10-25% of surgeries in certain specialties performed in the United States may be unnecessary, according to governmental and academic sources. Since 2005, more than 1,000 surgeons have made payments to settle or close malpractice claims in surgical cases that involved allegations of unnecessary procedures. When unnecessary surgery occurs, nobody wins. Not only is it a blatant violation of ethics in medicine, but when a surgeon performs unnecessary surgery, it undermines the basic trust that a patient has with the healthcare system.
Risks of Unnecessary Surgery
Unnecessary surgery endangers patients’ lives by exposing them to the needless risks of anesthesia, infection and postoperative complications. Surgeons who perform unnecessary surgery and their malpractice carriers become liable for larger settlements and punitive damages should the necessity of surgery be challenged in court.
Surgery centers and hospitals face similar liability when privileged or employed surgeons perform needless surgery. Employers, whether fully insured or self-insured for their health plan, as well as employees, continue to pay dearly through annual premium increases for these benefits.
Why Surgery is Incentivized
Operating rooms are a major profit center for surgery centers and both community and academic hospitals. As such, the incentives to eliminate unnecessary surgery are misaligned. I believe these institutions have a fiduciary responsibility to weed out surgeons who perform unnecessary surgery. Herein lies a dilemma – Can hospitals and their staff adequately police procedures that are performed under their own roof?
How does your health plan safeguard against this from occurring? Most insurance carriers have pre-certification or pre-authorization processes that are grossly inadequate. The process is triggered by a surgeon’s office the moment surgery is recommended to a patient. Nurses employed by the insurance carrier often rely on a database to match ICD-10 diagnosis codes and CPT procedure codes. Surprisingly, some insurance carriers have no pre-authorization process for outpatient surgeries! Oftentimes personnel making these important decisions do not have appropriate qualifications.
Protecting Yourself from Undergoing Unnecessary Surgery
The only way to adequately safeguard against unnecessary surgery is peer review. We distribute medical records and imaging, in a HIPAA-compliant manner, to specialized surgeons for opinions regarding medical necessity.
Patients can then rest assured, that the correct procedure is being advocated to treat the proper condition. Other advantages include the potential to uncover non-surgical forms of treatment and uncover cutting edge technologies that reduce the morbidity associated with procedures.
The SurgiQuality Solution
SurgiQuality helps deliver smart, actionable data to patients so they can compare surgeons based on outcomes and make well-informed choices.
The end result is an empowered, well-informed patient who makes intelligent decisions. Now that is a situation where everybody WINS!