All posts by Russell Bessette

Joan Rivers and Office Based Surgery

This weekend, we say goodbye to the great comedian — Joan Rivers.  She said so many things that made us laugh.  My most favorite was  — “Can we talk.”

Joan Rivers
Joan Rivers

She often used those three little words while interviewing someone whom she felt was less than frank.  I can still see her leaning forward, as if to whisper, and saying with a crafty smile, “Can we talk.”  Those words immediately shifted the conversation to what was really important.  It was as if she said, “Ok let’s stop beating around the bush;” or  “Let’s get down to the juicy stuff.”  The words disarmed people in a simple, yet funny, way that made us see the real story.

Though no one could use those words the way she could, I often pilfered her expression to get others to say what they really meant.  In my many years in university academics, medical forums, and governmental service, I’ve attended countless meetings.  It’s always impressed me what people say in public compared to what they say immediately after the meeting, perhaps in a rest room, snack bar, or quiet corner.  Generally in the latter locations, their true sentiments explode with slang, profanity or worse.

Joan Rivers could cut through this politically correct “public speak” and get people to say what they really meant, which sometimes wasn’t always nice.  Yet Joan had a way to use self-deprecating humor to put folks at ease.  Almost as if to say, “See look at me, I’m not embarrassed and neither should you be.”

In matters of healthcare, truth is vital.  However, in this era of political sensitivity, freedom of speech appears extinct.  Unless we couch every sentence in words that couldn’t possibly offend anyone, we risk unmasking an unintended offense.  Discussing important matters under this camouflage begs for Joan Rivers and her three little words — “Can we talk.”  To speak otherwise elicits Winston Churchill’s admonition, “If you can’t say what you mean, how can you possibly mean what you say.”

From what I have read surrounding Joan Rivers’ death, it’s reported that the family suspects complications due to surgery performed in a non-hospital environment.  In other words, surgery/procedure carried out in an office.  Since others have also suggested this cause, the family is considering malpractice litigation.

It’s ironic that she died in this manner, considering the extensive debates over office-based surgery in New York State.  I can’t help but wonder if a little more “Can we talk,” — I mean really talk, would have helped.

The year was 1997, and I was Chairman of the New York State Public Health Council.  As a practicing surgeon at the time, I disagreed with the market driven recommendations to dismantle hospital based surgery and instead move so-called minor surgical procedures to a physician’s office.  I held that opinion for two reasons:

  1. There is absolutely no such thing as a minor surgery.
  2. And any surgery on me or you is never a minor procedure.

Whether it’s passing a tube down a person’s windpipe, or going up in the other direction, there are inherent risks dependent on many factors, age, co-existing medical illnesses, anxiety, and drug history to name a few.  I have seen complications from vocal cord spasms that stopped breathing, perforated livers and spleens from faulty colonoscopies, and collapsed lungs from a simple needle touching the lung.  Though these complications are admittedly few, their occurrence in those affected is 100%.

As Chairman of the Public Health Council, I had the privilege to recommend that the Council undertake a study to investigate the movement of surgical procedures to an office setting.  The Council supported this initiative and selected an all-star panel of medical experts from all sectors across New York.  That empowered committee then held public hearings in the major cities across the state to elicit comments from patients, business leaders and other interested stakeholders.

Over a several month intensive effort the committee forwarded to the Council its report, which was immediately endorsed and recommended to the New York State Commissioner of Health, Dr. Barbara DeBuono and the NYS Legislature for consideration of possible legislation.

Unfortunately we found that sometimes “Can we talk” just isn’t allowed.  The New York State Association of Nurse Anesthetists sued the Public Health Council and barred the report from becoming public.   Since the Council report was muffled by the lower court’s, New York State’s Health Department appealed the lower courts decision to the state’s highest court, the Court of Appeals.  Finally with the report requiring some “tweaking,” a decade later in 2007, the report was released.

I don’t believe Joan Rivers would have allowed ten years to pass, if only we could have talked.  And what exactly did we need to talk about, and why all the sensitivity about what and how to say it.

