The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry

I recently retired from working as an anesthesiologist in private practice for 36 years, spending my time with virtually every surgical specialty. As such, I believe I have a pretty good perspective on general surgeons and can comment with some insight into THE COST OF CUTTING. Before doing so, let me say that I have never before written an extensive review of a book, as I have never before felt it important enough to do so.Virtually every adult can benefit from reading THE COST OF CUTTING for 2 reasons. The first is because, sooner or alter, almost everyone will need a surgical procedure at some time in their life. Facing a major illnesses is daunting enough, but with personal deductibles running as high a $5,000 or more, the economic impact can be devastating. As Dr. Ruggieri so thoroughly explains, there is a financial medical world that is almost unknown to patients, but one that potentially has a major impact on their lives. Dr. Ruggieri, with a remarkable amount of supporting evidence from medical journal articles that are vetted and peer-reviewed, shows how the quest for profits (from hospitals, medical equipment manufacturers, insurance companies, and yes, sadly, sometimes physicians) can work in direct conflict to what is best for a patient. For example, referrals from a hospital-employed primary care physician to a surgeon are almost always made to someone who is also employed by the hospital system, when occasionally more capable surgeons (experience, expertise) are available outside the hospital system. I'm not saying this happens often, but from my own experience it can happen in selected high risk or especially complex cases. It is not that referring doctors want their patients to get less quality care. It is simply human nature to try to justify why your fellow-employed surgeon is "good enough" and keep that patient in the system that is paying your salary. Patients are depending on the integrity of the surgeon to admit his or her limitations and refer the patient elsewhere when appropriate.There are plenty of examples of how patients can benefit financially from reading the THE COST OF CUTTING. But one that is poorly appreciated by many patients is to make sure you are getting your money's worth with cosmetic surgery. As Dr. Ruggieri points out (and I can attest to, from the myriad number of patients I anesthetized to repair botched cosmetic surgery results done by non-qualified surgeons who advertised some kind of bogus "board certification"), that is an area where one needs to be absolutely certain of the credentials of the person who is operating on them.While it is difficult for patients to navigate the intricacies of their illnesses let alone the finances, reading THE COST OF CUTTING at least arms patients with enough knowledge to know some of the questions to ask. For example, if your doctor is a neurosurgeon and orders an MRI scan, there is a reasonable chance he or she has a financial interest in the scanner. Almost all localities of any size have competing imaging centers. You can call and ask about the cost of a scan at the center you are referred to. You can tell them that you are paying cash up front out of your own pocket (as you are meeting your deductible) and ask for a discount. And then you can make a call across town with the same discussion. Same scan, likely an entirely different price, perhaps a larger discount. Maybe the best deal is the scanner you are originally referred to, maybe not. You might save hundreds of your own hard earned dollars by knowing this option is available to you. Sadly, not even physicians have the knowledge and skills to put themselves in the driver's seat with medical finances, but doctors and laymen alike can benefit from as much information as they can get. Dr. Ruggieri makes that information easy to understand.The second reason to read THE COST OF CUTTING is because we are all voters. Health care - its cost, its quality, its availability - usually ranks in the top 3 of voters' concerns. And well it should. Much of what you will read should influence your thinking on subjects such as "Medicare for all" and the Affordable Care Act. You will be far more informed as to why Medicaid patients have generally poorer outcomes than do well-insured patients. If you are a Medicare beneficiary with co-insurance, you will hopefully understand your responsibility to not consider that, once your premiums are paid, all your care is "free." In the end, everyone in society pays, either financially or by using resources that are not unlimited. To his credit, Dr. Ruggieri acknowledges his own responsibility in being a good financial steward while working in medicine.In terms of style, THE COST OF CUTTING is breezy and remarkably enjoyable for a book that is, of necessity, a bit "wonky." If you have read Dr. Ruggieri's other book, CONFESSIONS OF A SURGEON - and I recommend that book highly, as well - you will appreciate his common sense and down-to-earth manner of making sometimes difficult concepts easy to understand. He uses vignettes from his own personal practice to show how the things he is relating happen in the real life practice of medicine.Several reviewers of THE COST OF CUTTING complain that Dr. Ruggieri "rants" against the Affordable Care Act. I did not find this to be the case at all. He does bring up legitimate questions that have, at least to a degree, been answered since the publication of the book.Finally, Dr. Ruggieri ends the book by asking, what is the worth of the individual operating on you? Here is how I see it: picture yourself coming into the ER at 1 am to see a patient with a perforated appendix. You get to the OR around 2:30 am and the difficult case finishes an hour later. After a discussion with the family at 3:30 am, you dictate the case and make it back to bed at 4:15 am. Try turning the mental switch off and getting back to sleep. Given all the expertise the surgeon brings and the responsibility they assume, is $300 or $350 being overpaid? And don't forget, the days in the hospital that follow and the eventual follow-on office visits are "bundled" into that payment. I worked my entire career with general surgeons. They are a dying breed (not enough are going into the specialty at present), and they are absolutely NOT overpaid.Finally, a word about the humility and humanity of Dr. Ruggieri that comes through in the book. The humility is evidenced by his repeated admissions of how, like all physicians, he has to struggle to make financial considerations fall behind always doing what is best for his patients. Fortunately for us all, the great majority of physicians make the correct choices day after day in their practice lives. As for the humanity, I note that in the Afterward, the first individuals he pays tribute to are the patients that have allowed him to take care of them.That's my kind of surgeon.Buy this book and read it. If you are like me, you will benefit enormously from doing so.

