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?

Who Should Determine “Medical Necessity”?

The following is a guest post.

These days, there is a lot of talk about expanding scopes of practice for the group of folks who used to be called “physician extenders” and then “midlevel providers” and more recently “non-physician providers,” many of whom are now getting degrees with the title “doctor” incorporated.  While it seems to vary, these folks may include nurses, physician assistants (one day to be called “physician associates” perhaps), pharmacists, and more.  Lots of forums are discussing whether folks who are not doctors should be calling themselves “doctor” or whether they should be expanding their scope of practice via legislative rather than educational means. But a recent personal anecdote has made me wonder about a slightly different question: should non-physicians be able to certify “medical necessity”?

Two family members are covered under the same insurance policy.

He has had a history of knee injury, related surgery, and subsequent successful rehabilitation. He recently ran a marathon, and now has new knee pain that has persisted after 8 weeks of conservative therapy at home. After a long wait for an appointment slot, he finally sees an orthopedic surgeon with knee expertise. The doctor recommends an MRI to evaluate the nature of his ongoing pain. 

She has chronic back pain that seems to be acting up, and sees a chiropractor mostly out of convenience, since the office is in the strip-mall near her home and he can see her anytime as a walk-in. After just two sessions with the chiropractor, he suggests an MRI, since she isn’t responding as well as he had expected to the adjustments.

The insurance company immediately approves the chiropractor’s MRI, but denies the orthopedic surgeon’s.  The request was appealed, and again denied, on the grounds that it was not medically necessary. The insurance company issued a requirement that the physician first document the patient’s participation in a physical therapist’s prescribed self-care routine for at least 6 more weeks (recall that the patient has essentially already done this for 8 weeks, having had formal PT for the knee in the past, and familiar with the appropriate self-care, but this did not satisfy the payer). Only after jumping through this hoop may the doctor meet the standard of “medical necessity” to obtain the MRI.

Lest I be misunderstood, I do not object to the idea that the chiropractor can order imaging tests. A chiropractor is an autonomous professional after all, and is a doctor of chiropractic, just as a dentist is a doctor of dental surgery, and an optometrist is a doctor of optometry (but that doesn’t qualify him to do eye surgery– a debate for another time.).

In the modern landscape of myriad healthcare providers and payers, if a non-physician can certify “medical necessity,” surely a specialist physician should be able to as well.

Marjorie Stiegler is an anesthesiologist. She blogs about patient safety and decision-making errors at www.marjoriestieglermd.com.

Patients can be clueless about their insurance coverage

Not long ago, I blogged about a plastic surgeon who aggressively pursues patients who refuse to pay her bills. The state is suing her to make her stop and also considering lifting her medical license. You may want to take a look at that post to get the details, but the central theme is that she makes patients who she sees in the ED to sign a form stating that they will pay her. It is unlikely that the patients are aware of the amount of the fee up front. Then she won’t accept what insurance considers a reasonable reimbursement and goes after the patients with lawsuits and liens on their houses, ignoring the fact that balance billing of emergency department patients is illegal in her state.

A number of doctors have defended the surgeon. Many have said that the patient should have asked her what the fee would be. In my experience, that is a rare occurrence. I’ve been a surgeon for four decades and I can’t recall a single patient asking me what the fee for an elective operation would be. I hardly think a patient would ask at the time of an emergency.

Most patients either don’t think about it or don’t consider it an issue. In many cases, they don’t understand how the system works at all. Here's an example.

A new patient arrived for an appointment with the doctor. At the time he called to schedule it, he was told that the doctor did not accept his insurance. At check in, the secretary reminded him of this, and having amnesia for the previous conversation, he was taken aback and said, “I thought everyone had to accept WeDontCare.”

Further questioning revealed he had a $5000 deductible policy and he had not used any of it yet this year. Even if the MD had participated in WeDontCare, the patient was shocked to learn that he would have had to pay for the office visit.

He was then told that the fee for the comprehensive new patient examination would be $250.00. When he balked at this, the nurse asked him why he chose such a high deductible policy if he didn’t want to pay for visits out of pocket. He said it was because the premium was so much lower.

The nurse explained that the point of a high deductible policy was that in exchange for the lower premium, he accepted the risk that some or all of the money saved might have to go toward paying for medical care, probably a reasonable risk for someone in good health. He didn’t seem to understand that unless he paid out of pocket for more than $5000 (less what the lower premium cost was) worth of medical care in a year, he was ahead of the game.

The patient then began to see the light. If this man, who was a retired financier, had never thought this through, how would anyone expect the average patient to do so?