"Anesthesiologists add billions to cost of....

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foxtrot

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This article highlights growing sentiment that I hate. It's frustrating to hear people quarterback doctors based on cost. Physicians (for the most part) seem to do things based on what is needed and what will provide the best for their patients. Why is it that a growing number of people feel that they think they need to start determining what someone elses role should entail when they're NOT a supervisor but a customer. Let them decide at the point of purchase.

My gut tells me they too will want to go with the highest level of care; however, the real issue is they want it for free / a fraction of the cost.

I have illness x --> I need treatment y ---> treatment y requires these professionals and equipment to treat ---> costs z amount. The first place people go is "make it cost less". WTF. Pay or dont pay - end of story.
 
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ask my dad, who had a horrible experience, with GI doc giving sedation whether having anesthesiologist giving sedation is worth it. Not a life or death issue for him just a patient satisfaction issue.
 
yappy said:
My gut tells me they too will want to go with the highest level of care; however, the real issue is they want it for free / a fraction of the cost.

I have illness x --> I need treatment y ---> treatment y requires these professionals and equipment to treat ---> costs z amount. The first place people go is "make it cost less". WTF. Pay or dont pay - end of story.
Click to expand...

This! This!
 
yappy said:
Physicians (for the most part) seem to do things based on what is needed and what will provide the best for their patients. Why is it that a growing number of people feel that they think they need to start determining what someone elses role should entail when they're NOT a supervisor but a customer. Let them decide at the point of purchase.
Click to expand...

I'm not sure I'm qualified for this discussion as a CA-0, but in the 60-70% of folks who are ASA 1-2 level patients, is there any added value to having an anesthesiologist present during routine GI procedures?

I agree, if patient satisfaction is important, then great, let 'em pay the extra, but from a free business/economic standpoint, I think they can get by.

The bigger problem is, folks aren't picking off a menu regarding their choices. I'm sure if I strolled in with a list for the price to the patient for a simple BMP/CBC, they'd say screw it and go ahead without the labs depending on how I couched the discussion. This makes it really important that we as physicians do these annoying cost/benefit analyses where you look at the cost/benefit matrix and figure out where the system can cut corners and help break even. The demand aspect of this economy is totally broken.
 
urge said:
That guy is sinking the specialty. I'm sure his house is paid off and his kids are out of college.

Do you think he is trying to bring down the price of Med school also?
Click to expand...


Riiiight. Unfortunately, this is the attitude of many "high ups" in academia (not everyone). Many of these professors and chairs turn a blind eye to what is going on in the "real" world because they are not in the trenches. They are politicians who have made big bucks off the system they like to criticize. [NOTE: I am not saying everyone is academics is like this but you all know the types of people I am talking about]
 
I have had 2 colonoscopies with sedation provided by an endo nurse. Some discomfort and cramping but it was fine. The truth is that while I agree this is second best, from a cost/benefit standpoint it is probably worthwhile to reserve anesthesia services for the sickest patients or those patients who have failed @ sedation by an endo nurse/GI doc combo.

(Unless of course the patient wants to write a personal check)
 
Orin said:
I'm not sure I'm qualified for this discussion as a CA-0, but in the 60-70% of folks who are ASA 1-2 level patients, is there any added value to having an anesthesiologist present during routine GI procedures?

I agree, if patient satisfaction is important, then great, let 'em pay the extra, but from a free business/economic standpoint, I think they can get by.

The bigger problem is, folks aren't picking off a menu regarding their choices. I'm sure if I strolled in with a list for the price to the patient for a simple BMP/CBC, they'd say screw it and go ahead without the labs depending on how I couched the discussion. This makes it really important that we as physicians do these annoying cost/benefit analyses where you look at the cost/benefit matrix and figure out where the system can cut corners and help break even. The demand aspect of this economy is totally broken.
Click to expand...

Ok CA-0.....remember this when you're looking for a job 4 years from now.
 
Consigliere said:
Ok CA-0.....remember this when you're looking for a job 4 years from now.
Click to expand...

