Is The US Suffering from an Over-Abundance of Specialization?

In a previous posting, the geographical misdistribution of primary care physicians in the United States was discussed.  There is another skewing of physician allocation with similar serious implications, particularly in the current maelstrom threatening the financial sustainability of our healthcare delivery.  As opposed to all other economically developed countries, there is an inordinate number of specialists compared to generalists practicing.  This is exacerbated in urban and wealthier communities.  The causes are multidimensional and unique to our fee-for-service price structuring.  I do not want to incite polarization as to whether this is a good or bad thing per se, but wish to emphasize that the situation is real and fraught with consequence.

A comparison of the practice of cardiac surgery in the United States with that in Germany is illustrative.  These data presented are from the surgical registries of the Society of Thoracic Surgery and the European Society of Cardiac Surgeons and enumerate case load and clinical outcomes for 2010.  In that year, the approximately 300 million Americans were served by a little over 1,000 hospitals that performed open-heart procedures (that is number of centers; the number of surgeons working at each center varied widely).  The case volume was sorted by deciles, the lowest 10% of hospitals performed less than 100 cases per year and incrementally increased to the highest decile center, which did more than 450 cases per year. As one might discern, there was a significant inverse relationship between adverse outcomes and cases performed.  Practice makes better, if not perfect.  In contrast, that same year the 85 million Germans had only 55 open-heart centers available, 5 times less indexed for population.  The lowest third did less than 1500 cases per year, the middle group did 1500-2500 cases per year and the highest volume third did over 2500 open-heart procedures yearly.  Parenthetically, only a handful of the thousand US programs achieved this highest volume that a third of German centers attained.  And no German center did less than 750 cases.  Moreover, surgical results were identical across the low, medium and high volume programs as defined by the German caseloads.  The German centers did not substitute efficiency and volume for quality.  Risk-adjusted, mortality at centers of all volumes was comparable to American centers of excellence and better than the lower volume American programs.  In particular, the more sophisticated and complex cardiac surgeries were done at all German centers with equal efficacy as the select, specialized American hospitals.

Granted, the land mass of the United States is proportionately greater than Germany so travel considerations preclude exact replication of center to population ratio. This does not negate the serious implications of these numbers.  The implications are equally applicable to other high-volume tertiary and quaternary medical care such as transplantation, genetically tailored cancer therapies, neonatal surgery, endovascular vascular surgery, complex orthopedic implantations and seizure ablation.  In addition, resources for treating serious, but infrequent pathologies such as disorders of metabolism or inherited immunodeficiency can be aggregated for better effect.

Clearly, there is a level of surgical volume sufficient to provide proficiency accomplishing optimal results that is applicable to all centers such that every individual in an entire nation can expect the same beneficial outcome.  The implications for introducing into clinical practice new technologies and procedures (translational research) is also huge as fewer, high-volume centers accelerate entry to trials, blunter learning curves, and facilitate comprehensive monitoring of compliance, safety, and outcomes.  Are these issues optimally addressed by the American healthcare system?  Finally, there are obvious financial benefits to such consolidation, economies of scale are immediately achieved in bricks and mortar, personnel number and training and administrative complexity.  Is this not a salutary outcome for a country that spends 17% of Gross Domestic Product on healthcare?

Obviously there would be much push back practically and ideologically to changing the zeitgeist of “world-class care right in your neighborhood”.  However, Obamacare is health insurance reform, not healthcare delivery reform.  A dispassionate assessment of what we do, how we do it, and how much it costs is needed.  Physicians should be part of the push to change.  I write this not as a polemicist, but as one hopeful that our profession can evolve to meet present and future challenges with fresh ideas and certainly welcome your input.

By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton

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