Monday, March 21, 2011

Scoping The Problem

This is emblematic of a large part of the problem with health care costs, and why it'll be next to impossible to do anything about it.

In roughly the third iteration of my surgical career I've been assisting on cancer operations around once a week. As always it's fun to be in the OR, and a little sad to know I'll never again be standing on the operator's side of the table, nor be anyone's surgeon any more. More than that, though, there's a certain frustration in seeing things that are unnecessarily costly while knowing that even though I'm right, it'll never change.

A while back I helped with a sigmoid colectomy, for colon cancer. Of all the locations in the colon, it's cancers of the sigmoid portion that are the easiest to remove: it's as if the anatomy there was specifically designed for the surgeon. Which is nice, because it's also the most common location for colon cancers to occur. No question I'd have done the operation open, with an incision starting below the belly-button and extending downward; it's the least painful location for any abdominal incision. I'd have taken about forty-five minutes to do the operation, and, most likely, the patient would have been discharged, comfortable and happy on the second or third post op day. (If anyone wants to read a detailed ten-part description of how it's done, written for the lay reader, s/he can start here, and get to each subsequent installment by clicking on "newer post" at the bottom of each, below the comments.)

The operation I assisted was done laparoscopically. It took three hours (operating rooms charge by the minute, not including equipment and set-up charges), and the number of very expensive and non-reusable components was in double digits. After being mobilized using a scope and various costly instruments, the colon was then, in order to complete the removal and prepare the reattachment, partially pulled out through a two-and-a-half inch incision above the umbilicus. In that location it'll be at least as painful as the one I'd have made, despite being a couple of inches smaller. I'm certain the patient will be in the hospital longer than mine would. (In addition, he was asthmatic; two extra hours of inhaling gases is not entirely benign. But any patient would be in that long.)

Finally, there's this: the hookup between the two ends of bowel is high up from the rectum, made with a (very cleverly engineered and cool) circular stapler. For anatomic reasons -- namely, the corkscrew-like nature of the upper rectum and lower sigmoid -- passing the stapler that high is difficult and -- so the surgeon said -- requires using the smallest diameter device. That makes eventual narrowing of the hooked up area much more likely than if a larger diameter stapler had been used. I stapled bowel many times in similar situations, but only when it was low enough in the pelvis that hand-sewing was very difficult or impossible. I always used the largest device, so narrowing was rare; when it happened I could dilate it permanently and painlessly, in my office, using only my finger, with no risk to the patient. Not to mention free of charge. If it occurs in this patient, it'll require colonoscopy, a special ballon, at the cost of several grand, and will occur outside the pelvis where perforation is possible.

All totaled, the operation in question cost, I'm guessing, around ten thousand dollars more than mine would have, not counting the possible future occurrence and treatment of stenosis (narrowing), with no advantage in terms of pain or length of hospitalization. Doing it open would not have been seriously entertained by the surgeon, a young guy (who is, I must add, an excellent surgeon, extremely well-liked by his patients, very good at what he does, exceptionally knowledgeable) who was trained to do it this way. And patients have been even better-trained to want laparoscopic surgery as if it's magical as fairy dust.

Were there ever to be "effectiveness research," I'm certain (if my way were compared to his, which it won't be because hardly anyone does it like I did any more) it'd be obvious that whereas each approach is safe and effective, there's a huge cost differential with no benefit to show for it. You'd think it reasonable, therefore, that payors would be disinclined to keep paying for the operation to be done laparoscopically. But what, then, do you imagine would be the public response?? And how about from the RWS™??!!?? (Unless, of course, if it were under a Republican president)

Much of what we do in health care is consumer-driven -- more than most would acknowledge. People blame doctors for running up charges for more profit, but that's not at all what's going on here. The surgical fee for colon resection is the same whether you do it one way or another. Nor do docs cash in on the equipment they use in ORs. People think they want laparoscopy ("non-invasive," "minimally invasive," "bloodless," are, bluntly, deliberately dishonest terms), just like they used think they wanted lasers. The money to be made is with the suppliers (and, as long as they are paid based on charges instead of globally, with hospitals*) and they spend big bucks convincing people to want their products, and convincing doctors that if they don't adopt the next big thing, patients will go elsewhere. Which is, in fact, true.

As I've written on Surgeonsblog, I love laparoscopic surgery, in the right circumstances. It's fun, and I've done a lot of it. There are several abdominal operations (NOT including gallbladder removal, by the way) that are best done laparoscopically: fundoplication, bariatric surgery, total colectomy (probably), adrenalectomy (maybe), splenectomy (under certain circumstances)...

Realistically, though, like pointing out the disastrous consequences of teabagger policies, this particular argument is me paddling toward a tsunami.

