Surgery News - May 2008 - (Page 4)

S U R G E R Y NEWS • M AY 2 0 0 8 THE VISION Evolutionary Changes in Surgical Practice Massachusetts Finds Ways to Widen Health Coverage B Y J OY C E F R I E D E N 20/20 Else vier Global Medical Ne ws WA S H I N G T O N — Don’t believe what you read in the national media: The Massachusetts health coverage plan enacted in 2006 is actually doing quite well, thank you very much. That was the message from John McDonough, D.P.H., executive director of Health Care for All, a consumer health advocacy organization in Boston that has supported the plan. “We’ve expanded affordable coverage to 325,000-350,000 of the [state’s] estimated 550,000 uninsured,” he said at a diabetes meeting sponsored by Avalere Health. But significant challenges are ahead. The state recently announced that the program will cost “significantly” more than the proposed $869 million budgeted for it in 2009. One reason is that state regulators approved a 10% increase in payments to private insurers for each person enrolled in the program, in which the state subsidizes the insurance premiums. The insurers had sought a 15% increase but agreed to settle for 10%. Richard Powers, a spokesman for the program, said in an in- terview that the real driving force behind the increased cost is growing enrollment. “Certainly, the rate increases will factor into the final figure—which has yet to be determined—but it is minor in comparison to the enrollment,” he said. The payment increase will take effect July 1. In addition, the state said it would be willing to take on additional financial risk if enrollees end up using more medical care than expected. Also, premiums will be increased for about one-fourth of enrollees—the other threefourths will continue to pay no premiums—while copays will go up for half of those enrolled. Dr. McDonough said cost increases were not unexpected. “When you enroll a ton of people, costs do go up,” he said during his talk, which was given before the announcement but after state officials had projected an increase in the program’s budget. “Most of [those costs] were expected and, by the way, most of those costs are being paid by the federal government, not by Massachusetts.” The Massachusetts plan has engendered dislike on both extremes of the health care re- form debate, Dr. McDonough said. “You have health care fundamentalists on the left who worship at the shrine of the perpetual single payer, and you have fundamentalists on the right who bow down before the consumer-driven goddess of the unregulated market,” he said. “They agree on absolutely nothing, except for one thing: they hate Massachusetts’ ecumenical experiment.” Health Care for All receives financial support from the Massachusetts state government to support its enrollment and outreach efforts. 20/20 FORESIGHT: An Expert’s View of the Future In this first installment of an ongoing series smaller and expanding to pediatrics. We’ll of practitioner profiles highlighting leaders be able to slip catheters into places we in the surgical field, SURGERY NEWS spoke couldn’t before. And we’ll see not only a with Dr. Paul Taheri about the future of the convergence but an integration of technologies. For example, the electronic practice. Dr. Taheri, who also holds an M.B.A., is medical record is not clinically applicable president of the faculty practice plan for in surgery, but we’ll have all that inforFletcher Allen Health Care and is senior as- mation at one point. Decision making will sociate dean for clinical affairs at the Univer- be much more refined and quicker. sity of Vermont in Burlington. As president SN: Will there still be solo practitioners? How will groups have evolved? of the faculty practice, he leads Dr. Taheri: The days of solo the group of more than 480 practitioners are clearly dwinphysicians at UVM/Fletcher dling. We’ll see much more of Allen and is part of the senior a consortium model in which management team. As senior we may have a loosely knit associate dean for clinical afgroup. Solo practitioners don’t fairs, he oversees the office of have the economies of scale clinical trials research and needed to purchase the latest graduate medical education. electronic systems, and don’t In addition, Dr. Taheri, an have any clout to negotiate ACS Fellow, is a general surPAUL TAHERI, fees. If you’re a solo practigeon specializing in trauma, M.D., FACS tioner—particularly in a rural burns, and critical care. area—you’ll need electronic systems, SURGERY NEWS: Overall, what changes and the ability to use the electronic meddo you expect in surgery in the next 10- ical records system of a local hospital in your practice could be a key survival 20 years? Dr. Taheri: We’ll be doing more and technique for you. Data indicate that groups are tending more things we couldn’t actually do before. Procedures are actually getting