By 1997, healthcare costs were sky-rocketing and the wisdom of that decade was to unleash market forces on healthcare.  Surely if American competition made us wealthy, easily it could make us healthy.  Performing surgery in a hospital was expensive.  Why do we need this costly infrastructure for a “minor” procedure?

Many physicians rallied to this cry.  Some doctors argued that most of their routine surgery could be carried out in an office, if only the insurance company would pay them an augmented fee.  To many this was a win-win situation.  Insurance companies got to pay less than the hospital charge, and physicians got a raise.  The only downside was that equipping an office just like a hospital was expensive, so medical supply companies filled the gap by providing equipment which was nearly like the hospital’s.

Another advantage to market based decisions was that now non-physicians could perform services in an office which they formerly were not allowed to do in a hospital.  That was the key element of the litigation against the Public Health Council cited above.

According to market driven theory, this competition would greatly improve public health at a lower cost.  As we have suggested in an earlier blog, apparently this hasn’t yet achieved the intended result.

Perhaps Joan Rivers’ spirit acting through her family may trigger some meaningful changes as this investigation progresses.  However, it may not happen unless we ask — “Can We talk.”

 

Physician Quality Scores

Physician Quality Scores:      What You Don’t Know — Can Hurt You.

Before choosing a doctor, we investigate.  And before investigating, we usually begin with a premise.  While the scientist may devise an elaborate experiment to test the premise, choosing a healthcare  provider may only involve a superficial analysis.  For example, one may simply ask their friends: “What do you know about this doctor?”  Or perhaps the analysis may go deeper and employ a search on Google or Angie’s list.

Insurance companies try to assist by giving doctors in their network titles like “Preferred Providers,” or “Gold Choice Doctors,” or “Approved Quality Physicians.”  But in the end those titles are generally garnered by any licensed physician in good standing willing to accept the insurance company’s fee schedule.

If the doctor has a web site, there may be pictures of the office and smiling staff, along with a list of degrees and awards.  Hopefully the entire page will confirm a wise choice.  But colorful web pages may be more of a testament to the web designer than the physician.

How then can we evaluate a service industry populated with so many different providers?   A problem made worse if one needs a specialist from a medical field unknown to us.   Are choices in healthcare dependent on personal taste only?  Is it like finding a good restaurant?  Unfortunately for a person struggling with a chronic illness, this choice is crucial.

Currently marketing companies, using metadata mining, can predict our buying habits even before we make a purchase.  Where then can people go to gather the necessary information they seek?  One likely source is government agencies created to protect the public health and identify problem doctors.  Let’s explore what we can learn from these state medical boards.

State Medical Boards

Physicians in the United States are regulated by individual state medical boards. These boards license and oversee medical practices.  Their authority evolves from either the state Department of Education or Department of Health.  The Office of Professional Medical Conduct (OPMC) is a sub-agency that investigates doctors accused of poor conduct. Their findings are significant.  Yet these agencies may be limited either by law or regulation as to what they share with the public.

It wasn’t until the late-1990’s that some states passed legislation that required state medical boards to use the world-wide web and share information about physician conduct.  In 1996, Massachusetts became the first state to provide information about doctors online.  By 2006, only twenty-two states had laws requiring state medical boards to provide basic physician profiles online.  Unfortunately that information is still limited.

One organization proactive in driving transparency is Public Citizen.  This nonprofit group with offices in Washington, D.C. and Austin, Texas monitors several public utilities, and also has a division focused on monitoring healthcare information available to the public.  In 2006, they released an extensive report on the state medical boards from all fifty states. The medical boards of thirty-five states oversee both medical doctors (MD’s) and doctors of osteopathic medicine (DO’s).   Fifteen states have separate boards for doctors of osteopathic medicine, bringing the total number of state boards in the U.S. to sixty-five.

The bare bones information about a doctor is called the physician profile.  It contains only each doctor’s name, license number, and license status (active, inactive, retired, or suspended).  In addition, there may be information on each doctor’s education, where the degree was obtained, and whether the doctor is board certified by the American Board of Medical Specialties.  Some states include additional facts like which hospitals the doctor is affiliated with, whether there has been any disciplinary action by any state or federal agency, or the existence of civil and criminal court actions.