*It's a pretty interesting subject: time was, hospitals counted on the use of surgical disposables for profit. Because of changes in Medicare reimbursement rules, they no longer could charge processing fees for cleaning and re-sterilizing reusable instruments, or for laundering surgical drapes; but they could charge for the use-once and throw-away (and nearly always non-biodegradable) stuff, and charge a "reasonable" marked-up price. There became, in other words, a perverse (and presumably unintended) disincentive regarding cost-containment. To the extent that hospitals are starting to be reimbursed with global fees (ie, they get x-thousand dollars to care for a colon-resection patient), the opposite has become true. The most efficient surgeon is, theoretically, the most desirable one. Yet so-called "economic credentialling" is almost never done; and when it is, there's generally nothing in it for the surgeon. Meaning people like me, who saved payors thousands of dollars per case, while still getting excellent results, got neither recognition nor monetary reward. Further, on the rare occasions when it does happen (one insurer collected data, identified those of us who were the most cost-effective, and sent us checks!) the other docs scream bloody murder and have all sorts of reasons why their costs are justified. (That insurer stopped after one cycle.) There could be benefit if hospitals were to give more operating time to the more effective surgeons, which, no doubt, would also cause screaming and the gnashing of teeth.

In health care, it's really not hard to identify problems; it's just that it's next to impossible to fix them. And -- dare I repeat myself -- the first serious attempt by a president to give it a shot has been demagogued by the RWS™ as death panels, killing grandma, communism, terrorism, paraphimosis, and Sharia law.


  1. Sid,

    What do you think about the AMA? From an economics point of view it certainly seems that there should be more doctors. I wonder if the supply isn't kept artificially low to boost wages. So far as I can tell anyone who can maintain his or her credentials is nearly guaranteed some kind of job.

    Also it's hard for me to understand why nurses can't perform some of the duties reserved for doctors. Within my own small sphere, I've interacted with a dermatologist and a psychiatrist, and I'd bet heavily that both of these men could do 75% of their jobs with a few months of training.

  2. Sam, I never joined the AMA although I was a member of the state association. I think such conspiracy theories are false: the number of doctors, far as I know, is limited -- or not -- by the number of places available in medical schools, and the AMA has nothing to do with that, far as I know. The federal government does, though, and has, variously, forced cutbacks on residencies (with the thought that fewer specialists meant fewer people charging for care) and increases (with the idea that more specialists meant lower charges.) Take your pick.

    In my former clinic, there are dozens of nurses doing work formerly done by docs, and I'm pretty certain that's a trend that will continue and widen.

    The problem with your 75% thought is knowing when one is in the other 25%: knowing what you don't know is critical to providing safe care.

  3. Dr Schwab, do you know how nationalized health care in other countries conduct their costs vs procedures, i.e European countries or Canada? To make an anology, veterinary medicine can be cutting edge, even revolutionary compared to human. It can also be cost prohibitive, as there is essentially no insurance guaranteeing payment. (Mostly the costly options have been researched for benefits to human health, private/agenda-based.)But only the people that can afford the cutting edge can opt for that.

    On the other hand, there are vets that perform equally efficient procedures without the oversight of human medicine constraints, and people can choose to have a less expensive procedure performed on their pet by a knowledgeable Dr., ex: Acl/Rcl surgery can be a done by an orthopedic vet with complicated surgery and lots of money, or a simpler surgery by an older-school vet with longer recovery but equally good results. (yes, personal experience, both cruciate surgeries happened a year apart; our companion animals age so much more quickly than we, and yet are as family to many of us.)

    To bring it back to my original question, do the countries that have nationalized medicine weigh cost vs efficiency? Do they opt for less expensive but accepted procedures to reduce cost to the system? And if so, can Americans accept that? I doubt it. We want it all, cutting edge, and paid by insurance, even though insurance premiums are leaving many uninsured.)

    (I realize my anology may be offensive to a human surgeon, but I mean no disrespect. Having worked in animal health for years, I tend to consider the others that share our lives and planet.)

    Thanks ahead for your input.


  4. bl: without doing some research I can't answer your question about other countries, with specific respect to cost effectiveness. I know that in some there are criteria for receiving certain therapies; eg, age, severity of illness, etc.

    I've always thought it interesting that equivalent veterinary procedures -- joint replacement, for example -- are WAY less expensive than the same done on humans. The factors at play probably shed light on some of the reasons for the extreme expense of procedures on humans. Among them is the fact that most people don't pay the full cost themselves... That's a multi-faceted issue, to say the least.

  5. Good comments on the cost of open vs closed procedures.

    Fixed fees, bundled payments and capitation will modify behavior over time. When that surgeons fees become a piece of the payment pie I predict a change in behavior.

    If surgical problems relate to the length of surgery/anesthesia and if prolonged hospitalization exposes the patient more opportunity for care giver errors, infection etc, why would a surgeon chose the "longer option?"

  6. Good question, Tom. I think the answer is based on data comparing laparoscopic surgery to open surgery; but most people who do it open make a larger incision, take more time, and need to keep their patients hospitalized longer than I did. Which is why I like the idea of "effectiveness research" so much, in theory.

    Would that there were such evaluations when I was doing my own operations. I'd have loved to have had the opportunity to show how it can be done faster, more safely, and how patients can be treated well while staying less long...

    I recall a paper that was published about using laser to do mastectomy. The authors found that with laser, their blood loss went from three to one unit, and their hospital stays were shortened from seven to three days (or something in that range.)

    My reaction was to wonder how such a thing could be published. I never even ordered blood for mastectomy, much less used it. And my patients most commonly stayed one night, with some going home the same day, others needing two, rarely...

    In my experience, getting doctors (surgeons maybe more so) to change how they do things, how they were trained to do them, is no easy task.


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