Challenges of Domestic Surgical Volunteerism
There are barriers within the US healthcare system that limit the ability of organizations and individuals to provide surgical care to the uninsured and underinsured. Outpatient surgical consultation is considered specialty care and often requires prior authorization from insurers, including Medicaid. Furthermore, where these patients receive care also is limited and often dictated by insurers.
While the government has provided various ways to assist citizens with access to healthcare, via Medicare and the Affordable Care Act, for example, the US healthcare system remains fragmented and difficult to navigate, particularly for those with poor medical literacy, language barriers, and geographical or transportation challenges.
Medical insurance premiums also are expensive, particularly for small business owners who may not have employee-subsidized premiums, leaving people to choose whether or not to pay for medical insurance coverage.
When uninsured patients have surgical emergencies, they often have nowhere to turn other than emergency departments. It is not uncommon for marginalized populations and uninsured individuals to present to emergency departments with diagnoses requiring urgent or emergent surgery, including but not limited to strangulated hernias or undiagnosed cancers that have perforated.
In these situations, emergency Medicaid reimburses hospitals for procedures needed to treat life-threatening conditions but does not cover outpatient surgeries—an apparent flaw, considering that emergency surgeries often are more costly and resource-intensive than outpatient scheduled procedures.
The question of hospital costs and payment further complicates matters. Many healthcare systems separate professional and facility fees. In other words, even if a surgeon is willing to donate their time to perform an operation, the surgery center or hospital also must be willing to donate resources, including medications, supplies, OR availability, not to mention staff, such as anesthesia providers, OR nurses, scrub technicians, a pathologist to evaluate specimens, and perioperative personnel. The question remains, however, as to how costs are covered if postoperative complications arise.
Credentialing and licensing present another challenge. If a surgeon wants to volunteer outside their community or health system, would their credentials to perform surgery be recognized?
Currently, there is no solution to this issue across state lines, as licensing in one state is not recognized in another—a significant barrier that fundamentally disrupts efforts to collaborate and direct care to communities in need of surgeons. This circumstance also limits the ability for surgeons to volunteer in the event of a disaster as was demonstrated during COVID-19. Moreover, liability insurance is a necessity for surgeons and an additional barrier to domestic volunteerism.
Beyond hospital administration and licensing barriers, uninsured patients often are apprehensive about interacting with the healthcare system, a reality that is exacerbated by public objections toward using resources for noncitizens. Nonetheless, care must be provided, and resources must be used when patients present to safety net hospitals for urgent and emergent care.
