Surgery Costs for Self-Pay Patients

Surgery is expensive... there are no doubts about that. However, there are a few things a patient without insurance who desires surgery can do to minimize the costs as much as possible. Before going into cost-cutting measures, you first need to understand where the costs come from.

In rank order, the costs of surgery come from (highest to lowest):

• Hospital Charges (MOST expensive charges)
    a) Use of OR Room
    b) Paying the Circulating Nurse
    c) Paying the Scrub Nurse
    d) Paying for the medications used during surgery including anesthesia
    e) Paying for the OR room cleaning
    f) Paying for administrative overhead
    g) Use of surgical instruments including cleaning/sterilization after use
    h) All disposable used for the surgery (ie, masks, drapes, wires, IV tubing, gauze, etc)
• Anesthesiologist Fees (excluding anesthesia medications)
• Surgeon's Fees (LEAST expensive charges)

The hospital charges run into the many thousands of dollars (typically charges start at around $3000 and goes up from there). The surgeon's fees can be as low as $100 to around $1000 depending on the surgery. The anesthesia's fees are between the hospital charges and the surgeon's fees (yes... anesthesiologists are paid similarly or more than the surgeons per case).

So now that you know where the costs come from, what are some ways to reduce them? Please be aware that the surgeon has no control/authority/influence over the anesthesia and hospital charges which the patient needs to individually deal with each separately.

• Have the surgery done in an Ambulatory Surgery Center if possible. Oftentimes, the costs are almost 50% lower than the same surgery done in a hospital. If possible, the hospital charges can be completely avoided if the surgery is done in the surgeon's office.
• Ask the hospital about self-pay discounts/payment plans.
• Ask the surgeon about self-pay discounts/payment plans.
• Ask about further fee discounts if the total cost is paid all at once up front in cash rather than a payment plan.
• DO get referred by a free clinic if your income level qualifies you. Free clinic referral pretty much means (for most patients), the care including surgery will be provided completely for free. Fauquier County residents have one here.
• If possible, request only local anesthesia which is cheaper than MAC anesthesia (twilight anesthesia) which is cheaper than general anesthesia which is the most expensive.
• Request medication samples (ie, antibiotics for after surgery).

Cocaine the Soft Drink Being Sold in the United States

It was a little bit disturbing to me when I found out there is a soft drink being sold in the United States called "Cocaine". Made by Redux Beverages, LLC, they have a very aggressive marketing campaign using the tagline "Cocaine is a hell of a drug!" with a website DrinkCocaine.com, YouTube channel, Twitter feed, and a Facebook page (over 3500 fans).

It is marketed as an energy drink high on caffeine and packs 750 grams of taurine like most energy drinks. Unlike Four Loko (pulled off the market), it contains no alcohol.

Even in spite of the warning label on the can:

"WARNING: This message is for the people who are too stupid to recognize the obvious. This product does not contain cocaine(duh). This product is not intended to be an alternative to an illicit street drug, and anyone who thinks otherwise is an idiot."

What's next?

An orange juice called "Marijuana"?

Bottled water called "Roofie"?

Labeling benign food/drink items with illicit drug names is a travesty and should be banned. In essence, such illicit drugs are receiving free advertisement and can desensitize children to how dangerous these drugs are given the sugar-coating and flippant warning and potentially lead them to become users later in life.

Given the restrictions on cigarette ads imposed by law, I shudder to think when cigarette companies get wind of this marketing ploy and start producing water called "Malboro" and a candy bar called "Camels" as a form of indirect advertisement to get around the restrictions.

Remember the cigarette candies of the 1970s - 1990s now banned in many countries?

Illicit drug names should go the way of the Dodo as well...

Simple Rubber Device Mimics Complex Birdsongs & Implications for Human Voice

A team of US researchers at Harvard has developed a simple rubber device composed of two pieces of rubber replicating the 'vocal tract' and a motor that replicates the action of a contracting muscle. With this device, the researchers have been able to EXACTLY mimic the birdsong of a variety of species including the bengalese finches and vireos.

