of nowhere are still viable in this model as access to care 200 miles is not accessible care. But hospitals in say Greater Cincinnati or Greater Denver will have to change their business models.
Gin & Tonic
That’s why a good friend went into eye surgery. He said “my patients won’t die.”
O. Felix Culpa
Wow, Richard, you did this before coffee? I’ve always been impressed by your posts, but even more so now. From – a highly-caffeinated fan. :)
I’m a primary care physician in West Virginia, and I don’t look forward to where this “best practices” approach to surgery is going. Having our patients go off to the specialty hospital for surgical procedures may lead to better immediate outcomes. But when they come back home to a fragmented and failing local system with no effective follow up to maintain the good outcomes they briefly have, or to address the complications that local providers don’t want to have any part of, any benefits the patient briefly experienced from having the procedure performed “better” is lost. And the ongoing train wreck of failed Health Information Technology / EMR’s means that getting even minimally useful records of the services provided at those centers to me in my office just doesn’t happen with any meaningful regularity, although I’m constantly told that this will somehow just happen REAL SOON.
I recognize that these changes are not unique to medicine. The world is increasingly being overwhelmed by “complexity”, and the closer you are to large population centers, access to better services improves accordingly. Try getting a computer or printer (or any other piece of modern technology) competently and cheaply repaired out here in the hinterlands. It’s usual practice to just junk things that could (and should) be repaired, and buy new, because everything is now so complex. Fewer and fewer people have access to competent service providers who can understand the byzantine systems well enough to actually fix things.
It is possible to put a given number of people in a large virtual healthcare “playpen”, and with adequate resources provide them with outstanding care. These are your large insurers, your Cleveland Clinics, and your Keyser Permanente’s. And the payment system just determines how the work and profits are distributed. But those of us outside those systems are unlikely to experience “trickle down” benefits from these approaches anytime soon.
@BurntOutDoc: Agreed, there needs to be systemic wrap-around care for patients. And it might be easier to build that system of care in dense urban areas (Pittsburgh is a natural hub compared to say Williamson WV). There could be an urban model of care and a rural model of care that relies on more generalists and helicopters to urban centers for specialty acute cases and long drives for deferrable odd-balls.
Is there any place a prospective patient can go and get solid data on how many operations a Doc performs ? Like FOIA request thru Medicare ?
I wouldn’t consider an “Angie’s List” or other patient rated guide be used because of the wide bias and “I gave her one star because she was 20 minutes late seeing me”.
Raven: Great luck with your hernia !