Thursday, February 24, 2011

Paying to have surgery performed in a public hospital? What’s the spin on this?

When a non-insured patient undergoes surgery in the public hospital system, the costs of treatment are worn by the public hospital system. As a public or non-insured or Medicare patient, it is accepted that their care, including surgery, will be primarily in the hands of registrars who are generally doctors in accredited advanced specialty training programmes. Senior specialist doctors are responsible for the supervision of the registrars who generally provide a superb service and are good at what they do. As registrars are not yet fully qualified as specialist doctors, they still require guidance and supervision from senior medical staff.

In NSW, we have seen the system of ‘self insured’ or ‘private elect’ or ‘self pay’ patients being encouraged in the cash strapped public hospital system. Under such an arrangement, a non-insured patient can elect to be a ‘private patient’ for two days of their admission to hospital in order to have the doctor of their choice performs their procedure or surgery. After the two days are over, they revert to being a ‘public’ or ‘Medicare’ patient. A typical fee charged by NSW public hospitals to exercise this right is $660. Additional to this, the patient will have to wear the cost of ‘out of pocket’ fees from the surgeon and anaesthetist so it can end up being a costly exercise. The hospitals are ever happy to see patients exercise this right as it means additional funds that they would otherwise not have to run their budgets. Government funding is essentially fixed so these funds are a bonus. Hospitals have indirectly encouraged this process by issuing memos to doctors reminding them that this service is available and encouraging doctors to allow their patients to know of the availability of this service. More recently, the addition of a check box for “Self Pay” amongst the various check boxes that determine the funding status of the patient have appeared on public hospital surgery booking forms (See picture below). Other check boxes include “Private” (means that they are in a private health fund), “Public” (means non-insured Medicare patient) and “Veteran Affairs” (cost covered by Department of Veteran Affairs). The “Self Pay” check box is strategically positioned as the first check box in the list although the most commonly ticked box, being “Public” is well 'down' the list.

There is a belief by a number of surgeons (and patients for that matter), that the option of being self insured should be highlighted at the time of consultation. There is also the belief that it should be reinforced that the surgery in the public hospital will generally be performed by a registrar rather than the consultant surgeon. This latter disclosure could arguably be something that all non-insured patients already know, given that accessing the hospital system through the Medicare system does not afford them a choice of surgeon. I absolutely agree with providing such information as part of the informed consent process but there are of course ways in which this can disclosed. You can either disclose it as a routine matter of fact or it can be presented in a way to scare the living daylights out of your patient and leave them thinking of certain surgical misadventure if the registrar was to be doing the operating.

Will it make a difference if the registrar does the operation instead of the consultant surgeon? Repeated scientific papers evaluating this have demonstrated that in the setting of close and meticulous supervision, that there are no difference in the outcomes. Once more, I repeat that the key to good outcomes is the close and meticulous supervision of the trainees. An argument used to oppose this view is that the surgeon who has had less experience or has done fewer numbers of cases might have inferior results - there have certainly been some publications which suggest this to be the case. This effect as observed in fully trained surgeons cannot be extrapolated to the situation where a registrar is being closely monitored by an expert trainer. It is up to the surgeon to ensure that the registrar has reached a level of skill where they can tackle the various aspects of an operation and if not, it is incumbent upon the specialist surgeon to perform that part of the operation him or herself. If the surgeon does not believe the registrar has the ability to perform all or part of a procedure, then the surgeon is responsible for performing that part of the procedure whether the patient is insured or not insured.

