Dear Dr. Fife,
I am writing this letter as a general surgeon who is deeply concerned about our healthcare system. As you have pointed out in your blog, physician payments by CMS and private insurers are a fraction of what they were 20 years ago because physician payments (and only physician payments) have not kept up with inflation. (This is why there is a shortage of physicians and why care is increasingly being provided by less trained individuals who complete their degrees with lower educational debt and can accept lower wages.) This reduction in physician payment is particularly evident in the “90 day global” fees for surgery and post operative management. Surgeons are disincentivized from managing post-operative patients, because the overhead cost of dressing supplies and skilled labor are higher than they can afford.
The net result is that surgeons select patients and procedures that are uncomplicated and likely to require little or no post-operative management. Patients who need complicated operations may not be able to find a surgeon who can afford to provide their care. Unfortunately, even standard cases can become complex. Last night I operated on a patient with a ruptured appendix which means that I had to leave the wound open in order to prevent infection. This commits the patient to a long treatment course as we wait for the wound to heal slowly. I am paid $946 for the operation which took an hour, and which assumes 4 post operative visits each taking 15 minutes. Half of my payment goes to overhead, so I pocketed less than $500. However, to provide good care for the patient with the ruptured appendix requires weekly visits over the 90-day time frame – more than 12 post op visits (not 4), not to mention dressings that I also can’t afford.
Negative Pressure Wound Therapy (NPWT) is a fantastic advance in the management of open surgical wounds. NPWT device rental is around $1800/month so assuming about 2 months of treatment, the cost is ~$3,600 for the device and another ~$1500 for supplies, for a total of ~ $5,100 for two months. Surgeons can provide NPWT in their office, but this further increases the financial burden on the doctor (the visits take an hour) and most surgeons can no longer afford to employ nurses who can do such complex care. Therefore, I will shift the cost of NPWT to a Home Health agency. The Home Health agency to whom I sent the wound care orders receives a separate payment under the Home Health Prospective Payment System (HH PPS) which has an episode of care of 30 days – although patients are certified for 60 days of care. The math around their payment model is complicated but the average 30-day payment rate is around $2,038 so that’s $4,076 for 60 days of home health care (which must cover all nursing salaries and other overhead expenses).
The home health agencies are getting squeezed by their capitated payment model and it may cost them more to deliver the care for time consuming treatments like NPWT. So, many Home Health Agencies will shift the cost to a mobile wound care company. The Home Health agency calls a mobile wound care company and let’s them know that they have a new patient with a wound. I am not informed of this referral by the Home Health Agency, nor does the “mobile” nurse practitioner contact me after he or she sees my patient. In some cases, the Home Health agency may even stop seeing my patient, pocketing their 60-day payment and turning the care of the patient over to the mobile practitioner. Remember that an open surgical wound like this can be quite large – let’s say it’s 5 cm x 20 cm = 100 cm2. The cost of the skin substitute that large is ~$250,000 and the mobile practitioner can apply one each week for 6 weeks at a cost to Medicare of >$1 million. Those applications take only a few minutes and require little clinical training.
All of this is legal. Is it ethical? I don’t know. Medicare created the problem by reducing physician payment to the point that physicians cannot afford to care for patients. Medicare could have saved a million dollars by paying the surgeon (me) a fair wage for the real cost of performing the operation and the post operative care, including the costs associated with wound care for dressing. Even if Medicare paid me over $6,000 for the 90-day global (which is what I estimate is the true cost), it would have saved the tax payer a lot of money. Now you may ask, why didn’t I apply that amniotic tissue and make a million dollars for my practice? Because for 90 days after the procedure, I can’t charge the patient additional fees. It would be illegal. We have created a system in which the shifting of costs continues until someone gets paid enough to do it. That’s how we got here. I have no idea how we get out.
Name withheld
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
