Waking Up Costs

Aetna, Colonoscopy, and Money

Clark Venable — Mon, 11 Feb 2008 20:52:38 GMT

I suspect that there is much more to Aetna's recent decision (pdf) to stop paying for Propofol for all (exceptions exist) colonoscopies than either Propofol or colonoscopies. At first glance it just look like they're trying to save themselves the additional cost the anesthetist or anesthesiologist that is needed if endoscopists want their patients to receive propofol adds. But I think there's more to it than that.

Let me state at the outset that my practice does not derive significant income from providing anesthesia for colonoscopies. The vast majority of colonoscopies done with propofol use RN's with anesthesia training (CRNA's) to provide the service. I point this out because it seems that having any financial involvement at all is cause for discounting ones opinion--it should not be, but it is.

Using propofol allows colonoscopies to be done without patient awareness of discomfort, true, but the real advantage is that patients recover from the drug fast. By way of example, if a colonoscopy is done the 'old fashioned way' using the sedative midazolam and the narcotic demerol or fentanyl, the patient will likely need to remain in the center for one to two hours before they meet discharge criteria (assuming they don't have any nausea). Propofol allows them to go home in about 30-45 minutes. Roughly twice as fast from completion of colonoscopy to discharge. That means they occupy a recovery bed for less time and that's the limiting step for many centers. Once all the recovery beds are full, you can't do any more procedures until one opens up. Being able to quickly discharge patients after their exam allows much greater throughput in terms of exams per day that can be done .

Here is where I think the policy change will have its real effect. Either endoscopy centers will continue to provide the option of propofol sedation but charge the patient for it (in which case the insurance company will pay less), will provide it as part of the facility fee as a way to compete more effectively for patients (in which case the insurance company will pay less), or centers will go back (and I do mean back) to using older drugs but sacrifice throughput (in which case the insurance company will pay less).

Is having a colonoscopy easier with propofol? Don't take my word for it. Ask any endoscopy nurse which way he or she would prefer having a colonoscopy done.

Aside from cost and cost savings there's the issue of who decides what appropriate care is. If insurance companies are allowed to dictate who can and cannot get a certain kind of anesthesia, what will they do next? Get rid of anesthesia payments for cataract surgery? How about for trigger finger releases and carpal tunnel surgery. Vasectomy? See where I'm going with this?

Health Care Reform Distilled

Clark Venable — Wed, 19 Dec 2007 01:49:57 GMT

GruntDoc has an excellent distillation of the choices to be made in health care reform:

"Price.
Quality.
Access.

Pick any two"

Sort of a permutation of C. Everett Koop when he said that Americans want the best medical care in the world, they want it for free, and they want it now.

Patients pay only 14% of health care costs? Wow.

Clark Venable — Sun, 16 Dec 2007 19:55:06 GMT

Free the market; Government interference hampers healthcare reform

"In a system in which medical care seems free or is artificially inexpensive, with someone else paying for one's healthcare, medical costs spiral out of control because we are encouraged to demand medical services without having to consider their real price. For every dollar's worth of hospital care a patient consumes, that patient pays only about 3 cents out of pocket; the rest is paid by third-party coverage. And for the healthcare system as a whole, patients pay only about 14%."

This article has several nice pieces of data.

Pennsylvania's Ed Rendell Playing Games With Mcare Abatement

Clark Venable — Sat, 15 Dec 2007 21:00:17 GMT

The Governor of my state, Ed Rendell, has decided he wants to spend any surplus from the catastrophic malpractice insurance fund (which pays awards and settlements over $500,000) on providing insurance for uninsured adults in Pennsylvania. He wants this so much that that he's threatened not to renew the Mcare program unless he gets what he wants. Thought he State Senate has voted to extend the abatement, the House adjourned before voting.

Here's an interesting quote from Rendell:

"We're not going to go through the pain initially of having the doctors send in their checks, and then having to return them if we continue the (subsidy)," Rendell said after speaking at a nurses' conference in Hershey."

What about the pain of the physicians who will have to figure out how to get the money to pay the full amount in January rather than April? Does the Governor think it's harder for the State to issue a refund than it is for doctors to get their hands on that kinds of money?

There should be no linkage between renewal of Mcare abatement and funding of the Cover All Pennsylvanians insurance program. Mcare funds should be used to cover the program's unfunded liability and make it easier to privatize later. The Governor's Cover All Pennsylvanians should get funding in a way that does not impact Mcare's ability to retire unfunded liability and he should stop playing political games to fund it otherwise.

Sicko: Socialism in a capitalist society?

Clark Venable — Wed, 20 Jun 2007 00:54:16 GMT

This is the best summary I've read of the barriers to implementing significant change to our current health care system:

Sicko: Socialism in a capitalist society?:

"Bang the Drum with some analysis of whether a government-run health care system is possible in America:

To accomplish any meaningful reform, Americans will have to dismantle the insurance and pharma lobbies at a minimum, and begin to tackle the question of how to deliver universal health care without tying it to employment, marital status, or other qualifiers (and figure out how to put all those unemployed pharma and insurance reps to work, too). Once those lobbies have been set aside, the questions of how to implement a healthcare system which avoids the pitfalls faced by Canada, the UK and France, embraces the positives in the Cuban system, and essentially folds a socialist system into a capitalist society will have to be addressed.

[Via Kevin, MD - Medical Weblog]