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Surgery Grand Rounds

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Grand Rounds

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Educational Schedule

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Educational Schedule - March 2014 (PDF)

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The New Healthcare - Surgeons Should Take the Lead

Harry C. Sax, MD, MHCM

By Harry C. Sax, MD, MHCM
Professor and Executive Vice Chair, Department of Surgery
Physician Liaison, Cedars-Sinai Medicine Clinical Transformation Initiative

Last month, Bruce Gewertz, MD, surgeon-in-chief, outlined the challenges we are facing with healthcare reform and a shift from a volume-based, fee-for-service practice to one of populations and "value." Although these terms are ambiguous, surgeons routinely deal with ambiguity and make definitive decisions in the best interests of their patients.

In fact, in the new healthcare world, surgeons will play a greater role in expeditiously and efficiently dealing with disease and restoring patients to improved health and function. As surgeons share risk for the total care of the patient, there will be increased efficiency by eliminating unnecessary testing, improving the coordination of care and shortening the time required for the patient to be in the hospital. Minimally invasive techniques will be honed, allowing more outpatient and short-stay procedures and increasing value.

Not surprisingly, there is healthy skepticism from the medical staff regarding the new initiatives intended to adapt to the changing world. It is easy to think the status quo will continue and that our healthy finances won't change. But the shot across the bow with our exclusion from exchange networks was a wake-up call.

It is not a stretch to recognize that individual practitioners are at the same risk for exclusion as the hospital systems. Some may choose to not take insurance — in the short term a potential option, until the market saturates. Others will take advantage of the multitudes of performance data available, and understand how to use best practices, good judgment and skills to tap into a large and expanding pool of patients.

Cedars-Sinai has several important programs supporting this effort:

  • A major effort is underway to reduce length of stay with real-time interventions. Physician advocates are meeting daily with nursing, case management, and social work to help your patients get to the OR and then have well-coordinated post-discharge care. You may be contacted to clarify questions and care plans in support of your efforts.
  • In preparation for public reporting, unblinded performance data such as length of stay will be shared among groups of clinicians with similar practices, to allow those with opportunity for improvement to learn from their colleagues. The insurance companies already have these data, as well as costs — it will be important to understand how we look to the outside.
  • New population health programs focusing on the continuum of care will open opportunities for surgeons to intervene earlier and prevent costly admissions.
  • Neil Romanoff, MD, associate chief medical officer, vice president for Medical Affairs and chief Patient Safety officer, is leading the development of preferred home health providers that will have a higher quality and range of services, allowing you to confidently treat many of your patients at home after discharge and reduce readmissions.

Recently at a morbidity and mortality conference, Ken Adashek, MD, related a story (confirmed by Leo Gordon, MD) from one of the giants of American surgery, Mark Ravitch ("A Modest Proposal," Surgical Rounds, June 1982). Ravitch said the most efficient way to practice medicine is to have surgeons admit everyone out of the emergency room. They would rapidly identify and operate on those with surgical disease and rule out significant pathology among the rest. Those remaining patients would then be transferred to nonoperative disciplines for care. There were smiles around the room, yet the premise is not far off.

Surgeons are capable of leading the charge and adapting to a changing environment, just as we deal with unexpected pathology or a patient who decompensates postoperatively. Surgeons have a unique, proactive skill set that will be valued in the new era of healthcare. The future is exciting and the opportunities unlimited.

And if you doubt that, think about if you could only have only one doctor in a town: Is there any question it would be a general surgeon?