Given complex birdsongs have been faithfully reproduced with such a rudimentary device as shown here, it does suggest that complex neurologically processes are NOT required. In reality, physics is all that is needed with just a little brain power.

You can listen to samples of birdsongs produced by the device here (halfway down the page).

If birdsongs can be replicated with such a simple device, just maybe, better vocal cord devices can be created for humans who have lost the ability to produce a clear voice.

Humans can lose the ability to talk/sing clearly due to cancer, papillomas, scarring, paralysis, etc. Although research on vocal cords is active, I'm not aware of any projects pursuing complete replacement with a biological equivalent of the rubber band. In fact... I'm not aware of any research project being pursued to create the biologic rubber band in the first place.

If you read any textbooks describing the vocal cords, it does seem mind-numbingly complex which perhaps explains why researchers have been discouraged from pursuing this line of inquiry.

But, if it can be done for birdsongs whose vocal cords are anatomically similar to humans, than theoretically, a simple rubber band device can also be created mimic-ing the human voice. This does sound like a fun high school science project the more I think about it.

Once that has been achieved, the physical characteristics of this rubber band can be broken down and than replicated by biochemists to create a biologic equivalent (or biologically inert) rubber band which can than be transplanted into a human with a damaged vocal cord.

Even to just more faithfully replicate a human voice would be a boom for those whose voiceboxes have been completely removed due to cancer (laryngectomy). Current replacement talking devices sound like a robot using state-of-the-art electrolarynx. Watch video below:



Just a thought that I am sure is easier said than done.

Read the full article in the BBC here. Research paper on this topic to be published in near future.

Anesthesia Sleep is Actually a Coma and Implications for Snoring Evaluations

On December 30, 2010, the New England Journal of Medicine published a paper titled "General anesthesia, sleep, and coma". The article goes on to describe normal sleep as well as sleep induced by anesthesia at time of surgery. What researchers have found is that anesthesia-induced sleep actually is more like a deeply unconscious coma patient than someone sleeping.

This actually makes sense to me... When a person sleeps, they can be aroused if noxious stimuli is introduced causing the person to wake up... and most likely yell at the person trying to wake them up. However, in a coma patient, the person does not "wake" up no matter what is being done to them.

During surgery, the last thing you want is for the person to wake up. As such, a coma-state would be preferred rather than a true sleep state.

This finding does have implications for snoring research as there have been several papers (see references below) in the recent past that proposed the use of anesthesia in order to pinpoint where a person's snore is coming from.

Why would this exam be helpful at all? Because one could perform a variety of endoscopic evaluations while a patient is sleeping (or rather coma) to find the culprit tissue vibration causing the snore. Is it the soft palate or nose or tongue or voicebox or a combination of factors? Such an exam is not possible if the person is "sleeping" as they would just wake up.

Without knowing where the snoring is coming from, treatment is at best a good guess.

Though at this time, insurance does not pay for this type of exam... this sleep research does potentially cause one to pause and wonder whether an exam of snoring during anesthesia is an accurate portrayal of snoring during sleep.

After all... a coma is not the same as regular sleep. It does follow that potentially, snoring during a coma is not the same as that found in regular sleep which would invalidate any exam findings regarding snoring localization.

In fact... I wouldn't be surprised if snoring sources found during anesthesia-induced coma is more severe (and potentially different) than that found during regular sleep and may needlessly lead the surgeon to pursue more aggressive snoring surgery than truly required.

Clearly, more research is needed. Indeed, in one paper published back in 1998, snoring was produced during anesthesia in 45.3% of non-snorers and could not even be produced in 18.1% of snorers!!!

References:
General anesthesia, sleep, and coma. N Engl J Med. 2010 Dec 30;363(27):2638-50. Press Release

Validity of sleep nasendoscopy in the investigation of sleep related breathing disorders. Laryngoscope. 2005 Mar;115(3):538-40.

