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Economic Terms of Surgical Practice

Division of Surgical Oncology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia

To the Editor:

I read Dr. Lucci’s article¹ and the editorial reply by Dr. Mabry² in the December 2004 issue with great interest. Both authors highlight the current problems with our medical economic system. Most economic systems in our society are driven by the consumer and thus are outcome based, whether it be a product purchased or a service rendered. Pricing is thus predicated on the balance of the perceived value and demand with the cost of production and delivery. Our medical economic system does not fit this formula when we as physicians and surgeons serve as the gatekeepers of demand (whether for modified radical mastectomy, segmental mastectomy with axillary dissection, or segmental mastectomy and sentinel node biopsy, as in the topic of Dr. Lucci’s article) and arbitrators of value (certainly as pertains to risks of morbidity and mortality even when other measured outcomes of value, such as cancer-free survival, are considered) while a third party determines our cost of production and delivery. This reversal of role threatens to remove us from the medical economic system, because surely our patients will increasingly demand the role of gatekeeper and arbitrator for products and services for themselves and will no longer entrust it to our care. We should support this transition, because our patients are the ones who take the greatest risk to achieve their desired benefit. We should always care most about patient outcome, and the economics of our practice should reflect this. Continuing on as gatekeepers and arbitrators of what products and services to render can only engender suspicion of our economic motives when outcomes are not correlated with reimbursement, as presented by Dr. Lucci. Thus, if we cannot garner greater control to determine the cost of products and services, we as a profession will become the third party in our own health-care system. We must be proactive in defining the economic terms of our surgical practice instead of hoping for favorable reimbursement.

REFERENCES

1. Lucci A, Shoher A, Sherman MO, Azzizadeh A. Assessment of current Medicare reimbursement system for breast cancer operations. Ann Surg Oncol 2004;11:1037–1044.[Abstract/Free Full Text]
2. Mabry CD. Appropriate payment will follow quality care. Ann Surg Oncol 2004;11:1027–1029.[Free Full Text]

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