Socrates25

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http://well.blogs.nytimes.com/2012/05/28/waking-up-to-major-colonoscopy-bills/?ref=health&gwh=7D090FC05739037768BCE2802D8F32E7

OK here you go, another doctor bashing NYT article. What else is new. The gist of the article is that GI docs are using propofol-based sedation requiring a anesthesiologist in the colonoscopy suite, rather than use conscious sedation which the GI doc can manage simultaneously with the scope. By bringing in these out of network gas docs, the costs skyrocket.

It brought up a couple of questions for me though. I just finished residency, and where I trained we were always instruced that it was not allowed to have the proceduralist be the same person who adminsters/monitors the conscious sedation. I guess I was under the mistaken impression that there were some kind of overarching rules preventing this. Is this not the case?

If you are allowed to be the proceduralist and the sedationist at the same time, does that mean that GI docs can "double dip" and bill separately for the procedure and the anesthesia? If thats the case it seems strange that the GI docs would want the gas docs to get involved since they would make more money without them.

I thought using nurses to deliver anesthesia was supposed to make everything cheaper? :rolleyes:
 

BLADEMDA

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Did you see the bill for the 20-25 minute colonoscopy? The Anesthesiologist wanted $1600 for 30 minutes. Come on. The insurance company pad him over $500; yet, he wanted more.

Gi docs can't bill for the anesthesia unless there is an employed, licensed anesthesia provider in the room giving the propofol. Then, the company can bill for the anesthesia provider.

A CRNA providing this anesthesia usually gets paid $90-120 per hour by the "company" with the Gi doctor being the main owner of the company. The company bills the insurance company.

Anyone billing $500 or more for Gi procedures is likely making over $1,000 per hour from the anesthesia. That's $6,000 per day. Hence, a fee of $1400 is $2800 per hour or $16,800 per day (6 hour days).
 

cincincyreds

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Where can you sign me up for this job? I could make like $3 million a year with that gig working my 50 hours/ week.
 

jwk

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Did you see the bill for the 20-25 minute colonoscopy? The Anesthesiologist wanted $1600 for 30 minutes. Come on. The insurance company pad him over $500; yet, he wanted more.

Gi docs can't bill for the anesthesia unless there is an employed, licensed anesthesia provider in the room giving the propofol. Then, the company can bill for the anesthesia provider.

A CRNA providing this anesthesia usually gets paid $90-120 per hour by the "company" with the Gi doctor being the main owner of the company. The company bills the insurance company.

Anyone billing $500 or more for Gi procedures is likely making over $1,000 per hour from the anesthesia. That's $6,000 per day. Hence, a fee of $1400 is $2800 per hour or $16,800 per day (6 hour days).
Our billing goes by the usual unit-based system - procedure + time + modifiers - not a flat rate. As I recall the RVU for a colonoscopy is 8 units - seems high to me, but that's what it is. Add 2-3 units for time and you're already at 10+ units for the most basic colonoscopy. Mulitply that by your unit charge and there you have it. Of course it's rare that anyone pays that fee because of network arrangements and discounting. And there is nothing that says an anesthesia group has to be in every single network a hospital and/or a GI doc decide they want to be in. We already give away enough care, and Medicare rates don't cover our costs now.
 

BLADEMDA

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Our billing goes by the usual unit-based system - procedure + time + modifiers - not a flat rate. As I recall the RVU for a colonoscopy is 8 units - seems high to me, but that's what it is. Add 2-3 units for time and you're already at 10+ units for the most basic colonoscopy. Mulitply that by your unit charge and there you have it. Of course it's rare that anyone pays that fee because of network arrangements and discounting. And there is nothing that says an anesthesia group has to be in every single network a hospital and/or a GI doc decide they want to be in. We already give away enough care, and Medicare rates don't cover our costs now.
JWK, I understand the game/system well. Still, charging an individual patient over $1000 and sending him to collections while you got paid $580 from the insurance comapny is as close to immoral as you can get. This was for 30 minutes.

Any Gi doctor allowing this to go on in his/her office is also responsible for the immoral behavior. I always made sure that my patients were in-network or arranged pre-payment plan prior to the procedure. We both know how long these scopes take so "estimating" a cost isn't difficult.

FYI, the Gi gig is getting harder and harder to find as the GI Docs want that anesthesia fee (a large portion of it) for themselves.
 

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JWK, I understand the game/system well. Still, charging an individual patient over $1000 and sending him to collections while you got paid $580 from the insurance comapny is as close to immoral as you can get. This was for 30 minutes.