Acoustic parameters of snoring sound to compare natural snores with snores during 'steady-state' propofol sedation. Clin Otolaryngol. 2006 Aug;31(4):341-2; author reply 342.

Propofol-induced sleep: polysomnographic evaluation of patients with obstructive sleep apnea and controls. Otolaryngol Head Neck Surg. 2010 Feb;142(2):218-24.

The value of sedation nasendoscopy: a comparison between snoring and non-snoring patients. Clin Otolaryngol Allied Sci. 1998 Feb;23(1):74-6.

Should You Have Surgery Far From Home???

I am in the fortunate position of seeing patients who live locally as well as a handful who travel across one or more state lines to see me on a weekly basis, as well as the sporadic few who come from even other countries.

When patients travel great distances to see a doctor, this puts the physician in a particularly humbling position. However, it also places additional strain on how care can be provided efficiently and reasonably when geography logistically makes it difficult.

To begin, why would a patient even want to travel great distances to see a doctor? The basic answer is due to the perception that they would receive better care than can be obtained locally. If true, such long distance travel is justified. After all, if you have thyroid cancer and there are no surgeons who can remove this cancer, than by all means, travel is merited.

However, too often, I see patients travel great distances to see a surgeon due to the perception that this one particular doctor is better than the one found locally, EVEN if the local surgeon is quite competent. Here is where the decision to travel becomes... well... less logical, especially if the surgery is for a routine problem.

IF there's a local competent surgeon, I feel it is ALWAYS better to get the surgery done locally. Why? Because if there's any problems after the surgery, it can be easily addressed quickly and with minimal fuss. If the surgery was done hours away, think of the travel, expense, missed time from work, etc NOT just for the surgery, but for any post-operative problems that develop. Oftentimes, the patient concern ends up being unfounded and only reassurance is required, but in order to make that determination, the surgeon needs to do an exam. Imagine the frustration of the patient when a surgeon requests a visit before answering a question about a post-surgical concern... hours of driving to the office, waiting in the exam room, being seen by the surgeon for a few minutes only to hear that everything is fine and normal, and finally driving hours back home.

Even in the hands of the BEST surgeon, problems can arise after surgery. Is the surgical wound becoming infected? Where is that fever coming from? There's a little drainage occurring... is that normal? Why is the skin red? There's a lot of pain and his medications aren't working.

To complicate things further, narcotic pain killers can NOT be called in by federal rules. A hardcopy prescription is required. Now, wouldn't that be mighty inconvenient if a patient (who mind you is in pain), needs to drive hours to the surgeon's office just to pick up a hardcopy narcotic prescription.

The logistical difficulties of dealing with post-operative care after patient discharge is tremendous for both the surgeon as well as the patient if the distance between the two is large.

Now when should a patient travel to have their surgery done?

DO travel to see a surgeon when your local surgeon feels it imperative that you do so either due to the complexity of the problem or inexperience. Especially, if the local surgeon is well-respected and honest. This serves two purposes... you get the surgery done by the best possible... AND, if any problems develop after surgery, your local surgeon is in the loop and can probably handle most routine post-surgical concerns.

I should state that I HAVE performed surgery in patients who live hours away (some even an airflight away) but I ALWAYS encourage patients to try and get the surgery done locally if at all possible due to the reasons stated above. If a competent local surgeon is not available, than that's fine. But if competent local surgeons are present... I do my best to steer patients to get the surgery done locally as it IS for the patient's best interest.

I have also referred patients to other surgeons a long drive away due to one reason or another, even if the patient desperately wants me to do the surgery. I'll be the first to admit if I lack experience to address a given problem. I also follow-up in stating to the patient that if there's any problems that occur after the surgery, to please return to see me rather than making a long-distance trip as there's a good chance I'll be able to address the concern. Everyone wins this way.