There is one particular case that I was involved in several years ago and I have never been able to shake it completely from my thoughts. When I was still involved in caring for kidney stone problems, I had a patient who as a single working mother was doing it tough raising four kids by herself. She was incidentally found to have a problem that needed highly specialised surgery in a field outside of my own. She was obviously uninsured but this is exactly the type of person for whom the Medicare system was intended. I called up a specialist colleague who was somebody whom I felt that I could really trust and at that time regarded as a friend. I asked him to look after her and he assured me that he would. I saw her several months later and she was looking well and full of praise for my colleague. It soon came to light that she had taken out a second mortgage to pay for him to do her surgery in a public hospital. She told me how it was explained that the operation was too complicated for the registrar to do and that the only way he could do the surgery was for her to pay and be admitted as a “Self Pay” patient. I was shocked that she had been made to pay for this surgery when given its complexity, was not a case for the registrar to perform and he should have treated her without cost in the public hospital. It never ceased to amaze me how this lady was so upbeat about the experience even though her financial position was now precarious as ever. She was so grateful when I accepted her Medicare refund amount as full payment for her follow up consultation with me. I said nothing about my thoughts on this to the hospital administration or senior colleagues or the patient but as the years go by, I wonder if by my silence, I am as much to blame.

As a subspecialist prostate surgeon, it is not surprising that I have seen many second opinions from men who have already been seen by other urologists. Over the years, a couple have really stood out as cases I remember. One patient was a naturally sceptical type of person who was always quick to question motive and reliability of what was said to him. He was relieved to learn that I was only too happy to look after him as an uninsured patient at Westmead Public Hospital. He was aware that the registrar would be the primary surgeon but also that I would be there physically scrubbed in keeping a meticulous eye on every move made by the registrar and would be ready to take over any aspect of the procedure which I felt that the registrar was not performing to a sufficient standard. He was reassured that the chances of a catastrophic outcome as a result of the registrar operating were extremely low because of supervision. This is nothing more than what should be expected of a surgeon working in a teaching hospital and nothing short of an ethical responsibility. He disclosed to me that he sensed that he was being pressured into going in as a ‘Self Pay’ by implication that his outcome would be inferior with the registrar (who was not yet competent at performing the procedure) as well as several reminders that the surgeon himself had done superior training in radical prostatectomy surgery. A second case was a man who came to me almost in tears about his financial situation. He advised me that he felt too ashamed to go back because he could not afford the cost of going self insured. I felt it strange that he would be thanking me for accepting him as a public ‘uninsured’ patient as if his life depended on it. To be fair, these are the circumstances as put to me by these two men and I really do not know what was said by the original surgeon but I am sure that the original surgeon’s account would be different.

Over the last ten years, I have for the most part been a member of the NSW Training Accreditation and Education Committee which administers the urology registrar training programme in NSW. This position on the Committee, as well as being a hospital supervisor of urology training, has allowed me the privilege of getting to know many of the trainees more so than otherwise would have been the case. There is no secret that the trainees complain bitterly about lost training experience in the public hospitals when entire lists for specific surgeons are week after week filled with patients who have taken the ‘Self Pay’ option.

I advise all of my patients who are to be booked into the public hospital system that their surgery will primarily be performed by the registrar. Given that the cancer surgery I perform has many critical steps, it is not the type of surgery that I would permit any registrar to perform unsupervised. These men with cancer are vulnerable and anxious and I see it as my duty to try to provide them with reassurance that the risks of an adverse outcome should not be dissimilar to my own results if I performed the surgery myself. Again, it comes down to meticulous supervision. This is repeatedly supported in the literature where the results of surgery performed by trainees is examined. We also have to bear in mind that without this system of training, how else are the surgeons of the future to be trained? In some rotations, we see trainees complain bitterly of being deprived of surgical experience as yet another patient on the public hospital operating list is a self insured private patient. In spite of this, some of these very same complainants go onto to do the same when they complete their training. Hardly surprising given that surgeons are role models to the training doctors who attempt to replicate everything they are taught, both clinically and professionally.