He has a reasonable question, which is an extension of previous debates we've had here about how ethical it is to provide anesthesia services for unnecessary procedures.


Every week, we do a couple vasectomies in our main OR with propofol sedation because we have the capacity, one particular surgeon wants it, and the patients are expecting it after their initial appointments with him.

That doing so in the PP world could be lucrative doesn't make it necessary or even reasonable. I had a vasectomy (two actually :mad:) with nothing but local.
 
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pgg said:
He has a reasonable question, which is an extension of previous debates we've had here about how ethical it is to provide anesthesia services for unnecessary procedures.


Every week, we do a couple vasectomies in our main OR with propofol sedation because we have the capacity, one particular surgeon wants it, and the patients are expecting it after their initial appointments with him.

That doing so in the PP world could be lucrative doesn't make it necessary or even reasonable. I had a vasectomy (two actually :mad:) with nothing but local.
Click to expand...

Fine. Just remember, the less we do, the less need there will be for anesthesiologists. CRNA mills are cranking 'em out by the hundreds so less of a pie to share. Future anesthesiologists be wary.....
 
While we are at saving money. Why not release a study based in Europe showing that many Europeans women elect not to have labor epidurals and do well also.

Who needs epidurals for labor? right?

I am sure those anesthesia practices who have greater than a 50% no pay/medicare/medicaid OB population would welcome not having to spend a night in the hospital on OB call and doing an epidural on a high risk non-paying OB paying that the hospital reimburses the group $75 for.

The fact of the matter is it's impossible to predict who will do well with Versed/Fentanyl for colonscopies or EGDs.

I suggest the doctor who's did the study ask all his realtives including his wife/kids/siblings/aunts/uncles/friends to all have colonoscopies under versed/fentanyl and get back to us how they did.

Just look at the uproar when the preventive task force said women shouldn't have screening mammograms at age 40. Insurance companies love this cause they don't have to pay for it. Public outcry was loud and harsh.
 
It would be nice if the posters would separate self interest from the reasonablenss of their arguments. As a small business owner as well as a clinician I am apalled at what we have to pay to cover our employees health premiums. The dollars that pay these premiums and our salaries are coming from somewhere and the well is running dry.
 
aneftp said:
While we are at saving money. Why not release a study based in Europe showing that many Europeans women elect not to have labor epidurals and do well also.

Who needs epidurals for labor? right?

I am sure those anesthesia practices who have greater than a 50% no pay/medicare/medicaid OB population would welcome not having to spend a night in the hospital on OB call and doing an epidural on a high risk non-paying OB paying that the hospital reimburses the group $75 for.

The fact of the matter is it's impossible to predict who will do well with Versed/Fentanyl for colonscopies or EGDs.

I suggest the doctor who's did the study ask all his realtives including his wife/kids/siblings/aunts/uncles/friends to all have colonoscopies under versed/fentanyl and get back to us how they did.

Just look at the uproar when the preventive task force said women shouldn't have screening mammograms at age 40. Insurance companies love this cause they don't have to pay for it. Public outcry was loud and harsh.
Click to expand...

This is a good analogy. Is propofol necessary, no, is it preferable from a patient satisfaction standpoint....for sure. As far as safety, we can't tell who benefits from our involvement, we can make a guess but that's the best we can do. Follow this line of thought further, should we base our involvement in minor procedures like carpal tunnels, trigger fingers, access for renal dialysis on outcomes, my guess is the majority of those folks would do just fine with a monkey at the head of the table. Where do you draw the line? I hate doing endos, but if it's such a wrong to society that we are involved why are we becoming more and more involved in gi labs? The answer is that patients like it, gi docs like it and we as a service industry go where the business is. I would like to ask dr fleischer how many endos he has actually been involved with over the past year? I bet he's over 50, I wonder what he got when he got his screening colonoscopy.
 
dr doze said:
It would be nice if the posters would separate self interest from the reasonablenss of their arguments.
Click to expand...

