Colonoscopy and health care…


I just went through that ritual that officially makes me middle-aged: the colonoscopy. It wasn’t a hugely fun event, but guess what my out-of-pocket was? About thirty bucks, on the over-the-counter drugs needed for the “cleansing prep” plus a couple jugs of Gatorade to wash it down. Zero co-pay for the procedure itself, because my insurance calls it “preventive care”.

If I had to set rates, I’d figure that there were about 1 1/2 hours of skilled nursing time, 1 hour of MD time, a couple low-skilled hours for staff to clean up, receptionist, laundry, etc. Then add another half hour of clinician time and half an hour of MD time for the CLS and the pathologist who get the biopsies.
Then there’s the consumables: IV equipment, gloves, absorbent pads, wipes, etcetera; plus the liter of saline with Versed and Fentanyl.
Add in use of the equipment, figuring most of its many-thousand dollar cost to be spread over the thousands of people who use the facility.
Finally, add in the cost of the space: a miniscule portion of the cost of the building, utilities, etc.

So, that ought to come up to a pretty expensive total. Maybe $1200-$1500? Who really knows: it’s worse than airline tickets, where at least the price is “take it or leave it” and you can (usually) go with a competing carrier.

When I had my cat to the vet, to get two cysts removed and biopsies, we were given an advance statement with a range of itemized prices: “we might not need this, but here’s what it is if we do”. Granted, this was elective surgery, but Sandy counts as a family member. With a 100% out-of-pocket cost, it made sense to know in advance. It came to about a thousand bucks, total. I bet a similar cyst removal and biopsy for a human patient would be a lot more, even though the human wouldn’t need general anesthesia and (probably) wouldn’t need to be shaved or wear the “collar of shame”.

The New York Times ran this comparison of costs, in which I discover that $4000 is typical in Minnesota.
I’m looking forward to logging on to my insurance web site next week to find the “explanation of benefits” to find out what happens with all the Monopoly money that gets shifted around. I’ll write a follow-up when that happens.

Meanwhile, there’s an interesting discussion happening on a friend’s Facebook feed about the opacity of the system and unpredictable, ridiculous charges:
FOAF* MD:

How as a doc am I going to know? They don’t tell me, insurance companies cover differently and have different co-pays, and I’m busy keeping changing protocols, med regimens, lab goals, health maintenance guidelines, names and faces and health histories straight, plus doing extra jobs I was never trained in am nor paid for, like transcription and coding. Most of the money goes to the middle men in any case. It is truly a broken system.

Random FOAF:

Yeah. My son’s jammed finger (from football) was not broken and it healed uneventfully with a little splint. If I didn’t have insurance, we’d just have spent $10 at Walgreens on a splint and had the same outcome as going to urgent care (which bills more like an ER than a doctor’s office visit), getting x-rays, and having a follow-up appointment. I think the total billing was probably about $3000.

same MD:

(To:) [random FOAF]: if it had been broken and needed pinning to heal well, and not pinning it right away would have meant re-breaking it, what then? I can see waiting a day or two before coming in, but I wouldn’t blame the urgent care doc for doing what was warranted.

(To:) [another name redacted]: I know visits cost in the hundreds, labs under 100 unless obscure send-outs, xrays/ultrasounds in the 100-200 dollar range and MRIs between 1000-2000. I do look at whether pts have insurance or not, but I try to make an appropriate recommendation based on the facts/exam and give other options with risks/benefits. Should I avoid doing a stress test on that guy with chest pain and a family hx of CAD because he doesn’t have insurance?
If I am found to be constantly undercoding my uninsured visits, I can also be charged with fraud. Good times.
I intentionally work for a lower salary to work in a hospital system that has free care, discounted care, and helps folks find insurance if they qualify. I am not the bad guy. Neither are most of my colleagues.

another MD, same thread:

So a couple of thoughts from my 20 years of practicing medicine:

First if [kid] was cared for by the same doctor who put his cast on, then there should have been a “global” fee – to care for the fracture from beginning to end. There could be some charges for extra x-rays, but for the most part it should have been a set fee.
Taking an x-ray at the completion of treatment is standard of care. It is very important to make sure the healing occurred appropriately. If not, there can be serious consequences later.

The cost of medicine is definitely way out of control. However, that is not the fault of any one physician. The system is definitely broken, and there has to be some type of fix for it. I’m not saying that Obamacare is the best way, but something has to change. Parts of the affordable care act are good, others may not be. Much of it is unknown as to how well it will work. . . . But at least there is an attempt to fix it.

In terms of costs, there can be some estimates prior to visit. However, the art of medicine is deciding what is needed and what is not. Sometimes the workup is very simple, other times it needs to be very extensive. The costs are often hard to estimate, unless it is a very straightforward visit.

I truly believe that part of the broken system is all of the extra tests run due to litigation issues. This country is sue happy, and physicians often practice defensive medicine. There is a science of medicine, and an art of medicine. I think good physicians practice the art of medicine supported by science. Listening to the patient and taking time is very important, something I always try to do. Hopefully your physician does the same.


*FOAF = friend of a friend
CLS = clinical laboratory scientist

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