So why would a surgeon wish to participate in encouraging patients to go into public hospitals as self insured patients? As a visiting medical officer working in the public hospital system or as a staff specialist, one would earn in the vicinity of $100-150 per hour which really does not cover the background costs of running your office in the private sector. Effectively, surgeons are in reality paying financially for the ‘privilege’ of working in the public hospital system. On the other hand, working in the public hospital brings rewards in referrals from general practitioners who wish surgeons to look after both their public and private patients. It also brings prestige depending on which institution one is working at. It also provides an opportunity to put something back into a system, without which, one could not have been trained in the first place. Additionally, the public hospital appointment might be tied in with a university academic title which can also enhance reputation. It’s a great give and take system. So if we return to the situation where a public patient undergoes a radical prostatectomy, the surgeon might earn say $600 with the hourly rate indicated above, but this does not cover the costs of paying rent, staff and general running costs of an office in the private sector. If the patient were to come in as a "Self Pay" patient, the minimum a surgeon would earn would earn would be $1396 which is 75% of the schedule fee and payable by Medicare (as of the November 2010 MBS published rates). More often than not, the fee charged will be much greater than this. Don’t forget that the patient is still up for the $660 self insured fee and the anaesthetic fees. From a financial viewpoint, it seems a no-brainer for the surgeon but that doesn’t make it right.

We must also remember that there will be cases where some patients will make that conscious decision that they wish to have the specialist surgeon perform their surgery. These patients should obviously not be denied their right to exercise the self insured option. These patients are relatively few. When a surgeon has almost every one of their patients on the operating list as ‘Self Pay’, you make your own judgement regarding coercion.

It is interesting that all surgeons in the public hospital system know that this type of thing is happening. Most either turn a blind eye, avoid the subject or pretend that it is not happening. I even had one surgeon, not realising my thoughts on the matter, say to me “well, we’re all doing it, aren’t we?”.

The use or misuse of the ‘Self Pay’ option in NSW Public Hospitals is widespread. The majority of surgeons do not partake in this type of activity but there are the well known several in every hospital. It is a minority of surgeons who abuse this system week in and week out. All surgeons are aware this is happening but it is very much a taboo subject for discussion, and for that matter, daring to raise it by written word. For surgeons, raising the matter potentially runs the risk of professional isolation, loss of mutual collegiate behaviour and stymied career progression. Making a scene over inappropriate behaviour with ‘Self Pay’ is not likely to get support from the hospital administrations that obviously have a vested interest in maintaining the status quo. It is a lot easier to turn a blind eye but in doing so, we are perhaps being complicit to this whole behaviour. This practice will never change until patients come forward with complaints. Most patients do not wish to have conflict and are just glad to have their problem dealt with and wish to move on. Most I suspect are totally naive to the fact that being self insured is something that was probably never necessary in the first place.

Saturday, February 12, 2011

What makes somebody the best surgeon for you?

My colleagues and I have been working on our website with primary aim of being a portal for information about our practice as well as a source of documents relevant for patients of the practice.  We naturally look at what others in our field are doing with their websites to get an idea of what we like about some finished products and what we don’t like.  Some websites provide information to help you think that they are the right surgeon for you.

I found it fascinating to observe what things are said in order to bring in business and to convince the reader that they are dealing with the best surgeon for their condition.  Clearly there are many things that help determine what makes a surgeon the best for the job and amongst those, the things that are materially significant to some may not be to others.  One example is the bedside manner where a surgeon could have the reputation for being a meticulous and technically superior in their operative skills but where the bedside manner is abrupt, arrogant and seemingly uncaring.  Even for myself, I would have to admit that there are possibly some conditions where I would like one surgeon to do the decision making, another to be the technician (and then never see them again) and perhaps another to deal with the longer term monitoring (where you have to see them on a regular basis).
One of the statements made to generate the impression of prestige is boasting that he or she was the first to perform a certain operation in the state of NSW or Australia.  This could be indication that we are dealing with an innovative thinking surgeon who is always looking out for the latest advances to benefit patients but in the same breath could represent the surgeon who seeks to take a risk with their patient in hope of achieving kudos for their efforts.  Does the patient always know that they are the first?  Being the first to do a particular procedure does not necessarily mean that the individual is the most talented and technically adept at performing the procedure.

