The Experts Comment
Dr. William Kelley, Jr.
Richmond Surgical Group
Tuckahoe Medical Center
Richmond, Virginia
This issue of Laparoscopy in Focus highlights a series of critical cost issues that has been in the public and professional media for the past two years. We as surgeons should be aware that the time for attacking these issues is not soon, but now. The insurance industry is currently collecting data to generate cost profiles on surgeons and hospitals. In fact, it may even be too late for some individuals and institutions to effect changes that will alter their cost profiles. Economic credentialing is a very important part of many managed care systems, and inefficient, costly providers will soon be excluded from aggressively managed programs. True cost analysis and systems analysis such as the BEST PRACTICES* Program will allow each hospital to objectively assess its own efficiency. This program also allows the institution to compare its own systems against a standardized model, to identify areas where excess costs are generated.
"As surgeons, we must indeed become proactive and apply
pressure on each of our hospitals to embrace the kinds
of models outlined in this issue."
The BEST PRACTICES* Program provides hospitals with a syntax within which they can work to reduce the global cost of selected procedures. Expansion of the model to include pre- and postoperative patient care within "clinical pathways" will further streamline costs. The institution of standardized instrument kits has already reduced the cost of affected MIS procedures in our hospitals. We have also realized significant reduction in OR time for MIS procedures with the introduction of dedicated OR suites and, at one of our hospitals, an MIS team. As surgeons, we must indeed become proactive and apply pressure on each of our hospitals to embrace the kinds of models outlined in this issue of Laparoscopy in Focus. We must continue to analyze the economic impact of the choices we make for our own patients, and of the choices our hospitals make for us. Of equal importance, we must apply pressure on the hospitals to ensure that cost savings be reflected in patient charges. Increasingly, decisions will be made upon costs and charges. The managed care profile for each provider is based upon the global charges generated by that provider, rather than the cost of the care provided. Hospitals will make decisions based upon costs, but economic profiles (and possibly economic credentialing) will be based upon charges.
Dr. John Bertrand
Director of Reproductive Surgery, Presbyterian Hospital;
and Clinical Professor, University of Texas
We are currently faced with major changes in the delivery of health care. Cost-effectiveness and necessity are now issues of everyday life for the practitioner. Because many of us are mired in capitated environments, these questions are now directly affecting incomes. As each of us examines cost-saving measures, it is important to look at each surgical cure or correction as a process and not as an individual surgical occurrence. We must become outcomes-oriented and carefully evaluate any disability incurred by the procedures we perform.
"As each of us examinescost-saving measures, it is important to
look at each surgical cure or correction as a process and not as an individual surgical occurrence."
You have read in this issue one program, by United States Surgical Corp., designed to assist the physician in exerting control within the hospital while facing this new challenge. The program currently in my hospital, mirroring BEST PRACTICES*, is entitled value enhancement. Whether by using the BEST PRACTICES* Program or value enhancement, it is necessary for each of us to get involved. Areas targeted include length of stay, operating room cost, supplies, and ancillary services. The importance of this is that the total system cost must be analyzed, disability included. Studies have shown that even though minimally invasive procedures may increase operating room costs, all other expenses are usually decreased. When disability is factored in, the savings become even greater. A program such as the BEST PRACTICES* Program finds ways to achieve short-term economic efficiencies. Current assessments are viewed and comparisons are made. Specific goals and objectives are set. The immediate savings are then calculated and cost-efficient ideas implemented. These programs not only deal with economics, but also the logistics of effective health care delivery. Recommendations such as designating specific members of endoscopic teams and operating room suites are made. Also, the great debate pitting disposables versus reusables needs to be left to the physician. In certain institutions, one would be better than the other. But this cannot be qualified as all or none; common sense must prevail.
In conclusion, the real question that all of us must ask is: What will benefit the patient? Where cost savings do not infringe on patient safety, consideration of cost may be given. But in the end, any program embraced by the hospital or physician must keep the care of the patient uppermost in mind.
Dr. Joseph B. Petelin
Director, Surgix-
Center for Video-Enhanced Telescopic Surgery
Shawnee Mission, Kansas
"Americans still care about quality. The country is full of intelligent, courageous people who would change if they only knew how."
-W. Edwards Deming
This is an interesting issue. Americans have always valued our health care system, and it's appropriate that they should, because it's the best in the world. So it is natural that efforts to control costs have received so much attention in the past few decades. An episode of medical care is no longer measured in terms of its success or failure in treating an ailment. The focus has changed to encompass the costs associated with that incident. Health care providers, searching for "cost-effectiveness," have employed a myriad of consultants touting countless methods and wielding the latest buzz words and managed care acronyms.
"An episode of medical care is no longer measured in terms of its
success or failure in treating an ailment. The focus has changed to
encompass the costs associated with that incident."
