Monday, August 26, 2013

Budget Terrorism

Some years ago, before Governments and their agents, hospital boards and CEOs and CFOs were given an extra allocation for some surgical procedures that had been underbudgeted, those of us doing major joint replacements were struggling. Patients were waiting in Lotus City two and three years to get a surgical booking and in addition to pain and disability, actual hip pathology often altered, that compromised the end results. Since hospital budgets were usually predicated on the previous year and negotiated by the governing body of the hospital with the provincial government, there was inertia in the system despite the rapid advance of technology in replacement surgery. Rationing therefore flourished, and allocation of budgets both stalled and were applied to the most publicly attractive care packages that would seem to provide hospital boards and provincial governments, to its public, in a good light. Eventually a confrontation was engendered by the orthopedic surgeons and the hospital, occasioned by threatening the competency of these nonmedical decision- makers to, and through public channels!  It was ugly but provoked two things! One, our offer that an independant evaluator of the hospital's choice would review the entire procedures to determine the adequacy of the budget and the irrationality of the rationing. The orthopedic surgeons as a result of this review, won the round in spades, but the hospital, of course, never provided the details of the written report for our review. Typical! As a result however , at that time, and this is the kicker, the budget never changed!
However again, since they were beaten up by their own reviewer, they made an offer. We could increase the numbers of replacements by using a substantially cheaper prosthesis, manufactured by a different procedure, and that way, stay within the same budget. Can you imagine me saying to you that we can get on with your hip replacement with an inferior prosthesis? Of course the carrot they thought for the orthopedic surgeons was that they could do more hip replacements with the same hospital budget and therefore make more money for the surgeons themselves through the separate medical insurance plan. Their administation saw this as win, win! We both could pick the pockets of a different funder, the medical services plan! Budget terrorism!  It wasn't a win for us since, it isn't ethical to put an inferior prosthesis in a patient's hip or knee; our onus is to minimize post operative short and long term complications for our own survival and resist clever solutions derived on the backs of patients. Boards, CEOs and CFOs never have to see patients: never have to see surgical failures year after year in the office; groan! Fortunately adverse pressure worked to some degree and budgets much later were expanded for replacements; unfortunately after I retired. They never really understood why we didn't jump to their initial offer of B level prosthesis.

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