Surgery News - January 2008 - (Page 4) SURGERY NEWS • J A N U A RY 2 0 0 8 THE VISION Evolutionary Changes in Surgical Practice Shortage of On-Call Specialists Spreads Nationally B Y K AT E J O H N S O N 20/20 Else vier Global Medical Ne ws mergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y. The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the study’s authors wrote. The study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma sur- geons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the study authors stated. Although unwillingness to accept oncall duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has been mandated by hospitals under the Emergency Medical Treatment and Labor Act. But many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report’s authors. Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report. As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists’ availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of pa- tients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk. “It’s not a surprise that we’re having this problem—it’s a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify. “The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.” More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey. Lack of optimal on-call coverage is what will ultimately “cripple” trauma and emergency care, said Dr. L.D. Britt, an ACS Fellow and professor of surgery at the Eastern Virginia Medical School in Norfolk. “Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That’s unsustainable for many hospitals—it’s a major crisis,” he said in an interview. He sympathizes with physicians’ struggles with payment and liability issues, but believes the true bottom line is simply that obligations are being overlooked. “I consider it my obligation to provide emergency coverage if I am on call. I know that’s my responsibility—and I’m a chairman of a department. ” In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician’s liability exposure, he said. “Being on call doesn’t give you more litigation than being in general surgery— that’s well documented,” he said. Dr. Taylor disagreed: “The literature is very clear that emergency care is one of the highest liability environments in health care. You only have to look at what’s happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked.” Dr. Britt pointed out that no other country “is spending what we’re spending on health care, and yet we’re not getting what we should.” However, he expressed doubt that more spending could solve the problem. ■ COMMENTARY: MORE PATIENTS ARE SEEKING MEDICAL CARE ABROAD eled outside the United States for An estimatedin500,000 Americans travmedical care 2006, and a large inMany hospitals that are engaged in medical tourism boast that their medical staff includes physicians trained crease was projected for 2007 as part of and certified in Great Britain, the Unitthe rapidly growing phenomenon of ed States, Australia, or Japan. Indeed, medical travel. Residents of many oth- more than 4,100 board-certified fellows er countries also sought medical ser- who are members of the American vices abroad, making medical travel a College of Surgeons live and practice outside the United States worldwide industry. and Canada. Patients in Bumrungrad Hospital in countries that lack sophistiBangkok, Thailand, treated cated technology or have 50,000 American patients in long waits for procedures 2005, up 30% from 2004; can obtain faster treatment 75% of whom flew directly by going abroad. Most need from the United States. The major procedures such as 500-bed facility has state-ofjoint replacement or resurthe-art technology and is facing, arthroscopic procestaffed by more than 900 physicians in 55 subspecial- BY DAVID NAHRWOLD, dures, coronary artery stenting, coronary bypass, valve ties, 200 of whom hold M.D., FACS replacement, spinal fusion, American board certificaprostatectomy, and cosmetic surgery. tion. Medical travelers from the United In 2005, hospitals in Thailand treated 1,000,000 patients from other countries. States are seeking low cost. Almost all Hospitals elsewhere that reported treat- of these patients are uninsured. The ing patients from other countries in- cost of major procedures abroad is usucluded those in Singapore (375,000 pa- ally one-fifth to one-eighth the cost of tients), the Philippines (250,000), India those performed in the United States, so any travel expenses are insignificant. (150,000), and Malaysia (100,000). Many patients combine their postoperative recovery with vacations arranged by a medical travel organization. Approximately 50 medical tourism companies in the United States offer services such as helping patients select the best hospital, arranging consultation with the surgeon, arranging the travel, and securing living accommodations for the postoperative recovery. Medical insurers and employers are discussing the possibility of outsourcing expensive procedures for their subscribers. Blue Cross/Blue Shield of South Carolina has formed a medical travel organization as an affiliate, and their subscribers are covered for medical and surgical care outside the U.S. The Joint Commission, of which the American College of Surgeons is a corporate member, has given accreditation to organizations outside the U.S. since 1999 through its subsidiary, Joint Commission International ( JCI). The JCI’s mission is “to improve the safety and quality of care in the international community through the provision of education, publications, consultation, and international accreditation.” Currently, 170 institutions in 22 countries are accredited by JCI. Many medical travel organizations send patients to these hospitals, including Bumrungrad. In addition to its educational activities, JCI sets standards comparable to those used by the Joint Commission in the U.S. and determines performance against the standards through site visits by trained surveyors. The standards include patient safety goals, performance measurement, and reporting. JCI accreditation is highly sought because it provides objective validation that differentiates hospitals from competitors and assists the public in making decisions. Medical travel companies and their clients view JCI accreditation as an indicator of safety and quality. Unless the incentive for medical travel is removed by providing universal health insurance in the U.S., the phenomenon is likely to increase. The implications for American health care are both obvious and disconcerting. DR. NAHRWOLD is chairman of the Board of Commissioners for The Joint Commission.
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