What can we do about this? First, knowledge is power. Sometimes simply naming names is enough. A recently published paper showed that by simply providing surgeons with a monthly scorecard listing supply costs for each case they did, the intervention group was able to decrease costs by almost 10% with no changes in medical outcomes (JAMA Surg 2017; 152:284-91). And while that may work in some cases, given variations in case complexity, practice pattern, and the lack of granularity of billing data (ie, I bill a 52356 ureteroscopy laser lithotripsy with stent placement for both a 7-mm distal ureteral stone and a 2-cm renal pelvis stone), it is naïve to think that every case and every surgeon will have the same costs.
Correctly making tough intraoperative decisions is what surgeons are paid to do. With that in mind though, it is likely possible to cut some of the “fat” from the system. The general surgery article referenced above, which examined cost variation in laparoscopic cholecystectomy, provides one example. This group was able to identify the disposable equipment that produced the least costs without negatively impacting outcomes.
While this may work in the academic setting, I question whether it will work in the private practice setting. Why? For no other reason than the outcomes of interest for a hospital and a surgeon are not aligned. The goal of the hospital is to provide medically safe surgery in a cost-efficient manner. The surgeon’s goal, in contrast, is only to achieve a good medical outcome. A surgeon takes home the same amount of money if he or she spends $1 on disposables or $1 million.
My group is taking this to heart and approaching one of the hospital systems in town about better aligning our goals. We are proposing to internally evaluate our use of disposable equipment while monitoring clinical outcomes with the understanding that any gains are shared between the hospital and the surgeons. I don’t know if this is going to work, but I don’t see how it can hurt. I’ll report back in a few months with an update on how this turns out for us.
Primum non nocere. And I would argue that we make an effort to do surgery efficiently. If anyone else has thought about this issue and has ideas on how to reduce costs while continuing to provide excellent care, please write me at [email protected].
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