The Public Citizen report only gave one state, Maryland, an A grade for the information presented on its site and for its ease of use.  Ten other states were rated as “best,” which were in ranking order the states of: New Jersey, Virginia, Massachusetts, New York, Vermont (medical only), Georgia, California (medical only), and Idaho, Florida (both medical and osteopathic medicine).  Ten states were ranked as being the “worst” a title earned by only reporting the basic physician profile and board disciplinary action.

According to the Public Citizen report, there are six categories of information that should be available for public disclosure. Those categories and their explanations are as follows:

  1. Physician Identifying information – This would include the physician’s name, year of birth, address where the physician practices or resides, license number and license status as well as verification of specialty with board certification.
  2. State Board Disciplinary Action – This would include information that defined the offense committed, the action taken, the date of the action, the full board order, and a summary narrative of the offense.
  3. Hospital Disciplinary Action – This disciplinary action should include the committed offense, the date of the action, a summary of the hospital order, and the hospital order itself.
  4. Federal Government Disciplinary Action – This would include information on a physician disciplined by Medicare, FDA (U.S. Food and Drug Administration) or the DEA (Drug Enforcement Administration).  Medicare actions are generally on fraudulent billing or overcharges, the FDA would be misuse of medical instruments, devices, and medications in non-approved manners, and the DEA would be unlawful prescribing of narcotic substances.
  5. Malpractice Information – This would include judgments and settlements against each physician, including the dollar amount within the past ten years.
  6. Conviction Information – This would include information on all felony and misdemeanor convictions or nolo contendere pleas in the past ten years.

I abbreviated the following tables published in the Public Citizen report.  Although their report is over seven years old, I suspect, given current budget downturns in most states, the report’s information is still substantially the same.  Their report underscores the variable range of information found on state web sites.  Some state boards received a low score due to difficulty in use.  They required viewers to log onto a different web site to retrieve information, or request a written mailed report.

The table displays what information is available for each state:

Disciplinary actions against medical doctors or osteopathic physicians.

State Report Offense Action Date of Action Summary Board Order
Alaska YES
Ala. YES YES YES YES YES
Ark. YES YES
Ariz. Osteo YES YES YES YES
Ariz Medical YES YES YES YES YES
Calif Osteo YES YES YES YES
Calif Medical YES YES YES YES
Colo. YES YES YES YES
Conn. YES YES YES YES
D.C. YES YES YES YES
Del. YES YES YES YES
Fla. Osteo YES YES
Fla. Medical YES YES
Ga. YES YES YES YES
Hawaii YES YES YES YES
Iowa YES YES YES YES
Idaho YES YES YES YES
Ill. YES YES YES YES YES
Ind.
Kan. YES YES YES YES
Ky. YES YES YES YES
La.
Mass. YES YES YES
Md. YES YES YES YES YES
Maine Osteo YES YES YES YES
Maine Medical YES YES YES YES
Mich. Osteo YES YES YES
Mich. Medical YES YES YES
Minn. YES YES YES YES
Mo. YES YES YES YES
Miss. YES YES YES YES
Mont.
N.C. YES YES YES YES YES
N.D.
Neb. YES YES
N.H. YES YES YES YES
N.J. YES YES YES YES
N.M. Osteo
N.M. Medical YES YES YES YES
Nev. Osteo YES
Nev. Medical YES YES YES
N.Y. YES YES YES YES YES
Ohio YES YES YES YES YES
Okla. Osteo YES YES
Okla. Medical YES YES YES YES
Ore. YES YES YES YES YES
Pa. Osteo YES YES YES YES
Pa. Medical YES YES YES YES
R.I. YES YES YES
S.C. YES YES YES YES
S.D. YES YES YES YES
Tenn. Osteo YES YES YES YES YES
Tenn. Medical YES YES YES YES YES
Texas YES YES YES YES YES
Utah Osteo YES YES YES
Utah Medical YES YES YES YES
Va. YES YES YES YES YES
Vt. Osteo YES YES YES YES
Vt. Medical YES YES YES YES YES
Wash. Osteo YES YES YES YES
Wash. Medical YES YES YES YES
Wis. YES YES YES YES
W. Va. Osteo
W. Va. Medical YES YES YES
Wyo. YES YES

For the total 65 boards:

  • 58 report disciplinary actions taken against physicians
  • 31 summarize the action taken
  • 30 display the actual disciplinary order itself.

