According to Dr. Gutnisky, malpractice insurance and tort reform are the primary issues affecting his practice.  Louisiana is one of eight patient-compensation-fund states in the country.  Patient compensation funds (PCFs) are pools of money established by state law and formed by surcharge payments from doctors to provide additional funds in order to spread the risk of multi-million-dollar court decisions across a wide number of doctors. 

Louisiana’s fund was created in 1975 — during the nationwide malpractice insurance crisis, where costs were skyrocketing and availability was dwindling — by the state legislature’s passage of the Medical Malpractice Act (MMA).  The purpose of the act was to guarantee that affordable medical liability coverage was available to all healthcare providers, as well as provide a stable source of compensation to victims of malpractice.   This act currently caps non-economic medical malpractice damages at $500,000.  

Despite this law, medical malpractice insurance accounts for almost 50 percent of Dr. Gutnisky’s total overhead costs, with doctors who perform spinal surgeries paying the highest rates.  What’s more, physicians who perform emergency surgeries further increase their exposure to litigation.  Accident victims are more likely to sue and their surgical outcomes are more likely to be worse.  “Doctors face an enormous amount of liability for traumas,” said Melissa Hodgson, Director of Communications at St. Tammany Parish Hospital in Covington. 

 “Without tort reform or malpractice reform, we are not going to be able to contain healthcare costs,” said Gutnisky. 

Medicare and Other Compensation Issues 

A recent survey by the American Association of Neurological Surgeons (AANS) revealed that while most neurosurgeons still participate in Medicare, many indicated that if Medicare payments continue to decline they would stop providing certain services, reduce staff, defer purchase of new medical equipment, reduce time spent with Medicare patients, and begin referring complex cases elsewhere.  According to the AANS website, physicians faced a 22 percent cut in Medicare reimbursement on January 1, 2010, with total cuts in excess of 40 percent to come over the next five years.  “Eventually it will get to the point that specialists will no longer be available to take Medicare patients because of the poor reimbursement,” said Gutnisky, who still routinely sees Medicare patients. 

Unfortunately, private insurers tend to follow Medicare’s lead when it comes to reimbursement.   “When I started my practice here more than 20 years ago, I made more per procedure than I do now,” said Gutnisky. 

There are also problems of payment distortions.  For instance, why should surgery for a brain tumor, which may take 8-10 hours and be fraught with complications, be compensated at the same rate as a relatively simple, straightforward spine procedure that may take one hour?  “There’s just not much incentive to perform complicated surgeries.  I feel everything is upside down in the sense that the more complex, difficult surgeries in the sickest people are relatively the worst compensated,” said Gutnisky. 

Then there are the situations where there is no payment at all, which usually occurs for services rendered in emergency departments. “Uncompensated care is a big issue for specialists,” said Hodgson.  While insured people account for the vast majority of emergency room visits in the U.S., the proportion of visits by uninsured people is rising.  “It’s very simple, when you go to the ER, many times you don’t get any money,” said Gutnisky. 

An Artificial Shortage in Emergency Departments 

The traditional role of physicians taking emergency call as part of their obligation for hospital admitting privileges is unraveling and posing risks for insured and uninsured patients alike.  And while this is predominantly an issue for hospital emergency departments, it is also becoming an increasing problem for inpatients requiring urgent specialist care.  Driven by medical liability and reimbursement issues, specialists are seeking revenue generation elsewhere. 

Many specialty surgeons are now performing routine, scheduled surgeries at physician-owned hospitals and are no longer taking call at larger, full-service hospitals.  “The northshore’s biggest problem, by far, is the lack of specialists on call In the region’s ERs,” said Dr. Chad Muntan, Emergency Department Medical Director for Lakeview Regional Medical Center in Covington. 

There are only nine neurosurgeons practicing on the northshore and six full-service emergency departments struggling to provide services from these specialists.  Many doctors advocate regionalization to address the problem.  “There are just too many ERs for the northshore – the only solution is to create a single full-service ER on the northshore and then compensate specialists for trauma cases,” said Gutnisky. 

Luckily, the state of Louisiana, St. Tammany parish, and at least one area hospital are being proactive in addressing this issue.  The Louisiana Emergency Response Network (LERN) operates two call centers to advise and assist EMS personnel on the best facility for trauma victims at any given time and place within the state, based on the patient’s specific injuries.  Every hospital emergency department keeps information on staffing, wait times, and specialist availability up-to-date in the LERN network.  In addition, St. Tammany parish operates the Medical Control Line, a call center at St. Tammany’s Emergency Operations Center staffed on a rotating basis by each of the parish’s five ERs.     

EMS personnel follow specific protocols when on the scene to determine whether the parish or LERN network is accessed and to get patients to the hospital that has the appropriate resources to deal with their injuries.  “The LERN network and parish protocols make it a lot easier than it used to be to move patients from the scene to where they need to be quickly and efficiently,” said Lewis Taylor, Operations Manager for Acadian Ambulance Service, Inc. 

St. Tammany Parish Hospital in Covington also recognized this problem and in response started their Community Emergency Services Program in 2008.   “We wanted to ensure appropriate care through our ER and be able to meet the community’s needs.  Physicians who commit to provide services through our ER know they will be compensated and patients know we will have the specialist coverage they need,” said Hodgson. 

Will the Healthcare Reform Act Help? 

“It’s premature to tell what the effects will be.  The fact that more people will be covered is not a bad thing and maybe we’ll get paid for emergencies now,” said Gutnisky.  

While the Healthcare Reform Act addresses the issues of the uninsured and preexisting conditions, it doesn’t begin to address the larger issues of tort reform or compensation levels.  In fact, if the trends in Medicare compensation portend of things to come, access to specialists could get a lot worse, regardless of whether you’re insured.