SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
argue that a solution is for Medicare to provide a basic benefit plan with the option for beneficiaries to purchase additional coverage out of their own monies. Eibner et al propose imposing a Medicare means tested premium, introducing a premium support credit to purchase private health insurance and increasing the eligibility age to 67 as methods to save Medicare. They note that each has unintended negative ramifications regarding coverage and health. Frankly, I think that the idea of a basic benefit plan with the option to purchase additional coverage is the most reasonable choice. Many will find it distasteful that access to health care will be explicitly related to the income and/or wealth of the individual but this is, de facto, already the case. Time to put it out there on the table. David F. Penson, MD, MPH
Suggested Reading Jacobs BL, Zhang Y, Skolarus TA et al: Certificate of need legislation and the dissemination of robotic surgery for prostate cancer. J Urol 2013; 189: 80.
Re: Specialty, Political Affiliation, and Perceived Social Responsibility are Associated with U.S. Physician Reactions to Health Care Reform Legislation R. M. Antiel, K. M. James, J. S. Egginton, R. D. Sheeler, M. Liebow, S. D. Goold and J. C. Tilburt Department of General Surgery, Mayo Clinic, Rochester, Minnesota J Gen Intern Med 2013; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: The Affordable Care Act (ACA), also known as Obamacare, generates strong opinions from Americans. This is particularly true for physicians, whose livelihoods will likely be significantly affected by the legislation. These authors report the results of a large survey of physician opinion on Obamacare. The results expose who benefits the most from the legislation in the provider community. When asked whether the ACA would turn United States health care in the right direction, surgeons were 0.5 times less likely to agree with this statement than primary care providers (PCPs). Similarly those in procedural based specialties were 0.6 times less likely to agree than PCPs. No significant differences were noted in the rate of agreement between primary care providers and nonprocedural specialists. Clearly PCPs stand to gain the most from the legislation and, as such, are supportive. However, what is more interesting is that physician reimbursement structure also independently predicted agreement with the bill. Physicians who were salaried or paid salary plus bonus were significantly more likely to agree that the ACA would put United States health care on the right track than those who billed on a fee-for-service basis. These sorts of studies really make the specialists seem self-interested. David F. Penson, MD, MPH
Re: Surgical Skill and Complication Rates after Bariatric Surgery J. D. Birkmeyer, J. F. Finks, A. O’Reilly, M. Oerline, A. M. Carlin, A. R. Nunn, J. Dimick, M. Banerjee and N. J. Birkmeyer; Michigan Bariatric Surgery Collaborative Center for Healthcare Outcomes and Policy, and Department of Surgery, University of Michigan, Ann Arbor, Michigan N Engl J Med 2013; 369: 1434e1442.
Abstract available at http://jurology.com/ Editorial Comment: I have become convinced that the best way to improve quality is from the bottom up. Simply put, the current strategy of tying adherence to process measures to reimbursement
437
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SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
results primarily in more documentation but not more quality. As surgeons, we need to lead a grassroots effort to improve our procedures and, in so doing, improve outcomes. This study from the Michigan Bariatric Surgery Collaborative shows that surgeons can grade the technical skills of other surgeons in an objective and nonpunitive manner. The researchers had 20 bariatric surgeons submit videotapes of themselves performing laparoscopic gastric bypass procedures. These videos were then rated for technical proficiency by peer surgeons who were unaware of the identity of the operating surgeon. Importantly these ratings were shown to be independently associated with complication rates, operative times and hospital readmissions. The fact that peer rating of operative skill can repeatedly and reliably assess surgeon proficiency has important ramifications for quality improvement programs. This approach can be used to identify surgeons who would benefit from additional training or proctoring to improve outcomes. These sorts of programs are only possible in a setting where all of the surgeons trust one another and share the common goal of providing better care, as in the Michigan Bariatric Surgery Collaborative. A similar group exists in urology, the Urological Surgical Quality Collaborative, and no doubt the leaders of this group are aware of this report and will consider similar studies in their collaborative targeting procedures such as robotic radical prostatectomy. Organized urology needs to support these important efforts. David F. Penson, MD, MPH
Suggested Reading Miller DC, Murtagh DS, Suh RS et al: Establishment of a Urological Surgery Quality Collaborative. J Urol 2010; 184: 2485.