Ha ha.. good luck seeing that ever happen in this forum. This is one big reason I lost interest in participating here.


"It's hard to get a man to understand something when his salary depends upon his not understanding." - Upton Sinclair
 
Consigliere said:
Ok CA-0.....remember this when you're looking for a job 4 years from now.
Click to expand...

Its an honest question, and deserves an honest answer.

I can argue that turnover is quicker, patient and physician satisfaction is higher, and we scope many sick patients (even for screening) that all benefit simply from a trained set of eyes on the monitor. If those things are valuable in the current economic landscape, then there is your answer.
 
Orin said:
I'm not sure I'm qualified for this discussion as a CA-0, but in the 60-70% of folks who are ASA 1-2 level patients, is there any added value to having an anesthesiologist present during routine GI procedures?

I agree, if patient satisfaction is important, then great, let 'em pay the extra, but from a free business/economic standpoint, I think they can get by.

The bigger problem is, folks aren't picking off a menu regarding their choices. I'm sure if I strolled in with a list for the price to the patient for a simple BMP/CBC, they'd say screw it and go ahead without the labs depending on how I couched the discussion. This makes it really important that we as physicians do these annoying cost/benefit analyses where you look at the cost/benefit matrix and figure out where the system can cut corners and help break even. The demand aspect of this economy is totally broken.
Click to expand...

What if the GI doctor perforates the bowel in a 500 pound patient with a fused cervical spine with an infiltrated iv with the patient now in respiratory distress from their asthma being worsened by the acute clinical condition. Do you think some nurse in the endo suite is going to know what to do. What if that patient is your family member.

If you asked me that question and I knew you were coming to my program, I would promptly have you fired. You are showing me you have no idea what an Anesthesiologist does. Bad things happen, and having people present who have no plan or experience or ability to fix things is a recipe for disaster.

We are present for the disaster. Remember, any idiot can fly the plane Captain Sully was flying. Not too many would have been able to land safely in that situation. That is why we are paid the big bucks.
 
powermd said:
Ha ha.. good luck seeing that ever happen in this forum. This is one big reason I lost interest in participating here.


“It’s hard to get a man to understand something when his salary depends upon his not understanding.” - Upton Sinclair
Click to expand...

There will always be self interests (especially in regards to income) in any profession. Short of being a nun or a priest, all industries have to think what revenue is being generated and at what cost/benefit.

Medicine isn't any different. We all would like to be holistic and most of us are. But at the end of the day, we all have bills/life expenses just like the rest of the people.

The real issue to controlling health care dollars is rationing of services. And the public is terribly afraid of the use of the word "ration" and healthcare.

Ok, lets not use anesthesiologists for colonscopies/egd except for the sickiest of sick patients. Let's save the public a billion or so dollars.

But lets move this argument to extreme premature births (say the less than 28 week olds). How much health care dollars do we spend on them? Many that are saved go on to have CP, vision, breathing problems further adding to health care dollars. What about ICU dollars spent on end of life? Does that really improve overall quality of life?

No one wants to broach that subject.

If providing anesthesia for colonoscopies costs the public "billions". Imagine a report saying end of life care for chronically ill patients ends up costing the nations "trillions". No one wants to discuss that with the high voting senior population and no one wants to discontinue care for premature infants.
 
Let me break it to you gently... even in the best health care systems in the USA CRNAS administer propofol for Gi procedures. The vast majority of sedation is given by CRNA only practitioners across this nation. I'm sorry if this hurts but it is the truth.

Even in many "ACT" practices the CRNA administers the sedation for these cases with minimal to no input from Anesthesiologists. Yes, we may get consulted for the ASA4 patient, guy with a trach or severe sleep apnea but that is the exception and not the rule. I do know of Anesthesiologists who act as preop monkeys in GI mills where they see 80 patients or more a day while the CRNA does the anesthesia.

In summary, if you are relying on GI procedures to feed your family come 2020 then they may go hungry. I'm not sure how long the CRNA can keep the RN sedation nurse from taking this job away from them.

