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.

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*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.