Transforming Patient Care
The microscope added new dimension to operating on small structures, such as aneurysms and complex tumors, thus enhancing operative safety. The 21 st century has seen increased use of robotics, endovascular treatments and minimally invasive surgery. In fact, technology has advanced medicine significantly in the past years. At the turn of the 20 th century, the Roentgenogram gave us a view of the human body no one had ever seen before.
Electrocautery allowed us to control bleeding to avoid blood loss at dangerous, life-threatening levels. And electricity, yes, electricity, is the technological advancement that has made most of the above possible. So how can there possibly be any pitfalls in all of this? Every advance in technology is accompanied by a new learning curve aimed towards mastery. The literature abounds with experiences in new techniques and the process of learning these techniques that inform future success and reduction in related complications.
There are few technologies in neurosurgery that can be easily adopted without encountering some troubleshooting along the way. The blessing is that, over time, these issues often diminish, and the true advantage of new technologies promoting efficiency and safety can be fully appreciated and enjoyed, often becoming the standard of care. However, given the philosophy that life is about the journey, not the destination, the process of getting to the point of nirvana can be painstaking, tedious and frustrating.
Technology is always evolving. New things will eventually replace the old in our rapidly developing technological environment. However, relegating our time-honored tools to obsolescence may be counterproductive. Recently during a trauma performance improvement conference, we were surprised to find out that the operating room no longer supplied stethoscopes because they were considered infection control hazards. In our practice environment, the use of the stethoscope after intubation has largely been replaced by the end tidal CO 2 monitor — a technology that has increased the safety of general endotracheal anesthesia over the years, preventing anoxic brain injury from inadvertent esophageal intubations.
Nevertheless, the basic act of listening to the lungs to assure that they are being appropriately ventilated has been washed away by the notion that stethoscopes are potentially too unsanitary to be of use! There are many physicians rolling over in their graves. Imagine, this sacrosanct tool of the trade a vector for infection; old tried and true technology has given way to fear. However, what if the end tidal CO 2 monitor fails in the middle of an intubation or the power goes out? Without that stethoscope, we are back to square one.
Precision measurement and process control. Position and motion control. Request engineer support and learn more about our repair , calibration or refurbishment services. All were active in quality improvement processes. For those in private practice and a more traditional relationship with the hospital, Medical Executive Committees were vehicles to review data and make service-level decisions; larger groups utilized a Departmental or Service Line organization.
At Kaiser Permanente, there is now an effort to organize all its neurosurgical services nationally to study outcomes.
All neurosurgeons value autonomy and being able to make decisions about both patient care and practice management. The solo practitioners have complete control over their budgets, but less institutional support or financial backing if a deficit developed. The larger groups have a variety of relationships with institutional leaders like the Dean or hospital leaders, but in this survey, most neurosurgeons have significant decision-making authority and financial control.
However, the majority receive significant ongoing financial support from an institution, which necessarily decreases independence. Still, most have strategic and operational control over their practices, making hiring and firing decisions of staff among other functions.
Even at Kaiser Permanente, a fully integrated system with employed physicians, neurosurgical organization was similar to other group practices. The physicians are organized in a multispecialty physician practice with an exclusive relationship with the health plan and the hospital system, but separate physician management. At each medical center, neurosurgeons form a partnership and manage their own clinic staff such as practice administrators, medical assistants and nurses, with a budget determined with the larger medical group.
While recognizing that the healthcare system will remain heterogeneous with regional variation, all predicted significant shifts are occurring now and accelerating rapidly. This included an increase in restricted networks, bundled payments, and population health. Pennsylvania State University has already piloted a bundled project for stroke, sponsored by the Centers for Medicare and Medicaid Services; they are also engaged in a population health project with Lancaster County.
Most felt that partial or full risk contracting was looming, with increasing focus on quality outcomes and value. The executive team believed that the major shift driving change is the transition from a predominantly fee-for-service system to the introduction of capitation and population health. They believed that such arrangements would incentivize doctors and hospitals to keep patients healthy and provide efficient care.
The executive team felt strongly that only large systems or groups would be viable in this environment, able to negotiate adequate reimbursement, and enroll enough patients to maximize economies of scale. They predicted a wave of mergers or acquisitions involving providers and among insurers.
At Memorial Hermann, planning has already started to care for 2.
Neurosurgery | UCI Health | Orange County, CA
The executives cited physician integration as crucial to this future, and a high priority for their immediate strategy. Small practices cannot afford the substantial infrastructure required to track metrics, affect quality, and manage cost. More importantly, population healthcare requires the ability to provide all services in a single network; the government or an organization that purchases such a product will want 1 contract with 1 entity. This means that in situations of incomplete capability, other providers and groups must be subcontracted to provide care.
Costs cannot be readily controlled in such situations. Therefore, 1 organization will need to provide and manage most of the services for a given patient, from primary care to neurosurgery to ancillary services and rehabilitation.
Further, that organization will want to track and manage expenses, and develop processes that reduce cost and financial risk. Such capability requires a comprehensive and aligned physician group, a common and integrated informatics platform, analytics capability that provides accurate, timely data, and physician-administrative partnerships that can manage both clinical and financial outcomes. For this reason, a similar focus on quality and efficiency will apply to all patients. The executives acknowledged that autonomy is important to many physicians and that they may seek alternatives to employment.
They know that the perception exists among doctors that decision-making ability is lost with employment. Further, the executives acknowledged a major advantage of independence is the ability to enter joint ventures or other financial opportunities, which can be curtailed under an employment model.
While it provides guaranteed coverage and commitment to the system, hiring physicians is expensive and employed physicians may become less productive. In the late s and early s, many hospitals lost a significant amount of money employing doctors. Therefore, having other options for integration was important to hospital executives.
In summary, both physicians and executives agreed that episodic care and fee-for-service reimbursement will remain, but that population health is part of our future. In the past, physicians and hospitals had different spheres of influence and hospital administrators were unlikely to question physician decisions. With the advent of the quality movement and fixed payments per admission, physician decisions began to directly determine a hospital's quality and financial outcomes.
Now, physicians and hospitals will need to reorganize and develop closer relationships that can adjust to new payment models and manage risk. Can this be done by individuals and smaller groups, or is joining a larger group necessary? How do neurosurgeons align incentives with hospitals and other physicians like neurologists or anesthesiologists? How will revenue flow within such entities and how do neurosurgeons get appropriate resources? What is the best way to become efficient, yet maintain quality of care and other core values? What is the best way to teach the next generation and advance the science of neurosurgery?
In different institutions, there will be different answers with significant variation in management, authority, and organization. However, some sort of legal integration will likely be a necessary foundation for success.