argue that a solution is for Medicare to provide a basic benefit plan with the option for beneficiaries to purchase additional coverage out of their own monies. Eibner et al propose imposing a Medicare means tested premium, introducing a premium support credit to purchase private health insurance and increasing the eligibility age to 67 as methods to save Medicare. They note that each has unintended negative ramifications regarding coverage and health. Frankly, I think that the idea of a basic benefit plan with the option to purchase additional coverage is the most reasonable choice. Many will find it distasteful that access to health care will be explicitly related to the income and/or wealth of the individual but this is, de facto, already the case. Time to put it out there on the table. David F. Penson, MD, MPH
Suggested Reading Jacobs BL, Zhang Y, Skolarus TA et al: Certificate of need legislation and the dissemination of robotic surgery for prostate cancer. J Urol 2013; 189: 80.
Re: Specialty, Political Affiliation, and Perceived Social Responsibility are Associated with U.S. Physician Reactions to Health Care Reform Legislation R. M. Antiel, K. M. James, J. S. Egginton, R. D. Sheeler, M. Liebow, S. D. Goold and J. C. Tilburt Department of General Surgery, Mayo Clinic, Rochester, Minnesota J Gen Intern Med 2013; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: The Affordable Care Act (ACA), also known as Obamacare, generates strong opinions from Americans. This is particularly true for physicians, whose livelihoods will likely be significantly affected by the legislation. These authors report the results of a large survey of physician opinion on Obamacare. The results expose who benefits the most from the legislation in the provider community. When asked whether the ACA would turn United States health care in the right direction, surgeons were 0.5 times less likely to agree with this statement than primary care providers (PCPs). Similarly those in procedural based specialties were 0.6 times less likely to agree than PCPs. No significant differences were noted in the rate of agreement between primary care providers and nonprocedural specialists. Clearly PCPs stand to gain the most from the legislation and, as such, are supportive. However, what is more interesting is that physician reimbursement structure also independently predicted agreement with the bill. Physicians who were salaried or paid salary plus bonus were significantly more likely to agree that the ACA would put United States health care on the right track than those who billed on a fee-for-service basis. These sorts of studies really make the specialists seem self-interested. David F. Penson, MD, MPH
Re: Surgical Skill and Complication Rates after Bariatric Surgery J. D. Birkmeyer, J. F. Finks, A. O’Reilly, M. Oerline, A. M. Carlin, A. R. Nunn, J. Dimick, M. Banerjee and N. J. Birkmeyer; Michigan Bariatric Surgery Collaborative Center for Healthcare Outcomes and Policy, and Department of Surgery, University of Michigan, Ann Arbor, Michigan N Engl J Med 2013; 369: 1434e1442.
Abstract available at http://jurology.com/ Editorial Comment: I have become convinced that the best way to improve quality is from the bottom up. Simply put, the current strategy of tying adherence to process measures to reimbursement
437
438
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
results primarily in more documentation but not more quality. As surgeons, we need to lead a grassroots effort to improve our procedures and, in so doing, improve outcomes. This study from the Michigan Bariatric Surgery Collaborative shows that surgeons can grade the technical skills of other surgeons in an objective and nonpunitive manner. The researchers had 20 bariatric surgeons submit videotapes of themselves performing laparoscopic gastric bypass procedures. These videos were then rated for technical proficiency by peer surgeons who were unaware of the identity of the operating surgeon. Importantly these ratings were shown to be independently associated with complication rates, operative times and hospital readmissions. The fact that peer rating of operative skill can repeatedly and reliably assess surgeon proficiency has important ramifications for quality improvement programs. This approach can be used to identify surgeons who would benefit from additional training or proctoring to improve outcomes. These sorts of programs are only possible in a setting where all of the surgeons trust one another and share the common goal of providing better care, as in the Michigan Bariatric Surgery Collaborative. A similar group exists in urology, the Urological Surgical Quality Collaborative, and no doubt the leaders of this group are aware of this report and will consider similar studies in their collaborative targeting procedures such as robotic radical prostatectomy. Organized urology needs to support these important efforts. David F. Penson, MD, MPH
Suggested Reading Miller DC, Murtagh DS, Suh RS et al: Establishment of a Urological Surgery Quality Collaborative. J Urol 2010; 184: 2485.
