Metabolic surgery in private practice

Private practitioners played a major role in the evolution of advanced laparoscopic and bariatric surgery training. Academic physicians were disinterested in addressing obesity and were confronted with the distressing outcomes that followed the intestinal bypass. The private sector, with its marked surgeon autonomy and innovative mindset, was far more ready to accept early reports describing the successful outcomes of the gastric bypass operation. In fact, many of the first pivotal peer-reviewed papers in bariatric surgery were written by private practice surgeons, and the first certified bariatric centers of excellence (COEs) were private practices. Private practice surgeons also took the lead in initiating widespread training in bariatric surgery under the aegis of the American Society for Metabolic and Bariatric Surgery (ASMBS), which was originally the American Society for Bariatric Surgery.

Ultimately, industry support of private practice training centers for bariatric surgeons decreased, and surgical fellowship training became centralized in universities. Diminishing reimbursement, the cost of accreditation, and exponential increases in private practice overhead also have contributed to growth stagnation in this sector. The biggest hurdle has been the lack of referrals by primary care physicians who remain unconvinced of the value of metabolic surgical treatment, even though its value is well supported in evidence-based outcomes. The challenges that face private practice and academic surgeons may differ, but the common mission of ensuring the population’s health and safety requires synergy, collaboration under the leadership and guidance of the ASMBS, and a major initiative to inform the public.

Prior to academic involvement in metabolic bariatric surgery, formal training was limited to apprenticeships, whereby an experienced surgeon would impart his or her knowledge during the course of several years to a junior surgeon. Without a uniform curriculum, knowledge was often more anecdotal than standards- and evidence-based. Without these guideposts, many surgeons performed the complex metabolic bariatric procedures with little intensive training. Ironically, it was sometimes industry-sponsored encouragement of suboptimally trained surgeons that led to poor outcomes, which inspired the leadership of the ASMBS to create the first accrediting body for bariatric surgery COEs (BSCOE), the Surgical Review Corporation (SRC). Once bariatric surgery possessed a mechanism for quality assessment and a vehicle for education and data collection, academic centers embraced it and recognized bariatric surgery for the specialty it is. Unfortunately, because most insurance companies still adhere to the outdated 1991 National Institutes of Health (NIH) consensus statement,¹ metabolic surgery in private practice is still viewed limitedly as bariatric surgery; thus, insurance coverage is inappropriately tethered solely to the concept of body mass index, as opposed to the additional indications associated with the more encompassing term, metabolic surgery.²

The path to practicing bariatric surgery, a subspecialty of metabolic surgery, is a challenging one. This article addresses the following five topics regarding metabolic bariatric surgery within the private practice setting:

• Autonomy
• Research and innovation
• Education
• Accreditation
• Income

Surgical autonomy

Surgeons often select a career in private practice because of the autonomy it provides. The perception of independence in private practice is thought to facilitate broader opportunities and flexibility over the stages of a career. However, this independence also carries with it the responsibility of maintaining a small business and the additional burden that entails. Establishing and maintaining an office and its personnel, choosing partners, dealing with referral patterns, and contending with increasing overhead and diminishing reimbursement while competing with colleagues as well as hospitals and academic institutions is challenging. In today’s complex medical and economic environment, where managing a private practice is not part of formal surgical training, the virtues of autonomy may soon be only of historic importance.

In the early 20th century, an employed physician was considered unprofessional and denied membership in some professional organizations. The advent of managed care organizations, beginning in the late 1980s and early 1990s, in concert with increasingly complex administrative burdens, have driven many surgeons from practice ownership to employed positions. In 2001, 50.2 percent of U.S. general surgeons were self-employed. By 2009, the percentage decreased by 16.3 percent, with 66.1 percent employed³ (see Figure 1). Although surgeons and other health care professionals were initially disillusioned by managed care, this perspective has largely given way to an appreciation of the income and lifestyle stability this employment model provides, especially when physicians consider the increasing educational debt facing most medical graduates.

Figure 1. Percentage of self-employed surgeons vs. surgeon employees, 2001–2010

Unique to metabolic bariatric surgery is the need for lifelong follow-up of patients, including their nutritional and psychological support and the overhead expenses associated with data collection and reporting, insurance authorization, and supervision of the mandatory six- to 12-month weight-management program most insurers require. Although many insurers cover few preoperative requirements, patients bear much of the remaining financial burden within the 90-day period after surgery, or it is withdrawn from the surgeon’s fee. Given the present economic environment, it is understandable that most surgical graduates choose employment over ownership.