It’s noteworthy to consider that when state medical boards take an action against a doctor, it’s the result of an extensive investigation that may have taken several years.  It’s not based on a single patient complaint.  Usually it’s more than several cases which are then evaluated and distilled down to the most egregious cases.  The voluminous data is collected and verified and the doctor is given an opportunity to refute the evidence.

By the time a board action leads to license revocation, the potential for ongoing risks to patients is real.  As shown above, the lack of a summary report, or viewing the board order itself, forces people to speculate on what triggered the disciplinary action in the first place.  At the time of this report, four states did not have a web based mechanism to report state disciplinary board actions to the public.  Of interest are the fourteen states that distinguish between the types of material disclosed for medical doctors versus osteopathic physicians.  Of those fourteen states, two states report disciplinary actions taken against medical doctors, but report nothing for osteopathic physicians.

The practice of medicine frequently involves care rendered in hospitals.  If patients need hospital care, choosing quality providers is even more important.  The table below, summarized from the 2006 Public Citizen report, illustrates the available information concerning hospital disciplinary actions found on state medical boards.

Hospital disciplinary actions against physicians:

State Medical Boards reporting restricted physician privileges
State Medical Boards reporting restricted physician privileges

A cursory view of this table illustrates the paucity of such data with only eleven states displaying any information of this type, and only four boards displaying a summary of the disciplinary action taken by the hospital.

Since there are more hospitals than states, and each hospital is governed by quality assurance boards, there is a wealth of information on physician quality and treatment outcomes.  In addition, a hospital may decide to restrict a surgeon’s operating privileges due to many complications.  Such factors place the hospital at risk as a co-defendant in malpractice.  Even more alarming, in many states, when hospitals reduce a doctor’s privileges, they must notify the state medical board.  Yet that same information may not appear on the public web site.

Reporting Medical Malpractice:

How frequently malpractice embroils a physician is something most people would like to know.  The table below, also summarized from the Public Citizen report, reveals available information on malpractice made available on state medical board web sites.

State Medical Boards reporting medical malpractice
State Medical Boards reporting medical malpractice

Only eighteen states provide some information on their web sites.  Of those states, only 5 report the dollar amounts of the settlement.  Such information is also valuable because it speaks to the gravity of each specific case, and may distinguish between so-called nuisance suits.  Interestingly, at the time of this report, only four states displayed all information regarding malpractice litigation.

An AMA Forum presented an interesting solution to enhancing transparency in this area.

Finally let’s explore how criminal activity by physicians is reported by state medical boards.  In choosing any provider, be it doctor or baby-sitter, most people shun providers with a felony conviction.  Yet it’s surprising how this is handled among various state medical boards.

Reporting Criminal Convictions in Physicians:

Criminal Activity reported by state medical boards
State medical boards reporting criminal activity

In this report, only 13 states report criminal convictions on their web sites.  Eight of those states give details about the conviction and only four of those states report all of the conviction information.

Although personal privacy, forgiveness and compassion are important after someone commits a serious mistake, there is still a debate on how much information should be in the public domain.   After “paying back their obligation to society” and amending their ways, many feel that doctors should be granted a new start.  Yet  the nature of the conviction alters how far the public forgiveness can be stretched.  For example, people may be willing to forgive a DUI in a dermatologist nine years ago, but not a sexual offense in an obstetrician committed a year ago.

As we have seen thus far, it appears that healthcare prices are quite variable and unrelated to treatment outcome.  In addition, it appears that selecting a medical provider based on a background check is dependent on where one lives.  And most importantly, current information systems reveal nothing about the doctor’s skill for treatment results in patients with similar levels of illness.  It remains one of the greatest challenges facing good public health at reasonable costs.  It’s also what we will continue to explore in ongoing blogs.  As a matter of fact, healthcare is one of the few service industries where payment is primarily based on delivery of service, not outcome.

