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Fellow contribution
Further commentaries on surgical fees – with a touch of criticism In my March 2016 story in Surgical News discussing fees, it was titled ‘Milking the System’. In it I recalled historical references to this topic dating back to the time of Louis XIV and his Superintendent of Finances, Nicolas Fouquet. What did he do? He decked out his own chateau lèsemajesté, with splendiferous adornments, richer in appearance than that of the king’s. As the royal artistic director and regal advisor, he merely followed the king’s instructions, but when the artisans just happened to make two objet d’art for the price of one (which the king paid for), he picked the better one. ‘Things did not add up’ when the king visited Fouquet’s chateau (an example of 2+2 ≠ 5) and Fouquet subsequently went to prison. In the 2016 article I referenced current examples of exorbitant surgical fees, from $10,000s for hips and $2000s for carpal tunnel procedures done by the consultants’ former registrars who lacked the experience of the master. I recalled David Scott’s comments at the time when he was Surgical Director at the Royal Australasian College of Surgeons (RACS) that an open-heart transplant was cheaper then – only $4000 in the Medicare Benefits Schedule. However, not all are guilty, perhaps the 10 per cent rule emerges again. But in the public’s view, the value of private health insurance becomes contentious, and with the public health system overburdened, what is the future? The noose of financial largesse may tighten, or, as the French say, l’étau se resserre.
OPUS LXX
Now, antiques and historical items are forever on my mind and that is why I write these stories. I recently bought a plaster cast model of Hippocrates for $100 (I could not afford the 4th Century BCE stone carving priced in the six-figure range). He taught students the ethics of medical practice, to do no harm. The Oath, as illustrated, encourages all medicos to help patients to the best of their abilities while pursuing scientific gains and avoiding the traps of overtreatment and ‘therapeutic nihilism’ (an Oliver Wendell Holmes expression). I recently had a clinical episode which spurred me into activity regarding overcharging. The brother of a nursing associate of mine recently had a shaved biopsy for an in situ melanoma of the cheek. He was referred to a plastic surgeon for removal of this lesion, which was no bigger than one’s little fingernail. The patient was quoted an upfront fee of $3000 and his anaesthetic support team, playing the same game and painting with the same brush, wanted a prepayment of almost $400 above the rebate. This is totally divorced from any altruistic Hippocratic principles. The patient was
a farmer from country Victoria who had recently survived fires, droughts, floods and financial hardship. Incidentally, he already had a parotidectomy done by a senior Head and Neck surgeon I knew. I phoned his general practitioner (GP) to get the referral to that surgical practice and the problem was solved without any financial stress, thanks to his private health insurance. This episode led me to phone one of my colleagues in the College hierarchy, a former President, and he recounted his experience in worker’s compensation absurdities where quotes for proposed operations merely reflect the habit of inventive item numbering. I also have experienced cases in the medicolegal network, including fingertip reconstructions where the operation lists up to eight item numbers. Let us hope the surgical assistant, who usually does the paperwork, does not think this is the norm. A little belatedly, Don Marshall, in his heyday, asked me to write an article along these lines when he observed, “Felix, any fingertip injury should warrant a fee of no more than $500.”
The College has a way of processing such exorbitant fee trends, as confirmed recently by Professor Julian Smith. But quoting Ross Gittins, columnist for The Age, the most effective corporate solution for financial mismanagement under the Australian Securities and Investments Commission (ASIC) umbrella is collegial rejection. At our FRACS level, collegiate rejection can also apply. The Hippocratic Oath, with thanks to Kathy Bourke who found this in an op shop
