The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry - Softcover

Paul A. Ruggieri

Softcover

ISBN 10: 0425272311 ISBN 13: 9780425272312

Publisher: Berkley, 2014

Synopsis

Why is surgery so expensive?
 
Surgeon Paul A. Ruggieri reveals little-known truths about his profession—and the hidden flaws of our healthcare system—in this compelling and troubling account of real patients, real doctors, and how money influences medical decisions behind the scenes. Even many well-informed patients have no idea what may be contributing to the cost of their surgery. With up-to-date research and stories from his practice, Ruggieri shows how business arrangements among hospitals, insurance companies, and surgeons affect who gets treatment—and whether they get the right treatment. Pulling back the curtain from the hospital bed, he explains how to safeguard one’s own health (and finances), and how America can make surgery more affordable for all without sacrificing quality care.

About this title

About the Author:

Paul A. Ruggieri, M.D., is a board-certified general/laparoscopic surgeon and the author of books, including Confessions of a Surgeon.

Excerpt. © Reprinted by permission. All rights reserved.:

 

—from THE COST OF CUTTING

—

INTRODUCTION

I had my first inkling that I wanted to be a surgeon before I was even accepted into medical school. Once I was there, it wasn’t long before I knew surgery was my calling. That was more than twenty-five years ago and every day (well, almost every day) since then I’ve been able to say, I love what I do. As a general surgeon, using my hands, my brain, and the tools of surgery, I can make a difference in the quality of a person’s life every time I step into the operating room. Sometimes I can even save a life. I’m profoundly grateful for the opportunity.

A couple of years ago I wrote a book about what goes on inside an operating room from a surgeon’s perspective. I wanted to take people into that mysterious world where a day’s work can ricochet from the mundane (varicose vein removal) to the sublime (repairing a torn artery before the person bleeds to death) in a matter of minutes. Those moments when something truly exceptional happens in the operating room, and even the less exciting ones, are what keep me and my colleagues doing what we do. The work itself is truly the reward—as is the gratitude of our patients.

Why, then, have I written a book about the money side of the equation? Isn’t money supposed to be anathema to the high principles of the medical profession? After all, we’re not stockbrokers, we’re healers. Traditionally, it’s been almost unseemly to mention money in the same breath as patient care.

But a new conversation is taking place in our country, and it’s all about money and healthcare. None of us can get away from it, including those of us who work as physicians and surgeons. And maybe that’s a good thing. I’m finding for the first time in my professional life that doctors are talking openly with each other about reimbursement, about expenses, about the challenge of running a viable practice while taking on more and more Medicare patients as the baby boom generation turns sixty-five.

As the Affordable Care Act (ACA) kicks in, the conversation about the cost of providing care in America has become even more important. And more frantic. Who will be covered? What will it cost? How will we as a country afford it? How does all of this relate to quality—or does it? A lot of contradictory points of view are being put forth. It’s a topic worth careful consideration. And that’s why I’ve written this book.

Currently, the United States spends more than $2.7 trillion a year on healthcare. This figure translates to more than 17 percent of gross domestic product (GDP)—and more than any other nation on earth spends on delivering medical services. A healthy piece of this $2.7 trillion pie is spent by private insurers and the federal government on reimbursement for operations and all the related expenses: surgeon fees, anesthesia fees, operating room fees, recovery room fees, hospital inpatient fees, and the “state of the art” equipment used during surgery.

Surgical procedures, more than any other aspect of healthcare, generate revenue. Big revenue. Operations are the lifeblood of hospitals. And of surgeons. Surgeons do not make a living seeing patients in the office; they make a living seeing patients in the operating room. Without busy operating rooms, many hospitals would dry up, closing their doors and taking away other important (nonsurgical) services as well.

Without operating rooms full of busy surgeons, medical device companies (big international for-profit companies that produce a plethora of equipment used during surgery, such as artificial joints, mesh, robots, cardiac stents, sutures, surgical stapling devices, and laparoscopic equipment) could not survive. Nor could they face their shareholders.

With more than fifty million operations performed in this country every year, surgery is big business. Surgery is an engine that compensates surgeons performing their craft, supports hospitals promoting their surgical services, and profits medical device companies. Unfortunately, all this money carries with it power and influence. When it comes to medical decision making, power and influence are not what you want motivating your surgeon, your hospital, or your insurance company. I believe this taboo topic should be part of our national discussion as we shape the future of healthcare.