In this sequel to his previous book, Dr Ruggeiri looks at the economics of general surgery. It is certainly an eye opener, even for me; I works in the financial side of the mdeical industry.Sometimes he errs into what I would regard as CNN-like simplifications: "Many state -offered health insurance plans pay surgeons on the same level as Medicaid: twenty-nine cents for every dollar billed"; "Medicare pays close to thirty-eight cents on the dollar"; "Private insurance plans might approach sixty cents on the dollar" - this may be the case for his fee structure, but in fact the amount paid is a contracted amount, as rule, or a federally mandated amount. You can bill whatever you like and it won't alter what you get paid (unless you are insane enough to bill below the "allowed amount"). Sometimes, there is excessive repetition - these are both small quibbles, although they do make me wonder at the veracity of some of his numbers. The "cost"of a procedure is usually the billed amount, not the actual amount received by the physician and/or hospital.He points out that hospitals buying private physicians practices will only drive costs up as hospitals are usually paid more than private physicians while at the same time they have little or no interest in the classic patient/doctor relationship.Some people, of course, will prefer the new, more impersonal model.This book has many lessons that apply to all medical specialities. Three highlights for me were:1. When you have insurance, the physician will have to accept a set fee for services - this can be the biggest benefit of insurance if you have a high deductible plan. There are insurances that do not do this ("we will pay 50% of your bill"), but they seem to be becoming, thankfully, very rare.2. In high deductible plans, the hospital and the surgeon are in direct competition for the patient's money3. Many, well chosen, case studies that clarify the whys and wherefores for performing, or not performing, surgey.His conclusion is that under the current medical climate, patient choice will be reduced. Of course, choice has already been reduced - few people choose to need interventional medical care! On the other hand, as an example of the extraordinary topsy-turvy economics of medicine, until the affordable care act, medical complications after surgery actually increased profits for hospitals: "Abandon Hope, All Ye Who Enter Here"! Thankfully, this is being addressed by CMS/Medicare by refusal to pay for avoidable complications and reduction in pay for readmissions after short periods of time.Some of the more corrosive historical practices are steadily being changed - Dr Ruggeri discusses these changes and gives excellent advice on interpreting the publicly available data, which may not all be as it seems. He is reasonably even handed with the pros and cons of modern changes to the medical landscape.This is a denser book than his previous one, but overall, contains much more information about health policy and the changing landscape of medicine in the US. It is quite up-to-date - interesting to read his analysis of the literature on robotic surgery vs. laparoscopic surgery. Our local teaching University has been pushing robotic surgery hard (they invested an awful lot of money) and tout it as being "safer, fewer side effects, better recovery time, etc". They do not say what they are comparing it to - I'll bet it is open surgery!He ends with the thought "what is a good surgeon worth?". Another conclusion that I took away, as I'm sure I was supposed to, was "How do you find a good surgeon, assuming you have a choice?"Well worth reading for its insights into medicine as a business.

I gave his other book five stars, but this one is filled with misinformation in my view. I say this as a practicing surgeon myself. He tries to hammer a point across a number of times that surgeons should be rewarded and judged by outcomes. But most people understand that doing the easy cases on thin patients will always give better results than tough cases on fat patients. Judging a surgeon's expertise by using outcomes never takes that part of the equation into account. If this ever comes to pass, one will find surgeons avoiding the sick patients like the plague.