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?