It is an honor to have served as President of the Northern California Chapter of the American College of Surgeons.

There is a crisis in surgery affecting our colleagues in private practice, academia, and government service. Reimbursements have plummeted, overhead has soared, and we are confronted with a myriad of oppressive regulations and legal pressures. Implementation of HIPAA and EMTALA has hindered our ability to efficiently care for our patients and has further exposed us to legal jeopardy. Despite this onslaught the most dangerous and imminent threat to the practice of surgery is the incessant reduction of reimbursements.

Reimbursement for surgical services has not kept pace with the cost of maintaining a surgery practice. Without considering inflation I earn 65-70% of the amount I took home in 1999. Yet despite running a “no frills” practice, my overhead has increased by nearly 10% per year. These overhead expenses have, over the last 6 years, increased from 35 to 54% of my gross receipts.

The decrease in reimbursement from Workman’s Compensation, HMO’s, and PPO’s has been substantial and is due to a variety if reasons. The most insidious is a result of “silent PPO’s” and outright theft by insurance companies such as Aetna, Cigna, and PacificCare. The CMA has challenged these companies in court under racketeering statutes, but the settlements are only a small fraction of the funds stolen from us.

I am discouraged with the Federal government’s strategy to institute massive cutbacks in Medicare reimbursement. In fact the present plan calls for a 5.2% reduction each year from 2006 through 2012. This constitutes a staggering 35% slash in Medicare reimbursement over the next seven years. For those of us who have an office overhead of 50% this will result in a 70% reduction in our take home income. Since private insurances follow the RBRVS, we can anticipate further dramatic retrenchments. Contrary to Medicare’s expectations, it is impossible to compensate for this by increasing productivity.

Presently the Federal government is considering a 1.5 – 3 % fee increase for 2006. However, this modest sum does not come close to covering the annual increase in practice overhead and inflation. To further exacerbate the problem the state of California anticipates lowering the already abysmal Medi-Cal fee schedule.

It is incongruous that one of the most demanding and essential medical specialties has received the brunt of income reduction for rendered medical services. We treat the sickest patients under the most demanding conditions, but our natural independence and uncompromising advocacy of our patients allows payors to take advantage of our good will.

Our way of life is at grave risk. Fewer surgeons are being trained and experienced surgeons are retiring early or seeking salaried employment. A number of our colleagues want to invest in surgery centers to supplement their income, but the powerful hospital lobby continues to pressure the government to maintain the moratorium created 1 ½ years ago on new surgery center construction.

We can persist in this downward spiral, or we can say an emphatic “No” to third party payers. This is the only conceivable manner in which to preserve private surgical practice. Only when surgical services are not available on demand to the public will our economic health improve.

Our professional societies, the ACS, the CMA, the AMA, and others have made sincere efforts to publicize these inadequacies, yet there is little to show in terms of solutions for our beleaguered profession. This is because our societies can inform patients and payors about the inadequacies of reimbursement but they cannot say “NO, I will not provide the service at the reimbursement level you are offering!” IT IS UP TO EACH OF US INDIVIDUALLY TO MAKE THIS STATEMENT. It is my sincere belief we must stand fast together and refuse to care for patients at reimbursement rates that sound the death knell for our noble profession.

I look forward to your comments and suggestions. My Email address is: conmichas@yahoo.com.

Sincerely,

Con