Any Gi doctor allowing this to go on in his/her office is also responsible for the immoral behavior. I always made sure that my patients were in-network or arranged pre-payment plan prior to the procedure. We both know how long these scopes take so "estimating" a cost isn't difficult.

FYI, the Gi gig is getting harder and harder to find as the GI Docs want that anesthesia fee (a large portion of it) for themselves.
maybe the second time weve agreed on something non-science related
 

Mman

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FYI, the Gi gig is getting harder and harder to find as the GI Docs want that anesthesia fee (a large portion of it) for themselves.
If we are taking the risk and providing the service, they can take 1 guess what cut of the anesthesia fee I'd let them have. Hell, the risk from the anesthesia outweighs the risk of the colonscopy.
 

darby11

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JWK, I understand the game/system well. Still, charging an individual patient over $1000 and sending him to collections while you got paid $580 from the insurance comapny is as close to immoral as you can get.
Its only immoral because the insurance companies are paying for it. If you were paying for it it wouldnt be immoral. LOL

I think paying my dentist 3000 dollars for a root canal (45 mins) and crown(30 mins) is immoral.
 

BLADEMDA

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Its only immoral because the insurance companies are paying for it. If you were paying for it it wouldnt be immoral. LOL

I think paying my dentist 3000 dollars for a root canal (45 mins) and crown(30 mins) is immoral.
Your dentist doesn't offer his services for free and rarely does the same procedure at a 60% discount because the govt. mandates that he do so.
 

drccw

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Our billing goes by the usual unit-based system - procedure + time + modifiers - not a flat rate. As I recall the RVU for a colonoscopy is 8 units - seems high to me, but that's what it is. Add 2-3 units for time and you're already at 10+ units for the most basic colonoscopy. Mulitply that by your unit charge and there you have it. Of course it's rare that anyone pays that fee because of network arrangements and discounting. And there is nothing that says an anesthesia group has to be in every single network a hospital and/or a GI doc decide they want to be in. We already give away enough care, and Medicare rates don't cover our costs now.
RVU for a colonoscopy is 5 units.

so for 30 minute colonosccopy is 2 time units..

7 units..

$2800 charge is $400/unit....

I know Manhattan has a high unit value (I think it's $100+)... but billing someone $1600 is still $200+ a unit...

this is the sort of stuff that makes insurance companies want to drop coverage for endoscopies.... let's face it; they can be challenging but for the most part they are pretty routine... 5 units is over valued startup cost... especially because you can do 12 by 1 PM... 3 units would be a more reasonable start up (akin to a lower extremity, below knee procedure)... What's everyone's unit value there? Our avg (blended) reimbursed unit is about $45 a unit I think...

drccw
 

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Slow down now, base units were 5 for colon or egd, now MCR is paying at 4 base plus time = 6 units x $17 = $100 per case for MCR. What do you get paid per unit from some private payers ? .......$35-55/unit.....Pt's have deductables, Do you make them pay the full charge if you are the first guy in with a bill ...If you charge $75-100/unit( which you almost NEVER get paid), do you balance bill the full amount ? I see my bills , payments, patient feedback and write off 3X than what I charge. I didn't read the article because I have been in solo practice for years and do my own billing. A hospital or ASC will charge $28000 facility fee for a knee scope and get paid $2500-3500 (for everything) under MCR and the average commercial payer. I'll define "everything" another time, but it includes "Everything".... $16,800/day makes a great headline. I doubt anyone here has ever done 10 cases in a day , all of them OON (Out of Network) and gotten paid 100% after the dust settled, if you did please send me your zipcode, I will be moving to your town. One day I will explain here about IN Network vs OON and how insurers have increased the OON deductables or the new trend of denying coverage to their insureds for any OON service.
 

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Don't mean to hijack the thread, but you the insured should know 2 things about your personal health coverage. 1. Can you leave the network? 2. Lifetime maximum $$ they will pay.

