Monday, September 22, 2014

The $117,000 surgical assistant's fee

In a post a few months ago, I wondered why Medicare could not control its costs using the investigative power of the federal government instead of releasing physician payment data and relying on journalists to do the work.

Two stories that appeared within days of each other raise a similar question about the private insurance industry's methods.

An article in Modern Healthcare described the impending closure of the proton-beam therapy center at Indiana University, one of only 13 such facilities in the country. Proton-beam therapy, which is very expensive, has never been proven better than other types of treatment for prostate cancer.

Here's what Modern Healthcare had to say:

Blue Shield of California and Aetna last year said they would no longer cover proton therapy as a treatment for localized prostate cancer. Cigna Corp. does not cover proton-beam therapy in the treatment of prostate cancer either.

“I look at this closure as a sign that insurers are finally empowered to say this is a dubious medical technology” in the treatment of patients with prostate cancer, said Amitabh Chandra, director of health policy research at the Harvard Kennedy School of Government.

A couple of days later in the New York Times, a piece by Elisabeth Rosenthal related several anecdotes about patients who were saddled with large and unexpected bills from out-of-network physicians who were involved in their care.

A particularly egregious example was a $117,000 bill from the surgeon who assisted at a 3-hour cervical spine fusion operation. Just to put it in perspective, that's $39,000 per hour or $650 per minute—numbers a professional athlete might envy.

Although the procedure took place at a teaching hospital where residents are usually available to assist, the operative record apparently documented that no qualified resident was available.

The surgeon billed $133,000, but since he was in-network, he received only about $6,200.

Despite some pushback by the patient, the insurance company eventually paid the surgical assistant's $117,000 fee. If he's worth 19 times more than the operating surgeon, maybe he should be doing the operation instead of merely assisting.

Apparently this is not an isolated event. Quoting the Times, "J. Edward Neugebauer, chief litigation officer at Aetna, said the company had ... sued an in-network neurosurgeon on Long Island who always called in an out-of-network partner to assist, resulting in huge charges. The surgeons shared a business address."

The story in the Times related several other instances of insurance companies acquiescing and paying extremely high out-of-network charges.

If insurance companies can decide not to pay for proton-beam therapy, why do they agree to pay an assistant surgeon $650 per minute? I realize they didn't want to leave the patient holding the bag, but have they no recourse other than to pay?

On the home page of the Medical Society of the State of New York, its president responded to the Times piece by pointing out that New York's legislature just passed a law addressing surprise bills, and he correctly noted that some insurance companies do not pay in-network physicians enough to cover their expenses.

But he failed to acknowledge that many of the fees noted in the article are outrageous. Why not at least mention that issue? Doesn't he realize those fees make all doctors look bad?


Anonymous said...

smells like fee splitting?

korhomme said...

Not quite a year's salary in the "socialised" medical system for one operation; how can anyone really justify this level of charge?

Anonymous said...

The problem is getting someone to admit that reputation is a huge part of being a doctor. The other is the insurance company should have gotten nailed from the those who are insured because they pay the bills.

artiger said...

The last sentence says it all...the public sees an outlier like this and thinks all physicians are guilty. I'm all for making a buck but this kind of billing is irresponsible, and that's only a nice way of stating it.

Westerby said...

I would agree -- anonymous -- that reputation is huge. Reputation has always been huge. Folks who become physicians don't do so in order to escape society, they do because they would rather keep society on its feet. All the MORE reason, then, to make it clear to the population that you serve that that you would rather NOT be known as a robber baron. That is, after all, how your reputation improves (in most communities. there are exceptions I refuse to touch for the sake of argument).

How professionals of any type go to sleep at night thinking that these practices won't eventually catch up to and ruin them in this YouTube/Facebook/Twitter world is a mystery to me, but it is clear that this particular physician's reputation is anything but good today. His future as a physician, consequently, is in serious jeopardy. Being a doctor, after all, means convincing people you have something to offer them in their time of need.

Quality comes at a price in any endeavor, but that price really has no purpose in bankrupting the individual seeking opinion or intervention. There are those who would see and use medicine as a means to serve only those who can pay; in reality, this is a rare endeavor that, as is customary with the media, gets overlooked because it is not in line with the sensationalism it seeks to capture (Read: "Click here so we can get advertising revenues." Corruption, it would seem, runs far and wide!)

We can all agree that attention to these matters must be paid, because as usual we are finding that honesty, service, and responsibility are not rewarded nearly the way they should, while criminal-class cheating, swindling, and abuse seem to be remunerating very well indeed. And that is sad for everyone in every profession everywhere.

Skeptical Scalpel said...

Thanks for all the comments. Did someone say "fee splitting"? I never said that. I agree the $117,000 bill can't be justified and reputations are hard to rehabilitate.

Anonymous said...

Many yrs ago as a med student wanting to go into surg. I was doing a vascular surg rotation. I remember an obgyn attending running in the middle of our procedure pleading for my vascular attendings assistance in a procedure that went horribly wrong. This vascular attending was not a nice man, really talented surgeon. He started cursing, yelling, etc. He did not like the idea of leaving his own table to go help a colleague. This man was arrogant and the perfect example of someone who would bill 117K for being drive-by doctor. You know what though, he was the best surgeon. I know its not ethical, I know it is wrong, but if we are assuming that this doc was actually called in with no deal made prior. If he was called in for his talent, then I do agree that should come with a price, maybe not 117K. Surgeons do free procedures all the time in this day, no reimbursement. In addition, surgeons get short changed all the time. Seriously, skeptical scalpel, whats the reimbursement for a lap cole now compare to when you finished your training. If this was not business related, only the pt's well being in mind. If this surgeon was best of the best, that's why he was called upon, let him charge 20-30k. Why not? 117k is embarrassing. I'm just saying would you want your car to be taken care of by a certified GM mechanic or around the corner at some mom and pop place.

Skeptical Scalpel said...

I agree that fees are low for many procedures and many surgeons do a lot of uncompensated work. However, $117,000 for 3 hours of assisting, which usually does not require extremely gifted hands, is way too much. It riles up the public and justifiably so.

To put this in perspective, the median household income in the US is between $60,000 and $70,000. See:

Coleen said...

I had surgery a few years ago and like the case mentioned, the in network surgeon received less than the out of network physician assistant. I assume the person called physical assistant was not an MD and found it quite irritating to see the assistant make vastly more than the primary doc.
It took a year to get the insurance company to pay that bill since I had no control over an out of network person at the in network hospital with an in network physician.

Skeptical Scalpel said...

Coleen, I doubt they would pay a physician assistant (PA) more than the surgeon, but maybe it was a terminology issue. A PA can assist at surgery as can a physician. It was probably the latter, but who knows? This may be much more common than anyone realizes.

Anonymous said...

This GAO report over a decade ago highlights some of the problems seen today.

Skeptical Scalpel said...

Thanks for the link. For Medicare patients, I believe the rule is that the assistant surgeon's bill can only be as high as 16% of the surgeon's fee, which is limited by Medicare's payment policies.

Frank Cohen said...

I am the first to agree that this represents a serious problem and I am surprised that the insurance company allowed it to happen. They certainly are in a position to effect this type of abuse. To put this in a difference perspective, the CEO of United Healthcare was compensated at over $59,000 per hour last year. Seems that the abuses don't stop at the OR.

Skeptical Scalpel said...

Frank, I agree that insurance company CEOs are overpaid. I'm not sure what sort of value healthcare insurance companies provide. If I thought the government could run anything well, I would support a single-payer system.

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