Urologist Henry Rosevear, MD, discusses a recent OR experience that had him rethink his value as a surgeon and consider a possible alternative to better align the financial incentives of the surgeon with the hospital's goals.
Henry Rosevear, MD
How do you define your self-worth? I realize that may seem like a question better suited for a college philosophy class than a urology blog, but I recently had an experience in the OR that made me think about this. I also think this question has implications for health care policy makers.
I had just completed a left hand-assisted laparoscopic nephrectomy for a 9-cm renal mass. The patient was a man in his 60s with a history of a car accident decades ago status post-exploratory laparotomy and splenectomy. The mass had a R.E.N.A.L. nephrometry score of 10p. The case certainly had its own challenges, but 3 hours later the specimen was in a bag and I was sitting at the computer in the OR entering orders while my first assist closed skin.
I was sorting through the paperwork looking for a pen when I saw the equipment list the OR staff used to prep for the case and noted that next to each item was a column listed as “charge to patient.”
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I was amazed. The 4-0 monocryl I used cost $139.11. The gel hand port $495.00. The stapler I used to take the hilum cost $934.98 (each reload $348.91), and the LigaSure I used cost $2190.00. I remember chuckling to myself and moving on. It wasn't until later that day when I was submitting the paper bill that I realized that the wRVU for a laparoscopic nephrectomy was 25.06 and when using the Medicare conversion factor of $35.8279, that means that CMS values my portion of the case at $897.77.
Which makes my self-worth just under one stapler (without a reload). Or 41% of one LigaSure. Really?
Now I realize there are various forms of financial compensation available to surgeons and there’s variation in the valuation of a wRVU (I’ve seen advertisements as high as 75 per wRVU for people working in Fargo), but 36 per wRVU is likely ballpark for the majority of us small-town plumbers.
What does this have to do with the health care system in general and why is asking this question important to the powers that be when it comes to thinking about how to design an efficient health care system? Think about the decisions that go into surgery.
For example, let’s take that same 60ish-year-old man with a significant abdominal surgical history and a 9-cm enhancing renal mass. Why me? Should I have referred the case to the tertiary care center about an hour away? I know they have a great hotshot surgeon who almost for sure could have done the case faster than me. That would have saved OR time and hence money.
What about the approach I chose? I chose a hand-assist laparoscopic nephrectomy but I know of guys in town who use the robot for just about everything. How about pure laparoscopic? I felt safer with my hand in the abdomen but his risk of incisional hernia is likely higher as a result. Why not do the case open? Think of the extra gear that I used (and money spent) by my choice do to this in a minimally invasive fashion.
Yes, a flank incision carries more morbidity, but was it worth the cost? Should I even be contemplating these questions or should I just declare that I’m the surgeon and I’ll do what I think is right?
In today’s world of limited health care resources, these questions must be considered and I think most of us consider them even if we don’t realize it. A flank incision, while cheaper in the OR (disposables and time), would have left the patient in the hospital for many more days recovering. The unique abilities of the robot aren’t necessary in this case, and given the adhesions I encountered, would have slowed me down. A pure laparoscopic approach has none of the upsides of the robot and in my hands would have added significant time to the case.
On the other hand, given that I am paid the same amount regardless of the equipment I use in the OR, I think it is fair to look at my choices in the OR and question them.
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Is a LigaSure necessary? During residency, I was involved in a take-back following a laparoscopic nephrectomy where we found an active adrenal bleeder and the LigaSure certainly addresses that problem well. But is it necessary? How about that staple load? I certainly could have spent a few more minutes dissecting out the hilum and then simply clipped it (a five-pack of the large Hem-o-lok clips costs $450.61).
On the other hand, dissecting out the hilum does make my sphincter tense a bit but it’s something I certainly could have done (what if I had created a vascular injury in the process-scary thought). How about my decision to do the case in the first place? Nephrectomies are usually not the most challenging case we do, and the patients certainly prefer to stay local as Denver traffic is not the easiest to navigate. Besides, I don’t get paid to refer patients away, so why not? But I’ll certainly concede that there are more experienced surgeons in the world.
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I believe that in the ideal health care world, the financial incentives of the surgeon (complete the case safely and efficiently) should be aligned with the hospital’s goals (have the case done safely and with minimal cost), but how do you accomplish that? Giving me, as a surgeon, an ownership position in the hospital would help me consider the cost of the equipment I use while also tying my pay to outcomes to prevent me from skipping corners would work. This thought, though, is heresy given the inability of surgeons to own hospitals.
This topic is likely well above my pay grade but without the powers that be taking into account surgeon input, heath care costs will only continue to spiral with continued limited gains in care.
In the end though, to answer the question I began this blog with, my family defines my self-worth. I have a good day when a majority of my four daughters and my beautiful wife seem happy to see me when I get home. I’m not a greedy man; I don’t expect all five of them to be smiling every day when I walk through the door. But if most are, I smile too. Happy Thanksgiving!
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