big- to get bigger. We have 500 physicians, ger, not smaller, even though incisions which makes it much easier to take on are getting smaller, and more care is one more provider. We can amortize moving outside the hospital. Care is our costs better. Also, the bigger the more targeted, almost personalized med- group, the more negotiating leverage it icine. Ten years from now, you’ll look has. We do get more [money for the back and see a big difference—the rate of same procedures] than solo practitioners. Another issue is lifestyle. With a larger change is accelerating. SN: What changes will have occurred in group, the economics are there, and the lifestyle is there. the technology? Dr. Taheri: We will see a lot more focus SN: What will the operating room of the on better technology and different tech- future be like? nology being applied to the clinical space. Dr. Taheri: Surgeons will see a lot more Robotics and nanotechnology will come integration, particularly on the other into play. Catheters are smaller than they side of the ether screen. Right now, none were 3 years ago, and they’re getting even of the instruments are integrated. How we monitor people throughout the process should all be seamless. And there will be more targeted, localized pain control. On the operative side, incisions are getting smaller, not bigger. I don’t know if surgeons will use scalpels all the time. We’ll use sentinel node kinds of technology, and do procedures with much less blood loss. Even though we’ll be doing bigger operations, outcomes will be better. I’m very bullish on what surgery is going to provide. SN: How will surgeons and hospitals be paid? Will surgeons enjoy the same standard of living as today, or will that change? Dr. Taheri: Reimbursement should be fairly static. I’m not personally worried about our standard of living. But, there is a pretty significant exodus of physicians out of the clinical space, and that’s a huge issue. Surgeons train for a decade. To have these people switch careers is a loss to health care. Surgeons are increasingly moving toward the capacity model rather than the relative-value units model; they’re looking at alternative activities in their practices that aren’t RVU generators. They’re just trying to maintain their standard of living. For example, the person who runs the ICU typically gets something from the hospital. There’s not a lot of meat left in the RVU model. SN: How will future surgeons be trained? Will their experience be similar to yours? Dr. Taheri: Training clearly is going to be much more competency driven in the future. Tests need to be rewritten and prepared properly to prove competency. That means curriculums have to change. Because new surgeons are training in simulation centers, they’re coming into the operating room with some expectation that they know what they’re doing. But the downside is, they’re not as accountable as we used to be. On the service side, you actually are accountable— you own the patient. Trainees aren’t getting a full understanding about what their job is when they complete their training. SN: How will surgical performance and patient outcomes be monitored? Dr. Taheri: Surgery as a discipline should be credited with doing far and away the best job in peer review. If you get the data in real time to a surgeon, it will make a clinical difference. In the near future—a few years from now—we’ll have personalized medicine. We will be very much focused on outcomes, and they will be much more public. And there probably should be payments for outcomes at some levels. My general bias in this stuff is, the core transaction in health care is the interaction between the doctor and the patient. It is helpful to inform that transaction. In my institution, we have to get the information back to the doctor in the trenches—we have to make it easy to practice. It all stems from that central theme of the relationship between doctor and patient. SN: What else do you see in the future for surgery and surgeons? Dr. Taheri: There’s an issue of leadership. At the end of the day, doctors need to lead the enterprise. Right now, many physicians have a bit of a “woe is me” mentality. The reality is, they need to own their franchise; they need to drive that change. Physicians have ceded their leadership role—“I don’t want to do this, I just want to bitch about it”—and that’s the wrong attitude. There needs to be a real focus on physician/surgeon leadership. Interviewed by Jane Anderson, contributing writer.

Table of Contents Feed for the Digital Edition of Surgery News - May 2008

Surgery News - May 2008 Contents New Lung Approach Speeds Extubation Innovative GI Procedures May Improve Diabetes Quality Programs Differ on Risk Data Crystal Ball Medical Modeling Ventricular Valve Taking Stock

Surgery News - May 2008

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