Waking Up to NOT Just Major Colonoscopy Bills...

The New York Times published an article on May 28, 2012 regarding the high anesthesia charges associated with colonoscopy.

What people need to realize is that anesthesia charges apply not just to colonoscopy, but ANY procedure that requires general anesthesia... tonsillectomy, appendectomy, gallbladder surgery, ear tube placement in kids, etc.

With any procedure requiring general anesthesia, a patient is going to receive THREE bills... not just one which is what most reasonable people think.

1) A bill from the surgeon

2) A bill from anesthesia

3) A bill from the hospital

Sometimes the hospital and anesthesia charges are bundled into a single bill.

Often, patients mistakenly focus on the surgeon's charges thinking that's where their largest out-of-pocket cost is going to lie. However, the surgeon's fee is almost always the lowest of the charges.

Let's take a look at the New York Time's article...

The GI doctors actually performing the colonoscopy procedure got paid around $200. The anesthesia charges were around $2000 or 10x more (note that insurance coverage was an issue in this article and IF insurance did cover, out-of-pocket charges would have been significantly lower).

And than... if the procedure is done in the hospital, the hospital charges will often be around $5000 or 25x more.

These charges are similar to that found for many ENT procedures as well including tonsillectomy. (Of note, all insurances that we participate with... the anesthesia group I work with also participates with.)

On a more personal note, I recently underwent a general surgical procedure myself performed under general anesthesia in the hospital and got the following charges (3 different bills):

1) Surgeon's charge of $425 of which I owed $148.54 (difference covered by insurance)
2) Anesthesia charge of $1,400 of which I owed $140 (difference covered by insurance)
3) Hospital charge of $3,710.25 of which I owed $559.05 (difference covered by insurance)

Now if anesthesia did not participate with my insurance company, than I would have been fully responsible for anesthesia's full charge of $1,400. This situation is what the New York Time's article mainly focused on.

SO what is a cost-conscious patient to do?

Rather than focusing on the surgeon doing the procedure, the biggest cost-savings will occur negotiating with the hospital followed by anesthesia.

OR... avoid having procedures done in the hospital altogether to avoid hospital charges followed by avoid general anesthesia if at all possible and stick with local anesthesia alone. You will than ONLY have to deal with surgical charges which the surgeon should be able to inform up-front.

WHY do surgeons do procedures in the hospital rather than the office?

Beyond patient and procedural factors which may require general anesthesia, procedures may preferentially be performed in the hospital due to money. No big surprise there, but it may not be for the reasons people may suspect.

Let's take a real life example... balloon sinuplasty.

Balloon sinuplasty is an innovative minimally invasive surgical procedure to treat chronic sinusitis. Prior to 2011, this procedure was almost always performed in the operating room in the hospital though it could have been performed in the office.

Why?

The balloon used for this procedure costs around $2000 and is not reusable.

The reimbursement for the surgeon to perform this procedure was around $200+ depending on the number of sinuses addressed and insurance company.

SO... if balloon sinuplasty was performed in the office prior to 2011, the surgeon would have spent $2000 to do the procedure and than would have gotten paid only $200+ meaning a loss of ~$1800.

Why not charge the patient for the balloon device? Because it is called balance-billing and it is illegal.

So what is a surgeon to do if a patient desires balloon sinuplasty and yet the surgeon doesn't want to lose money?

You do it in the hospital... where the hospital eats the $2000 cost of purchasing the balloon device... and the surgeon still gets paid $200.

However, starting in 2012, insurance companies started reimbursing surgeons for the cost of the device which is why all of a sudden, balloon sinuplasty is now being performed in the office.

This type of financial calculation occurs all the time in medical offices.

Even a pediatrician's office where gardasil vaccination is often not offered... Why? Because the vaccine costs more than what the pediatrician will get reimbursed to give it.

Source:
Waking up to Major Colonoscopy Bills. New York Times 5/28/12

Doctor Distraction Happens... It's Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out... But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form... and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery... and often the surgery is already over... and the nurse is still busy filling out forms.

Talk about distraction... a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR... ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations... which is true 99% of the time... but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Reference:

As Doctors Use More Devices, Potential for Distraction Grows. NYT Dec 14, 2011.

Can What Makes a Lion Roar Help Human With a Weak Voice?

Researchers in Iowa have discovered what makes a lion or tiger roar so effectively. Apparently, there is a layer of fat within large feline vocal cords that makes the vocal cords especially prone to vibrate easily with minimal exhalation effort.

What import does this have to humans?

Well, there are patients who have a very weak voice due to vocal cord atrophy as well as vocal cord paralysis. Standard interventions include voice therapy as well as surgical procedures using an implant or injectable material in order to "bulk" up the vocal cord.

In fact... one such injectable material that has been used to inject into vocal cords is fat, typically taken from the belly of the patient!

Two points to keep in mind however...

Just like in lions and tigers, it DOES improve the vocal strength and volume to a patient who previously had a weak voice, may now have a much stronger voice after the procedure.

However, the second point is that by making the vocal cord "bulkier" you are making it thicker which can decrease the vocal pitch... just like a violin string where the thicker the string, the lower the pitch.

On another related note... human infants have fat within their vocal cords... that may be why something so small with tiny lungs can produce such a terrific loud cry!

Read a story in the NYT regarding this research here.

Reference:
Adapted to Roar: Functional Morphology of Tiger and Lion Vocal Folds. PLoS ONE 6(11): e27029. doi:10.1371/journal.pone.0027029