Few, however, have done little more than construct systems that offer discounts for goods and services (eg, PPOs), or strictly control (limit?) access to the health care delivery system (HMOs) as their solution to the cost issue. Hospitals have focused on the tangible: reducing the costs of "widgets" and personnel. Getting a good handle on the real issue-quality-has been more elusive.
While some of the issues of quality regarding equipment and personnel training seem very clear to surgeons, they may be difficult for OR managers to appreciate in the overall context of budget concerns. Compounding the problem is the fact that, in many institutions, equipment purchasing decisions are being made more and more by "materials managers" rather than the end users, the surgeons; and the dialogue between surgeons and these buyers has been reduced to "the cost per widget" rather than the value of the piece of equipment in question. So it often appears that the interests of these three parties are not aligned. This results in higher costs and poorer quality. For example, it doesn't make a lot of sense to save a few dollars on a poorly designed, ergonomically inferior laparoscopic scissor or clip applier, or any instrument for that matter, if it results in prolonged operating time, which may cost hundreds of times as much. Similarly, the concept that all OR personnel cannot afford to have dedicated teams is simply not an efficient way to manage quality instrument for a case, or who delays a case just 15 minutes, costs much more than the salary and benefits of a highly trained individual team member dedicated to a specialty.
The program described here is an excellent starting point for any institution seriously interested in improving the quality and lowering the cost of the surgical treatment of disease. Providers must first of all find out the true cost of a quality outcome, determine the critical pathway toward achieving that outcome, and then design an institution-specific program that aligns the interests of all the parties involved: surgeons, administrators, payors, employers and patients. The treatment environment that evolves from that study should provide the highest quality at the lowest cost.
Dr. William B. Saye
Medical Director
Advanced Laparoscopy Training Center
Marietta, Georgia
Congress has put health care reform on the back burner for the moment, but managed care has arrived and is moving to reform medical care in America as soon as possible. The American people will soon be faced with quality medicine being replaced by cost-effective medicine, unless something is done to prevent such a turn of events. All providers of medical care, including physicians, must join together to prevent this undesirable change. Teamwork is like a chain, and a chain is as strong as its weakest link. We must strive to continue to deliver quality medical care in America through a concerted team effort.
"The BEST PRACTICES* Program can assist us in using
technology and employing laparoscopic procedures by showing
that these can be cost-effective when used in an efficient manner."
Physicians are being introduced to the concept of financial profiling. We enjoy many modern technological and surgical advances in America; unfortunately, many such advances are being ignored because of cost. The BEST PRACTICES* Program can assist us in using technology and employing laparoscopic procedures by showing that these can be cost-effective when used in an efficient manner. Instrument and procedural standardization can be accomplished without taking away the surgeon's freedom of choice. Certain instruments must be available for all cases, and auxiliary instruments should be made available only when necessary. This will eliminate unnecessary instruments from being provided on the table for the surgeon during every procedure, regardless of whether these are reusable or disposable instruments. It is very expensive to clean, resterilize and repackage reusable instruments. This is sometimes overlooked in the surgical arena, but it is an issue that must be addressed as we look at the total cost of providing medical care.
"Nursing and other operating room personnel must be trained to
be more efficient. Studies of operating room times will raise
sensitive issues, but it is very important for all
members of the surgical team to realize that the goal is
total cost reduction while still delivering quality medicine."
In government, sometimes a task force is necessary in order to determine the best method to accomplish the goals that have been set. Physicians, especially surgeons, must make every effort to be a part of the task force for the BEST PRACTICES* Program and take a proactive approach to lowering health care costs while still providing quality health care, a major problem in America.
"Cookbook medicine" has never been effective; this has been shown over and over. Each patient must have appropriate medical and surgical treatment, which takes individual care and planning. The approach of the BEST PRACTICES* Program also means that nursing and other operating room personnel must be trained to be more efficient. Studies of operating room times will raise sensitive issues, but it is very important for all members of the surgical team to realize that the goal is total cost reduction while still delivering quality medicine. If efficient approaches to the BEST PRACTICES* Program are undertaken, the incremental savings to the hospital can be tremendous. These savings can even facilitate the use of higher-quality and more-expensive equipment because of the cost savings provided from the efficient provision of health care.
Surgeons in America must be aware that cost-effective medicine is coming. The task we undertake is providing quality medicine by using the BEST PRACTICES* Program so that efficient, well-trained, well-staffed and well-equipped operating rooms can continue to function, providing the quality of care that we in America have always been so proud of. We must not forget that the patient, not the bottom line, is still the most important part in the circle of success that is medical care in America today. The best way to provide quality medical care is to practice quality medicine, and the BEST PRACTICES* program can assist every physician in America in attaining this goal.
*Trademark of United States Surgical Corporation