Shifts in practice ownership

In June 2017, the American Medical Association (AMA) conducted a survey to categorize the different types of medical practices in the U.S. Survey response trends indicated that fewer than 50 percent of physicians had an ownership stake in their medical practice. In 2012, 53 percent had an ownership stake, and by 2016, 47 percent had an ownership stake. Of physicians younger than 40 years old, 65 percent are now hospital employees, whereas in 2012, only 51 percent were hospital employees. Surgical subspecialists had the highest ownership stake in their medical practice (59 percent), with emergency room physicians owning the lowest percentage (28 percent), and pediatricians employed at the highest percentage (58 percent). Hospital-owned practices remained stable from 2014 to 2016 at 33 percent.⁴

The survey also showed that 58 percent of physicians practice in small groups of fewer than 10 physicians per group, whereas only 14 percent of physicians practice in groups of 50 or more.⁴ These data on general trends in medicine reflect some of the challenges facing the private practice bariatric surgeon. Despite the fact that in private practice one can hire whom one wishes, work with whom one wants, refer patients to one’s specialist of choice, and care for patients in the manner one thinks is most appropriate, some of the original challenges remain, now coupled with new and significant ones.

Research and innovation

The conduct of research has undergone significant change due to industry- and government-imposed limitations and regulations. Even though most patient care data are produced in the private practice environment, industry is no longer willing to support private research initiatives at past levels, reducing the opportunity to generate peer-reviewed research articles.⁵ Over the years, advanced laparoscopic and bariatric training have evolved in the private practice arena, where much surgical innovation took place. The laparoscopic technique, for example, was initiated through a private bariatric surgery practice.⁶ It is clear that the more recent interest of academic institutions, by virtue of their resources and capabilities, has led to outstanding breakthroughs in our knowledge of adiposity-based chronic diseases, such as obesity, as well as to greater understanding of the physiological bases of our interventions.

Education

Until 1995, only a handful of academic centers performed and taught bariatric surgery. These institutions were located primarily in Iowa, Minnesota, Missouri, North Carolina, and Virginia. At that time, many academic centers were guilty of the same “fat bias” that is pervasive even today, which questions the validity of bariatric surgery. Until 2000, only a few hundred bariatric surgeons were practicing in the U.S., and the majority of these practitioners were in private practice.⁷ These surgeons operated and recorded their results, followed their patients, kept quality data, and educated and mentored new bariatric surgeons. Working together and understanding that it took a multidisciplinary team to assist in the care of the patient, they helped to gain hospital support for bariatric surgery and partnered with industry to support their educational and training missions. Many of the annual professional organization meetings were based initially on experience derived from private practice,⁸ and the first pivotal peer-reviewed evidence papers were authored by private practice surgeons.⁹ Private practice surgeons initiated the first certifications for centers of excellence, as well as widespread training using the ASMBS guidelines.¹⁰

Accreditation

The ASMBS created the original bariatric surgery accrediting body, which was designed to certify centers based on experience, individual surgeon volume, and the ability of the facility to care for morbidly obese patients.¹¹ In 2012, the ASMBS and the ACS merged their accreditation programs into a single program: the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).¹² This change was significant in that it required institutional support for data collection and the assignment of a leadership role to a bariatric surgeon. However, MBSAQIP reduces the autonomy of independent private surgeons by eliminating their ability to relocate their practice to another hospital, thus negating any option for professional strategic negotiation. It also fails to recognize the relationship between quality outcomes and procedure volume demonstrated by the evidence reported for many complex surgical procedures.^13-15 In addition, the cost of accreditation, primarily the full-time equivalent employment metric required for data collection and reporting, is often cost prohibitive for individual private practices, especially in rural communities.

Income

Historically, physician reimbursement accrued in private practice was an important consideration for graduates choosing between an employment-, academic-, or ownership-based practice. In recent years, the overhead expenses and bureaucracy of ownership have skyrocketed, and the relatively balanced pendulum of income versus lifestyle has swung away from the realm of private practice.¹⁶ With an average medical school debt of $190,000 in 2016, a 30-year loan at 7.5 percent interest would actually cost more than $400,000.¹⁷

According to an ASMBS survey conducted in 2011, the mean compensation for all hospital-employed surgeons was $419,103. The mean level of relative value units (RVUs) in which an incentive began above the base salary was 5,562 RVUs. For those surgeons who dedicate more than 80 percent of their time to bariatric surgery, the mean compensation was $445,314. The mean level of RVUs at which incentive began above the base was 6,003 RVUs. For private practice, the variation was greater, but for private practice owners, median income was $509,297, whereas for private practice nonowners it was $315,652.¹⁸

In addition to income issues for bariatric surgeons in private practice, insurance company payments often are delayed or denied, and their requirements change and are inconsistent, which leads to the need for more time and administrative effort. Government insurance and even some surgical specialty society regulations have become more challenging for the private practice surgeon. Recently, hospitals have purchased more practices and are, thus, in control of more patient lives. The private practice surgeon needs to be concerned about these issues and the diminishing referral patterns.