D’Youville College, School of Health Professions

Recently I had a great discussion with Dr. Anthony Billittier, the Dean of the newly created School of Health Professions at D’Youville College in Buffalo, New York.  For those unfamiliar with D’Youville College, it’s history began in 1908 when it was founded by the Grey Nuns of the Sacred Heart.  It was the first college in western New York to offer baccalaureate degrees for women.  After 100 years, it’s mission has expanded to 45 degree programs to over 3,000 undergraduate and graduate students of all faiths, cultures and backgrounds.

Dean School of Health Professions, D'Youville College
Anthony Billittier M.D.

Continuing its innovation, the college recruited Dr. Billittier as the first dean of the newly created School of Health Professions.  His background and enthusiasm is well know to me for many years.  He was the Commissioner of Health for Erie County from 2000 to 2011.  As the health guardian for the county, he streamlined the department and energized preventive health measures across the region.  Nationally he had a most important, yet painful task of identifying crash victims in Flight 3407.  This tragic event in airline history led to significant changes in FAA regulations governing pilot flight hours.

D’Youville College is well know in the western New York region as a top provider for dedicated and well-trained nurses at all levels.  From bachelor degree nurses to doctorates of nursing practice, the school headed by Dr. Judith Lewis has played an important role in improving public health and lowering healthcare costs.

The new school of Health Professions follows this tradition with a focus on technology and healthcare analytics.  Some of the new programs that Dr. Billittier has developed are clearly directed towards training a 21st century healthcare worker.  In typical humble fashion, Dr. Tony was quick to inform me that these new programs are due to his dedicated faculty.  And that he played only a small part.

Yet for his part, Dr. Billittier brings to the table a philosophy, which I believe, is critical, if we as a nation are to improve public health and lower costs.  When Dr. Tony was Commissioner of Health, and even now as Dean, he insisted upon continuing to work as a part-time emergency department physician.  He works on weekend hours only, which ironically is the busiest time for an ER.  Plus he performs this work in one of western New York’s busiest hospitals, the Erie County Medical Trauma Center.

In my opinion, this commitment can only strengthen his classroom experience, serve as a beacon for students, and keep him at the cutting edge of finding solutions to real world problems in healthcare delivery.  As an example of his work leading to fruitful benefits, he is the principal investigator of a CMS grant for over $2.0 million to train community health workers.  These community workers are selected on their ability to interact with people in their local neighborhood.  They have a trusted relationship with their peers and are more likely to influence their neighbor’s health habits.

As Dr. Tony pointed out, the underserved community has three causes for poor health:

  • lack of access in locating the right provider,
  • lack of medical knowledge tailored to their specific illness,
  • and lack of motivation to seek early preventive care in a complex system.

The goals for his ongoing grant is to motivate high utilizers of hospital emergency services to instead form relationships with primary care providers.  This will improve both personal health and costs.

Another initiative which impacts healthcare delivery and worker training was Dr. Billittier’s Inter-professional Education Collaboration Program, shortened to: IPEC.  This exciting and greatly appreciated program uses professional actors from the  Kavinoky Theater to assist in training healthcare providers.

Many schools use simulated training exercises employing robots, patient manikins, or computer generated graphics.  In this approach, Dr. Tony engages the services of the theater actors who are highly trained in acting out a typical encounter as patients afflicted with certain medical illnesses.  Not only do these actors play the role of a patient, but they are accompanied by team actors who play the part of a distraught spouse, or an overbearing parent.  In this way, students get to examine “patients” in a  controlled environment which not only mimicks real life, but also provides for ideal teacher student interaction.

Lastly in my opinion, one of Dr. Tony’s greatest innovations is the launch of his accredited B.S. degree in Health Analytics.  This degree program with already enrolled students, set to begin in September of 2014, breaks new ground in education.

For the past decade, the United States has invested heavily in converting medical information from paper formats stored in various medical office, hospital and laboratory, siloes into digital formats that are portable and readily accessible.  This endeavor has come at great cost and has spun out numerous careers for workers specialized in IT services, EMR installation, and support.  However the real payoff to storing terabytes of numbers and values is the ability to transform that data into meaningful information that improves health and lowers healthcare costs.

Unfortunately there is a shortage of workers to do that transformation and analysis.  In my experience, the big name universities are more focused on training professionals who consume health information rather than transform health data.