American Medicine is coming down to the "lowest common denominator" for care in all areas. The Gi procedure is just one example where adequate is going to be good enough unless the patient is willing to pay out of pocket.
 
Anybody have any data as to what percent of the endoscopies in the US have anesthesia personnel involved as opposed to sedation by endo nurses?
 
dr doze said:
Anybody have any data as to what percent of the endoscopies in the US have anesthesia personnel involved as opposed to sedation by endo nurses?
Click to expand...

And.......here comes the point in the thread where Blade posts 42 charts and graphs....
 
aneftp said:
There will always be self interests (especially in regards to income) in any profession. Short of being a nun or a priest, all industries have to think what revenue is being generated and at what cost/benefit.

Medicine isn't any different. We all would like to be holistic and most of us are. But at the end of the day, we all have bills/life expenses just like the rest of the people.

The real issue to controlling health care dollars is rationing of services. And the public is terribly afraid of the use of the word "ration" and healthcare.

Ok, lets not use anesthesiologists for colonscopies/egd except for the sickiest of sick patients. Let's save the public a billion or so dollars.

But lets move this argument to extreme premature births (say the less than 28 week olds). How much health care dollars do we spend on them? Many that are saved go on to have CP, vision, breathing problems further adding to health care dollars. What about ICU dollars spent on end of life? Does that really improve overall quality of life?

No one wants to broach that subject.

If providing anesthesia for colonoscopies costs the public "billions". Imagine a report saying end of life care for chronically ill patients ends up costing the nations "trillions". No one wants to discuss that with the high voting senior population and no one wants to discontinue care for premature infants.
Click to expand...

Very well said. To take it even a step further, lets now look at the amount that is spent on elderly people circling the drain in the ICU. ICU care is the most costly care out there. And Medicare is paying for most of it. With our aging population and less of us to pay for them, how can we afford ICU care for them when they fall ill towards the end of their life. No one wants to address these issues but there will come a time when we will be forced to and it will be ugly because the politicians just keep kicking the can down the road.
 
cincincyreds said:
What if the GI doctor perforates the bowel in a 500 pound patient with a fused cervical spine with an infiltrated iv with the patient now in respiratory distress from their asthma being worsened by the acute clinical condition. Do you think some nurse in the endo suite is going to know what to do. What if that patient is your family member.

If you asked me that question and I knew you were coming to my program, I would promptly have you fired. You are showing me you have no idea what an Anesthesiologist does. Bad things happen, and having people present who have no plan or experience or ability to fix things is a recipe for disaster.

We are present for the disaster. Remember, any idiot can fly the plane Captain Sully was flying. Not too many would have been able to land safely in that situation. That is why we are paid the big bucks.
Click to expand...

not the point. nobody argues those people need anesthesia services (ive even demanded some go to the OR instead of the GI suite), what about the countless ASA1-2 patients that come through?

Also, these are EXACTLY the kinds of things a young trainee/grad NEEDS to be asking questions about. The concept of "just having someone nearby who knows what to do" is not going to fly if there isnt anyone to pay for it, so if you cant find a way to justify your presence in the healthy population, you wont be doing those cases.

Id be inclined to fire someone who wasnt concerned about "what we do" because it implies no sense of direction.
 
foxtrot said:
Very well said. To take it even a step further, lets now look at the amount that is spent on elderly people circling the drain in the ICU. ICU care is the most costly care out there. And Medicare is paying for most of it. With our aging population and less of us to pay for them, how can we afford ICU care for them when they fall ill towards the end of their life. No one wants to address these issues but there will come a time when we will be forced to and it will be ugly because the politicians just keep kicking the can down the road.
Click to expand...

IPAB will address most of these issues.
 
cincincyreds said:
If you asked me that question and I knew you were coming to my program, I would promptly have you fired. You are showing me you have no idea what an Anesthesiologist does. Bad things happen, and having people present who have no plan or experience or ability to fix things is a recipe for disaster.
Click to expand...