Survival of the bariatric surgery private practice

Over the years, bariatric surgery has become safer, better accepted, and more reliably performed. A large share of this work has been achieved through the private practice community. And, today, most metabolic and bariatric surgery cases continue to be performed in the private practice setting.

The private practice community in bariatric surgery has a rich past and a record of surgical excellence. Metabolic bariatric surgery patients have been, and continue to be, cared for extremely well within the private practice environment. It is important that our professional surgical societies actively foster this practice category and its contribution to high-quality patient care. If the private practice model is to survive in the future health care arena, the challenges outlined herein must be addressed.

Acknowledgments

This work was supported by the ACS. The authors declare that they have no relevant conflict of interest.

We are grateful to the ACS for their generous sponsorship of the Metabolic Surgery Symposium and associated journal publication development. We thank Jane N. Buchwald, chief scientific research writer, Medwrite Medical Communications, Maiden Rock, WI, for manuscript editing and publication coordination. And we thank Patrick Beebe and Donna Coulombe, ACS Executive Services, for their expert organization of the Metabolic Surgery Symposium.

References

1. National Institutes of Health conference. Gastrointestinal surgery for severe obesity. Ann Intern Med. 1991;115(12):956-961.
2. Cummings DE, Cohen RV. Beyond BMI: The need for new guidelines governing the use of bariatricand metabolic  Lancet Diabetes Endocrinol. 2014;2(2):175-181.
3. Charles AG, Ortiz-Pujols S, Ricketts T, et al. The employed surgeon: A changing professional paradigm. JAMA Surg.2013;148(4):323-328.
4. Kane CK. Physician practice benchmark survey. Policy research perspectives. Updated data on physician practice arrangements: Physician ownership drops below 50 percent. American Medical Association, 2017. Available at: ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdf Accessed February 1, 2019.
5. Frezza EE, Robinson M. Bariatric and associated operations in private and academic practices. Obes Surg. 2004;14(10):1406-1408.
6. WittgroveAC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: Preliminary report of five cases. Obes Surg. 1994;4(4):353-357.
7. Johnson EE, Simpson AN, Harvey JB, Simpson KN. Bariatric surgery implementation trends in the USA from 2002 to 2012. Implement Sci. February 2016. Available at: ncbi.nlm.nih.gov/pmc/articles/PMC4761154/. Accessed February 12, 2019.
8. American Society for Metabolic and Bariatric Surgery. Dr. Edward E. Mason historical library. Available at: https://asmbs.org/mason-library#. Accessed February 12, 2019.
9. Fobi MAL. The history of bariatric surgery: Forty years in bariatric surgery. Bariatric Times. 2015;12(8):10-12.
10. American Society for Metabolic and Bariatric Surgery. Introduction: Private practice solution series. September 2017. Available at: https://asmbs.org/resources/introduction-private-practice-solutions-series. Accessed February 12, 2019.
11. Pratt GM, McLees B, Pories WJ. The ASBS Bariatric Surgery Centers of Excellence program: A blueprint for quality improvement. Surg Obes Relat Dis. 2006;2(5):497-503.
12. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, 2016. Available at: org/quality-programs/mbsaqip. Accessed February 12, 2019.
13. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med.2013;369(15):1434-1442.
14. Livingston EH. Relationship between surgeon volume and adverse outcomes after Roux-en-Y gastric bypass in Longitudinal Assessment of Bariatric Surgery (LABS) study.Surg Obes Relat Dis. 2010;6(2):587-588.
15. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med.2003;349(22):2117-2127.
16. The Physicians Foundation. Health reform and the decline of physician private practice: Nation’s frontline physicians unhappy with healthcare reform measures. Available at: https://physiciansfoundation.org/research-insights/health-reform-and-the-decline-of-physician-private-practice-2010/. Accessed February 12, 2019.
17. Kessler S. Average medical school debt in 2017. Student debt relief. June 2018. Available at: www.studentdebtrelief.us/news/average-medical-school-debt/. Accessed February 12, 2019.
18. American Society of Metabolic and Bariatric Surgeons. ASMBS compensation and practice style survey. April 2013. Available at: https://asmbs.org/resources/asmbs-compensation-and-practice-style-survey. Accessed February 8, 2019.