The role of health analytics requires a training program that merges the health sciences with the computer sciences.  It requires working with complex computer programs to sort, organize and format disparate numerical data into understandable forms for analysis in even more complex statistical software programs.  During this transformation, the worker must understand the fundamentals of healthcare management and delivery so that the final output is meaningful.  The need for this specialized activity is great.  Just as the reward for workers who complete this program is also high.

It’s estimated that graduates with a beginning degree in this field can find employment with starting salaries of $50,000 plus.  The future for such workers in an era where information analysis is king seems boundless.

For all these reasons, I congratulate D’Youville College for their long standing history in healthcare innovation and in particular to my colleague Dr. Anthony Billittier for his passion, commitment and lasting desire to improve public health.

At the close of our chat, Dr. Tony said something with which I completely agree.  “D’Youville College is big enough to make a difference; yet small enough to change.”  Indeed in my opinion, this is what defines state-of-the-art innovation.

 

Health Care Costs — Do they Vary Across the U.S.

Comparing quality to price is something we do almost everyday.  Whether it’s buying an expensive flat-screen TV, or simply choosing the freshest fruits or vegetables.  We do it by touch, feel or careful visual inspection.  People who excel at this are called “smart shoppers.”  A skill that some have by instinct.

But regardless of our shopping prowess, we all have opinions on whether we bought  good or bad quality.  Sometimes that opinion is based on the attitude of the sales person, the care shown to us.  Other times, we base it on internet searches.  If still in doubt, we trust other customer reviews on everything from books, electronics, restaurants, clothing, movies and cars to name but a few.

Can we do the same in healthcare?  Are the news reports listing the best hospitals, or the  airline magazines displaying the top plastic surgeons, cardiologists, are they reliable?  And what does it all mean to a person struggling with a chronic illness, living miles away from the 10 best hospitals?

Will the same instincts that guide us in buying food, clothing, homes, cars and electronics help us choose a quality doctor?  Or do we need better information?

Let’s look at pricing.  Generally, we expect to see a relationship between cost and quality.  Not always true, but generally true.  Does that statement apply to medical care?  If we believe care is superior in prestigious university medical centers, is it more costly there?  Or do the same procedures performed in remote rural facilities cost less?

Since health insurance is common, and in many cases administered by national companies, would not prices and reimbursements fall in a narrow range?  Why would an insurance company pay more, if the same procedure is available at a more prestigious facility just a short drive away?  Or do medical prices vary like gasoline pricing?  Which as we know can differ by as much as twelve percent or fifty cents per gallon?

On the other hand, do medical prices vary more like the cost of peanuts and gummy bears in hotel minibars?  But then again, when we’re on vacation, we expect higher pricing and we suspend our frugality, and even use the word “splurge.”  For good reasons, such as a special occasion or extra special care, we accept marked variation in pricing.  Is the same true for health care costs?

Let’s look at one example: a flexible colonoscopy.  Just about everyone understands the importance of cancer prevention and how certain cancers, if detected early, can be arrested or cured.  Colon cancer is a prime example.

Depending on one’s age or family history, a colonoscopy is recommended at certain ages.  The procedure, though somewhat distasteful in its preparation, is standardly employed across the country and is considered routine, safe and effective.  It’s also a procedure that has a definite beginning and end, and is very similar (as anything in medicine can be) from one patient to the next. It’s not like comparing heart surgery or brain surgery.

I decided to look at the cost and insurance reimbursement for this procedure in 19 different cities.  These cities were chosen because I was familiar with some of them, or because they were a city designated as a medically underserved or had a challenged economic environment.

Next, I took advantage of an excellent web site at Fair Health.  This excellent resource envisioned by then Attorney General, and now Governor of New York, Andrew Cuomo was brought to life by the diligence of Fair Health President Robin Gelburd.  The site has a very extensive database that permits consumers to see prices for healthcare services across the nation.  In addition, it helps patients discover what their out of pocket expenses might be if they use out-of-network doctors.

