Occupy the OR

Steven Peskin MD

Leaving the gym on an unseasonably warm night, I struck up a conversation in the parking lot with a vascular surgeon acquaintance. He recounted a technically demanding procedure that he had done the day before with a reported 10 percent risk of stroke and a 3 percent mortality risk.

The two-stage procedure was optimally done in one trip to the OR with two surgeons involved in the several-hour two-stage surgeries. My acquaintance commented that his reimbursement and that of his colleague came to about $70 an hour — and that does not include the 90 days of post-op care associated with the reimbursement for the surgery.

In the reimbursement of medical services, complexity abounds: new technologies or the application of existing technology in new ways; the supplanting of one modality for another; efforts to tie reimbursement to performance, outcomes, and/or quality.

This surgeon mentioned that he could have done the two-staged procedure as two separate surgeries and been reimbursed considerably more. I am heartened to know that he did what he perceived to be best for the patient versus his kids’ college fund. He also commented on witnessing interventional internists and surgeons who elected to separate procedures, for example, diagnostic cardiac catheterization followed by PCI, versus completing both in one trip to the cath lab.

Despite the enthusiasm that many of us share for the medical home and other forms of value-based reimbursement, there is still plenty of work to be done to rationalize the blocking and tackling in the still-dominant fee-for-service payment model.

Steven R. Peskin, MD, MBA, FACP is executive vice president and chief medical officer of MediMedia USA, which publishes Managed Care. He is Associate Clinical Professor of Medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School


Fight the power

Re: Occupy the OR

It strikes me that Dr. Peskin’s experience highlights the benefits of non-Medicare ACOs. While creating a competitive market where corporations can purchase healthcare services directly from provider groups, these ACOs will move treatment-related compensation decisions from distant, non-clinical insurance companies into the clinical organizations themselves, concomitantly moving the power associated with those decisions closer to the clinicians.

Eliminating input from insurance companies will certainly save money and marginally improve clinical decision making (insofar as clinical decision making is nudged one way or the other by the strictures of current payers). But will physicians benefit when compensation decisions are made for clinicians by clinicians? It depends how close the physicians are to those decisions.

Mark Cantor, MBA, is the president of Cantor Advisors, a turnaround consultancy that specializes in reviving and reinvigorating struggling companies and advising their financing sources. Cantor Advisors' healthcare services clients have been affected by the industry's increasing rate of change, complexity, and uncertainty.

Fee for service is a conflict of interest

Fee for service medicine is an inherent conflict of interest. The medical culture relies on doctors to manage this conflict by indoctrinating members to place the interests of the patient above their own. It is often difficult to do the right thing, whether it is in business or medicine.