It is common practice to highlight one’s background training.  Fortunately for us in Australia, the overall standard of surgery is very high and what we call 'average' is frequently well above average for many other western countries.  Some countries have the most prestigious institutions performing high quality opinion leading work but in the next town, there might be an institution that is perhaps a little ordinary.  Okay, if a surgeon goes to a prestigious institution to round off their surgical training in Australia or to subspecialise, does this mean that they can lay claim to being the best at what they do?  The answer is yes and no.  With the yes, they may be exposed to the latest techniques, benefit from state of the art training and also taught to think critically with complex cases.  We rely on these surgeons to return to Australia and become key opinion leaders in their field.  Contrary to this, we have surgeons who were ‘clinically and technically average or even below average’ when they departed for additional training overseas in a prestigious institution and on their return to Australia, they are still ‘clinically and technically average or even below average’.  I have often heard of trainees who lament that a particular surgeon was very disappointing technically for what they expected - this was not said meaning to say that a particular surgeon was inadequate, but more that there was a higher expectation that we would be better given the constant reminders of where he or she had some training after obtaining their Australian qualiftications. Some of the most prestigious institutions to much surprise may also provide a less than satisfactory experience and hands on training and simply trade off their reputation as a place to seek further experience.  In terms of hands on experience, there are notably institutions in the USA where the surgical fellows are merely glorified surgical assistants who will tolerate stifling employment conditions knowing that it is simply a means to an end.  I sometimes tempted to say to some surgeons who cannot help but to tell you that they have been to the best institution in the world for additional training as follows:- "Listen here honey, you're back in Australia now and have to prove yourself and not ride on the back of the success of where you have been."  I am a great advocate of surgeons undertaking additional fellowship training following the completion of their surgical qualifications in Australia.  I do however, urge you all to remember that whilst being able to say that one has been the best institution in the world to have further training, it does not mean that the training in Australia should be devalued in any way and it does not mean that the surgeon has necessarily become a better surgeon for it. We should not underestimate the worth of the training that was received in Australia which really matches the best in the world.

What about how many of a certain type of operation one performs and how many they have done over their career?  A high career volume or a high annual case volume intuitively reflects experience, which is valued in whatever endeavour is undertaken.  Some surgeons only need to do an operation a few times to be performing it as well as another who does many more.  It is possible to do large numbers of certain procedures but perform all of them badly.  Levels of skill and the uptake of these skills can vary considerably as is the case with any profession.  There is no easy solution for navigating through this minefield when trawling through individual surgeon’s websites.  Perhaps the best question one can ask is as to whether they are performing audit of their surgical results.  In other words, are they getting the results that they think they are getting?  As surgeons, how do we know what we are doing if we do not measure our outcomes?  I have personally found the practice of audit to be both humbling and illuminating and the best guide to assist with making improvements to my outcomes.  But suggesting that we all aggressively audit our cases has the potential of coming at a price to the community.  If surgical results become the primary focus of marketing campaigns, it runs the risk of influencing surgical case selection in fear of damaging one’s ‘figures’.  It would be disastrous and simply unethical if we were to find ourselves in an environment where surgeons refused treatment to higher risk patients in order to protect their own statistics.

This discussion is not intended to create confusion over the meaning of certain claims made by surgeons who market their surgical practices on the internet.  The aim of this discussion, is to introduce a healthy questioning of what is stated on various surgical websites.  Being a good surgeon includes more than just the operating and all of you need to consider what is important for you when making your decision. If you are not comfortable with your existing opinion, think about getting a second opinion.  Funnily, the surgeons who actively trawl for second opinions are probably the ones that I personally would not see.  If they are that gifted and appreciated, they should not need to waste any space on their website enticing readers to come in and see them for a second opinion as they surely must be the best.  Great surgeons who are comfortable with what they do and who are recognised for what they do are well patronised from word of mouth and do not need to cast out invitations to see them for a second opinion.  My own feeling is that the good old-fashioned approach of seeking out personal recommendations still has a great deal of merit.  If you know of somebody who is going to have surgery of ANY sort, forward them this blog link and see what they think after reading this.