Neurosurgeons, Hospital Forge Trauma-Care Pact

After five days of sending away head-injury patients, Scripps Memorial Hospital in La Jolla has forged an agreement that lured neurosurgeons back to work: Scripps will pay when patients cannot.

Saying they were inadequately compensated for indigent patients, the hospital’s four neurosurgeons, who each earn about $250,000 annually, refused to accept any emergency patients last week. As a result, four head-injury patients were sent to more distant hospitals.

Under the new agreement, Scripps will pay the doctors for their services when they tend patients who lack the money or insurance to cover the fees. The hospital also will assume billing duties and try to recoup funds from patients, as well as government agencies, said Martin Buser, a Scripps senior vice president and administrator.

The dispute is not over money, said Dr. Kenneth H. Ott, chief of neurosurgery, but over who should bear the responsibility for indigent patients.

“The county has foisted the health care of indigents onto hospitals,” Ott said. “If we all had our druthers, we’d just stop doing this (trauma duty). They can never pay enough to make it worthwhile. But we do it as our duty. So it isn’t about money--it’s about the responsibility of the county and society to provide care for indigent patients.”

Health experts say the nation is facing a shortage of neurosurgeons willing to operate on the increasing numbers of patients unable to pay them. Last month, 21 hospitals in Los Angeles County turned away head-injury cases, saying they lacked neurosurgeons willing to work on-call shifts. The action by Scripps’ neurosurgeons was the first in San Diego.

Neither Buser nor Ott was willing to disclose how much money the doctors will earn with the new one-year settlement, which became effective late Friday night.

“The amount they offered us,” Ott said, “is minuscule compared to what we make--frankly, it’s wrong for the county to force us to do this for free.”

County officials said they are caught trying to administer to an ever-growing population with diminishing funds. But the problem of staffing trauma emergency rooms is caused by a shortage of specialists, not a lack of money, they said.

“From my analysis of the problems, they (the doctors) have legitimate concerns. If the system is going to be maintained, those of us who designed the system are going to have to respond,” said Paul B. Simms, deputy director of the county’s physical health services department. “The biggest problem is not the lack of adequate financial compensation but the lack of numbers of surgical specialists.”

Since the county’s trauma system has been in place, ambulances now bring the critically injured patients to Scripps or one of the county’s other five trauma centers. Before this system was set up in 1983, 22% of the deaths in hospital emergency rooms were deemed “preventable.” Today that number has dropped to 1%.

Although the system has led to a significantly improved survival rate in emergency rooms, it has taken its toll elsewhere as a small number of physicians are called upon to treat the indigent, Scripps doctors say.

Under the former system at Scripps, on-call neurosurgeons were reimbursed for about 50% of their fees, Buser said. With the new settlement, Scripps officials will assume the responsibilities of collecting the fees and will pay the neurosurgeons, regardless of whether Scripps actually collects any money from the patient or other sources. To help with billing, the hospital will set up a team responsible for collecting from neurosurgeons’ patients.

Although the emergency room draws from about 35 specialties, Scripps has agreed to compensate only four fields: neurosurgery, orthopedics, anesthesiology and pulmonary.

Officials also will try to hammer out a better system of compensation with county, as well as state officials. Now, County Medical Services reimburses about 20 to 25% of the neurosurgeons’s fees, Simms estimated. That amount, hospital officials and doctors counter, is too little.

“We need to sit down with county and state officials and determine if society is willing to pay its fair share of trauma care,” Buser said. “If it’s not viewed as a tremendous value, then trauma hospitals across the country will have to decide whether they can afford to stay in it.”