Really, you'd fire an intern for asking this question? The fact that sedation for endoscopy is done by nurses, CRNAs, and anesthesiologists virtually everywhere essentially proves that there is room for debate about what's safe ENOUGH and cost effective ENOUGH.

If you don't want to take part in that debate or have a say in our future, fine, but don't pretend that the debate isn't going to take place anyway with or without us, or that questions reflect ignorance.
 
So maybe the title should have been "CRNAs Add Billions....." instead of "Anesthesiologists Add Billions..." :D
 
Idiopathic said:
ridiculous statement
Click to expand...

Dude, its a joke. But if the CRNAs are the ones doing most of the cases, and they are doing many of them without MD/DO supervision...just sayin.

Edit- per Blade's post- Let me break it to you gently... even in the best health care systems in the USA CRNAS administer propofol for Gi procedures. The vast majority of sedation is given by CRNA only practitioners across this nation. I'm sorry if this hurts but it is the truth.
 
Don't know what the answer is--perhaps a better screening tool.

When I had a colonoscopy, 2 of versed and 50 of demerol was like a general anesthetic from my perspective. "hey wake up and get out of here" I couldn't believe it was over.

On the other hand, some poor nurses I work with get forced by GI to sedate and jaw thrust people who require 10+ versed and 250 of fentanyl and are still moaning in agony. And the GI docs refuse to get ACLS certified. Horrible position for the sedation nurse.

I've also witnessed some codes (and heard of GI suite deaths) and know firsthand how many GI docs are simply technicians who just walk away when the scope comes out.

I'm sure you've all seen the same.
 
Guys and Gals. I found the scoop on the MD who did this study. Sell out.

Drums rolls....

Guess what -the guy who wrote about $cost of colonoscopies is paid by Endothicon computer assisted sedation

Bam. Huge conflict of interest.
 
aneftp said:
Guys and Gals. I found the scoop on the MD who did this study. Sell out.

Drums rolls....

Guess what -the guy who wrote about $cost of colonoscopies is paid by Endothicon computer assisted sedation

Bam. Huge conflict of interest.
Click to expand...

:laugh:
 
aneftp said:
Guys and Gals. I found the scoop on the MD who did this study. Sell out.

Drums rolls....

Guess what -the guy who wrote about $cost of colonoscopies is paid by Endothicon computer assisted sedation

Bam. Huge conflict of interest.
Click to expand...

Please bring us some proof that could be sent to Yahoo. :laugh:

On edit- the Dr. isn't the problem, the author is...
 
Last edited:
Something isn't adding up. Frankly, it sounds like whoever wrote that Yahoo article is spinning Dr. Fleisher's words against anesthesiologists. I found an editorial that Dr. Fleisher wrote in JAMA defending sedation for endo cases being done by anesthesiologists. I could copy it here, but it requires access and I don't want to get myself in trouble. Here is the title for anyone that is curious-

Assessing the Value of "Discretionary" Clinical Care

The Case of Anesthesia Services for Endoscopy

It can be found in the March 21, 2012 issue of JAMA.

Here is the first 150 words of the editorial-

http://jama.ama-assn.org/content/307/11/1200.extract?sid=e5a3a4da-b4b0-4ad9-94da-ca4e73c824a4
 
OK, the real story-

Hangsheng Liu, PhD; Daniel A. Waxman, MD; Regan Main, BA; Soeren Mattke, MD, DSc


These folks had a study published in JAMA on March 21, 2012 titled-

Utilization of Anesthesia Services During Outpatient Endoscopies and Colonoscopies and Associated Spending in 2003-2009

This is the article Dr. Fleisher was addressing in the link in my previous posting. He points out many flaws in this study and generally defends anesthesiologists and their role in the endo suite.