Using this site, I looked at the estimated charges, estimated insurance reimbursement, and estimated out-of-pocket cost for a flexible colonoscopy listed as a medical procedure with the billing CPT code of 45378.  This code designates a “Diagnostic examination of large bowel using an endoscope.”  I deliberately did not add on modifying codes, which are generally associated with this procedure such as CPT 45331 (Biopsy of large bowel) or a higher up code such as CPT 45385 (Removal of polyps or growths of large bowel).  I wanted to keep the procedure simple and expected to see the most conservative costs.

The Fair Health database is organized according to geo-zip codes, which is generally the first three digits of the area postal zip code.  For each of my selected cities, I looked up the zip code for the city’s center, generally based on the location of the town hall.  For estimates on per capita income, I looked up U.S. census data, or reports from city government web sites.

The chart I produced is shown below: (Which can be enlarged by clicking)

 

Health Care Costs Colonoscopy
Health Care Costs Colonoscopy 19 U.S. Cities.

 

When I began my medical practice, my concern for reimbursement was limited to my immediate location, Buffalo New York.  I knew that my colleagues in Rochester, New York (70 miles down the road) and in New York City received higher reimbursements for the same procedures.  But when I questioned the insurance company, I was told that my colleagues received higher pay because it cost more to live in those cities.  This was called a cost of living adjustment.  I accepted this explanation because like my patients, I had no informatics system to disprove it.

However in the table above, which lists cities by increasing charge for a colonoscopy, along with per capita income, it suggests that cost of living is not the criterion for provider reimbursement.  The column for estimated charge is the average charge that doctors make for the procedure within select zip codes for that city.  The column insurance paid is the average reimbursement made to providers, generally for in-network providers.  The second from last column labeled “out of pocket” would be the cost passed on to patients for out of network doctors, that is, the additional cost a patient would pay to the doctor after the maximum allowed insurance payment.

The table illustrates a striking difference in the charge for a colonoscopy in Selma, Alabama compared to the same procedure in Burlington, Vermont.  That difference is: $1,813.94 or 350% higher.  Interestingly insurance companies pay $507 for a colonoscopy in Selma and pay $1,777 in Burlington, a difference of $1,270.  That payment would cover the procedure twice in Tucson, Arizona and five other cities.

Since physicians are told that reimbursement varies by cost of living, let’s look at the cost for a colonoscopy in Beverly Hills, California which is estimated at $1,350.99 with an insurance payment of $945.69, and compare that to the cost in Allen, South Dakota which is $1,273.01 with a reimbursement of $891.11.   Allen, South Dakota is listed among the 100 poorest cities in the U.S. with 96% of the population living below the poverty line, the same isn’t true for Beverly Hills.

Perhaps it’s necessary to reimburse doctors at a higher rate because they practice in underserved areas such as Allen, South Dakota, or Potsdam, New York, both remote underserved areas with per capita incomes below $10,824.  Then why is it that providers in cities with per capita incomes in excess of $25,000 differ from each other by payments greater than several hundred dollars, and also differ by similar amounts from remote underserved cities?

If there is such a thing as a bargain colonoscopy, how is it that in Seattle, Washington with per capita incomes of $39,886, the insurance payment is $617, while in Boston and Honolulu; it’s reimbursed at $715 and $763 respectively?

Of further interest in my analysis is the variation in pricing reported across different zip codes within the same city boundaries.

Though these pricie differences are perplexing, the real questions should be: How are these fluctuating prices and payments related to quality of care?  Where is the best procedure performed?  Who are the most skillful providers?  Which providers have the best outcomes and are not likely to miss a cancer?

These are the important questions, which fall into a category called evidence based outcomes.  Such data supports how well providers detect serious lesions, as well as track their false positive detection rate.  This is important because if a doctor falsely suggests a benign lesion is cancerous, it commits the patient to an unnecessary surgical biopsy.

Finally it’s important to know the provider’s complication rate. Although the procedure is generally safe, occasionally it does have serious complications including perforations of the bowel with injury to the spleen or liver.  Just as airplane crashes are unlikely events, they do occur and generally occur because of pilot error. Physicians also can have pilot-like errors. And just like pilots, when these accidents happen, lack of experience, provider impairment, equipment failure, and lack of quality control all play a part.

In future posts, we’ll explore how we choose our health care providers, and when we are suspicious of their skills, the resources available to answer our concerns.