Historically, surgeons and hospitals have benefited financially by producing greater operating room volume, not necessarily greater quality. Surgeons know this, anesthesiologists know this, insurance companies know this, and hospital administrators especially know this. Ironically, the only ones who are unaware of the enormous amounts of money generated from their operations are the patients about to be wheeled into the operating room. It does not matter whether your heart is being bypassed, your stomach stapled, your knee scoped, your uterus removed, your spine fused, or your hernia repaired; a long line of healthcare providers, hospital administrators, insurance company executives, and medical device company big shots are profiting before, during, and after your operation. Maybe that’s as it should be. Money must be made from surgery or there would be no surgical care at all. The question before the nation is, How much is that worth?

Over the last ten years, healthcare costs have spiraled out of control. The average person knows something is awry but not exactly what, or how to address the problem. What we do know is that there is a limit to the amount of federal money we are comfortable designating for medical care, and insurance companies are in business to make money. We want greater access to care and we want quality care and we want lower insurance premiums. So who’s going to foot the bill for all that quality care?

The ACA means greater access to care for more of the population, but it also means even greater government scrutiny on healthcare costs, and it has already resulted in significant reductions in reimbursements to providers, including surgeons. In many ways, this scrutiny is a good thing. To remain viable, however, hospitals in every community across this country are consolidating to gain patient “market share” and buying up primary care doctors and specialists alike. This shopping spree is an attempt to control referrals to their operating rooms and retain patients in their network. Retention is the battle cry of hospitals today.

As a potential patient, you are affected by all this. Hospitals’ attempts to control surgical referrals affect your choice of surgeon. Insurance companies are encroaching on your choices, too, with limited healthcare plans and provider networks. Sure, you can still choose your surgeon, but it will cost you sky-high deductibles if he or she is an “out of network” provider.

If you’re very lucky, you may never need to see the inside of an operating room. But even if fate is that kind to you, the cost of healthcare and how it will be provided in this country is something that should matter to all of us. I don’t claim to have all the answers to this puzzle, but I do hope the information and perspectives offered in this book will be enlightening. I hope you’ll gain insights that will get you thinking about this topic in a new way.

Meanwhile, I look forward to getting back to what I love to do.

PAUL A. RUGGIERI, M.D., F.A.C.S.

1

The woman seated on the exam table was lean and fit and seemed to be enjoying perusing one of the magazines from our slightly out-of-date offerings. She looked like she was in her midforties; her chart showed her age to be fifty-two. Her face did not express any distress and when she returned my greeting she spoke in a clear, friendly tone. As I scanned her medical history, the portrait of a person in good health came into view—her lab work, blood pressure, weight: All were excellent.

Healthy and thin are two adjectives I do not often use to describe my patients. Why was this woman in my office?

Several weeks earlier, it turned out, her primary care physician had ordered an abdominal CT scan to investigate a nagging pain that he hadn’t been able to diagnose. Eureka: The radiologist reviewing the scan noticed gallstones. Mystery solved. The patient (we’ll call her Mrs. Brogan) was subsequently referred to me for a “surgical opinion,” a consultation to determine whether surgery could help. As I performed the physical exam, I questioned her and soon concluded that her gallbladder was working perfectly. While some of her symptoms were vague and nonspecific, the gallstones found during the CT were what we in medicine call an incidental finding, nothing more. The true source of Mrs. Brogan’s pain had yet to be determined.

An incidental finding happens when an apparent abnormality of some kind—unrelated to the source of the person’s symptoms—is discovered during a diagnostic imaging exam. For example, if a CT scan of the abdomen is ordered to help with the diagnosis of a bowel problem and the radiologist notices a dark area, a “density,” on the kidney, that information becomes part of the report and is considered an incidental finding. Similarly, if a CT scan of the chest for diagnosis of coronary artery disease reveals a nodule in the lung, that incidental finding is shared with the referring physician and, ultimately, with the patient. Let the testing (and worrying) begin.

Over the past fifteen years there has been a dramatic increase in the use of two sophisticated diagnostic imaging tools: CT and MRI scans. CT (often referred to as a CAT scan), stands for computerized (or computer-aided) tomography, which uses x-ray technology. MRI, which stands for magnetic resonance imaging, uses a magnetic field and radio waves. Both create incredibly detailed views of the organs and soft tissue. According to the Radiological Society of North America (RSNA), while between three and four million CT scans were performed in 1995, seventy million were done in 2010. A report published in the Journal of the American Medical Association (JAMA) in 2012 showed a 400 percent increase in the use of MRIs during this same period. It is no wonder, then, that incidental findings are becoming more common and surgery as a result of them is on the rise.