Now, who are the people I listed just above? Well, thats where it gets interesting. Here is some info from the article-



Author Affiliations: RAND Corporation, Boston, Massachusetts (Drs Liu and Mattke); RAND Corporation, Pittsburgh, Pennsylvania (Ms Main); and RAND Corporation, Santa Monica, California (Dr Waxman).
Corresponding Author: Soeren Mattke, MD, DSc, RAND Corporation, 20 Park Plaza, Ste 920, Boston, MA 02116 ([email protected]).

Author Contributions: Drs Liu and Mattke had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Liu, Waxman, Mattke.

Acquisition of data: Liu, Waxman, Main.

Analysis and interpretation of data: Liu, Waxman, Main, Mattke.

Drafting of the manuscript: Liu, Waxman, Mattke.

Critical revision of the manuscript for important intellectual content: Liu, Waxman, Main, Mattke.

Statistical analysis: Liu, Waxman, Main.

Obtained funding: Liu, Mattke.

Study supervision: Mattke.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This study was financially supported by Ethicon Endo-Surgery Inc, Cincinnati, Ohio.

Role of the Sponsor: Ethicon Endo-Surgery Inc had no role in the design and conduct of the study or in the collection, analysis, and interpretation of the data. A draft manuscript was reviewed by Ethicon Endo-Surgery Inc, but the study authors made final decisions regarding the content and study conclusions.

Yeah, I'm sure there was no influence by Ethicon. Yeah. So basically, per Dr. Fleisher, we have some junk "science" in JAMA. Given the AMA's recent history, I'm not that surprised.
 
More interesting tidbits.

These words from the Yahoo article...

Fleisher said that using an anesthesiologist during a GI procedure should not automatically mean more reimbursement from insurance companies or Medicare.

"There's probably some way … to make it a more rational, financial decision whereby for the appropriate patients it's utilized and ones in which it's not necessary it's not utilized," he said.

are not found in his editorial in JAMA. Did the author simply make that up? Seems so, unless he did some kind of interview with them, though they didn't indicate that. Rather they mentioned his editorial. They make him sound supportive of the study, which he doesn't seem to be. Shady indeed.

Fleisher did say that costs need to be addressed and both patient and clinician perspectives need to be considered.
 
aneftp said:
Guys and Gals. I found the scoop on the MD who did this study. Sell out.

Drums rolls....

Guess what -the guy who wrote about $cost of colonoscopies is paid by Endothicon computer assisted sedation

Bam. Huge conflict of interest.
Click to expand...

Was that disclosed on the paper? Or did you have to dig for it?

D712
 
aneftp said:
Guys and Gals. I found the scoop on the MD who did this study. Sell out.

Drums rolls....

Guess what -the guy who wrote about $cost of colonoscopies is paid by Endothicon computer assisted sedation

Bam. Huge conflict of interest.
Click to expand...

Was that disclosed on the paper? Or did you have to dig for it?

edit: never mind, wrote it before reading IlDBasco.

D712
 
aneftp said:
Guys and Gals. I found the scoop on the MD who did this study. Sell out.

Drums rolls....

Guess what -the guy who wrote about $cost of colonoscopies is paid by Endothicon computer assisted sedation

Bam. Huge conflict of interest.
Click to expand...

Could you share the source or the name here. I think I might know the guy.
 
Noyac said:
This comes at a good time, unfortunate as it may be:

http://www.sanfranciscomedicalmalpr...2012/03/san_francisco_medical_malpract_2.html

Sermo members may find this familiar.
Click to expand...

Many smart GI docs know that's if a patient was hard to sedate by versed/fent/Demerol etc that it's appropriate to have anesthesia give the anesthetic the next time.

In the hospital when I see a previous note for hard to sedate for ercp, I am going to Intubate them and secure the airway. Ercp can take anywhere between 10-40 minutes. I ain't taking any chances if there's any mention by GI that's it may take a while to compete ercp.
 
The conscious sedation nurses make me nervous. This one was obvious grossly incompetent. As for the GI, when the monitor says your patient it's dying, you might want to use a little common sense and take a good look yourself. The economic damages there will be considerable.
 
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