While the advance of technology has tremendous benefits in medicine, the information these tools provide can present problems as well. For example, according to the RSNA, one-third or more of all CT scans will reveal incidental findings, yet fewer than 1 percent of these abnormalities are cancer or in need of any medical treatment. Where is the problem in that? you may be wondering. Knowledge is power, is it not? The problem is that once the radiologist spots the abnormality, he or she will most likely include it in the report. (Seasoned radiologists struggle with “nonspecific” incidental findings and whether to say anything at all. Frequently, the decision to report them is heavily influenced by the ever-present shadow of a malpractice lawsuit.) This often means your doctor must share that news with you, causing you anxiety and necessitating further tests, exposing you to more radiation and often a visit to an operating room for a surgical biopsy.

By the way, the phenomenon of incidental findings is especially prevalent in the Medicare population (those age sixty-five and over). One study, published in the American Journal of Roentgenology in 2005, showed incidental findings to be as high as 75 percent in 259 individuals over age fifty who underwent CT scans. The reason: An aging body coupled with technology powerful enough to produce high-definition images of structures doctors have never seen before is a surefire recipe for incidental findings. Pandora’s box has been opened.

There is, of course, a financial cost for all this information. Americans now spend an estimated $100 billion a year on medical imaging. But more important than the cost in dollars and cents is the cost to a person’s quality of life. As H. Gilbert Welch, M.D., noted in his book, Overdiagnosed, “Imaging technologies are very helpful in finding the abnormalities that are making patients sick. But they are also increasingly able to find abnormalities in people who are well,” a vicious cycle he refers to as “seeing more, finding more, and doing more.” The studies cited in Welch’s book are provocative; it’s difficult to acknowledge that the number of individuals who are hurt by unnecessary medical treatment is far greater than the number helped by the advances in diagnostic imaging, but that’s what the numbers show.

To take a closer look, consider another study from the journal Health Affairs in 2009 looking at how the increased use of MRIs can lead to potentially unnecessary surgery. This data showed that as the use of MRIs for generalized back pain increased, more spine abnormalities were detected. Whether these abnormalities were the true cause of the back pain is unclear. Yet the subsequent increase in back surgery correlates with the increase in MRI diagnostic imaging, despite the lack of definitive evidence that surgery would be beneficial. What that means is a significant number of individuals underwent major surgery on their spines (ranging from a laminectomy to spinal fusion) and yet continued to experience the pain that precipitated the MRI or, even worse, a more severe and disabling pain.

Doctors order diagnostic imaging exams for the best of reasons. The results can be definitive and lifesaving. But they can also be equivocal, unclear. What you, the prospective patient, need to understand is that in some ways your doctor is a detective searching for clues, and what’s “wrong” is not always immediately clear. Incidental findings are often red herrings, diverting attention from the real problem.

—

Back to Mrs. Brogan.

I had in front of me a woman whose primary care physician had told her of the gallstones revealed on her CT scan. He had recommended that she seek a surgical opinion with me, telling his patient, “I can send you to a surgeon who will try to find any reason to operate on you. I can also send you to a surgeon who will find any excuse not to operate on you. Or I can send you to Dr. Ruggieri, who is somewhere in between.” Mrs. Brogan was free of “underlying conditions” (obesity or a chronic disease such as diabetes that can cause complications during what is usually a straightforward operation). And she was willing. As a matter of fact, when I told her there was nothing wrong with her gallbladder, she said, “Why not just take the thing out? I don’t need it anyway, do I?”

All that and she had very good health insurance. Reimbursement would not be a problem.

I had an opening in my schedule that week. . . . For a brief moment—and this is difficult to admit—I found myself tempted to schedule the surgery. A completely unnecessary surgery. The operation would have taken me twenty stress-free minutes, Mrs. Brogan would have gone home a few hours after the operation, and I would have been paid close to $1,000.

The only problem: There was no medical reason to do so.

Yes, the CT study had...

About this edition

• Publisher: Berkley
• Publication date: 2014
• ISBN 10: 0425272311
• ISBN 13: 9780425272312
• Binding: Paperback
• Edition number: 1
• Number of pages: 320