OK , now I'll go read the NY Times piece and get even angrier.
btw ... I have had insurers reject my application to become a provider because one facility I service isn't par with them. I was trying to better service their patients, avoid high bills , but that's another angle of theirs, pushing me off so "I" have to deal with their angry patients who get my bill, not the ins co. It has become very crooked the last couple years.
 

cincincyreds

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Slow down now, base units were 5 for colon or egd, now MCR is paying at 4 base plus time = 6 units x $17 = $100 per case for MCR. What do you get paid per unit from some private payers ? .......$35-55/unit.....Pt's have deductables, Do you make them pay the full charge if you are the first guy in with a bill ...If you charge $75-100/unit( which you almost NEVER get paid), do you balance bill the full amount ? I see my bills , payments, patient feedback and write off 3X than what I charge. I didn't read the article because I have been in solo practice for years and do my own billing. A hospital or ASC will charge $28000 facility fee for a knee scope and get paid $2500-3500 (for everything) under MCR and the average commercial payer. I'll define "everything" another time, but it includes "Everything".... $16,800/day makes a great headline. I doubt anyone here has ever done 10 cases in a day , all of them OON (Out of Network) and gotten paid 100% after the dust settled, if you did please send me your zipcode, I will be moving to your town. One day I will explain here about IN Network vs OON and how insurers have increased the OON deductables or the new trend of denying coverage to their insureds for any OON service.

you can sign me up also. I'll go anywhere for that type coin.
 

Idiopathic

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Slow down now, base units were 5 for colon or egd, now MCR is paying at 4 base plus time = 6 units x $17 = $100 per case for MCR. What do you get paid per unit from some private payers ? .......$35-55/unit.....Pt's have deductables, Do you make them pay the full charge if you are the first guy in with a bill ...If you charge $75-100/unit( which you almost NEVER get paid), do you balance bill the full amount ? I see my bills , payments, patient feedback and write off 3X than what I charge. I didn't read the article because I have been in solo practice for years and do my own billing. A hospital or ASC will charge $28000 facility fee for a knee scope and get paid $2500-3500 (for everything) under MCR and the average commercial payer. I'll define "everything" another time, but it includes "Everything".... $16,800/day makes a great headline. I doubt anyone here has ever done 10 cases in a day , all of them OON (Out of Network) and gotten paid 100% after the dust settled, if you did please send me your zipcode, I will be moving to your town. One day I will explain here about IN Network vs OON and how insurers have increased the OON deductables or the new trend of denying coverage to their insureds for any OON service.
very nice post.
 

yappy

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Why stop there? My plumber charged me $450.00 for a 20 min visit. In case you're worried about his overhead he used some goo from a tube lol. It seems like everyone gets pissed when people have a skill/business and are able to make money from it.

In contrast, the wage earners that get 25-40/hr + payroll taxes + health benefits feel their pay is well deserved :/ What they may forget is that all that compensation is coming from some revenue. But they're insulated from the acquisition of it so the general public sees the fees that doctors and other independent business types charge and feel offended.

I hate articles like the one you pointed out and the idea that everyone should work for "at cost" so we can all have more discretionary funds... mean while essentials like cable + cell plans go unchallenged lol. 2-4 g's / year? What's up with the recent trend of targeting doctors?

If you don't want it; don't buy it.




Its only immoral because the insurance companies are paying for it. If you were paying for it it wouldnt be immoral. LOL

I think paying my dentist 3000 dollars for a root canal (45 mins) and crown(30 mins) is immoral.
 
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Idiopathic

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yeah, id usually be the last to say it, but this article is pretty ridiculous

i do see an analogy that is valid, however. when you call a plumber or go to the dentist, those are choices you are making. you can have your tooth pulled for $100 or you can have a root canal/crown for $3000, you can call a plumber on saturday evening to fix a leaky faucet or you can do it yourself or at least shop around. many time when you go for this procedure, you are at the mercy of the institution. you may find a specialist that you really like, but will be forced to settle for whatever MD/CRNA/AA combo the ASC throws at you. Im not sure whether that is the right way to do it or not. i guess it works until it doesnt.
 

aneftp

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Like my favorite show, Fox News, "fair and balance"

NY Times equals ultraliberal newspaper: Take that story and look at both sides.

1. Patients have very high deductibles these days.
a. They mention nothing about pathology fees

(example: My colleague (also anesthesiologist ). Gi friend of his waived his fees. Anesthesiologist doing the MAC waived his fees. My friend paid the $500 facility fee.

Cool right?

Well not exactly....the pathology fee came back and was $3000 (yes $3000 freaking dollars). So his high deductible was $3000 and he ended up paying the entire $3000 fee to the pathologist.

There has got to be more to the story than the anesthesiologist billing company going after the patient for more than the $300-500 insurance pays for routine colonscopies. There could be pathology fees involved in this whole mess also.

In addition, patients can simply call the anesthesia billing company and say "this is ridiculous....I am only going to pay $300-500"

Maybe people don't know you can challenge the charges?

Agree with Blade, any GI center that does not offer the cancel the remaining charges of the $2800 is simply ripping off the patients.
 

Idiopathic

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fair enough, but perhaps they should get the choice to have the less expensive, and yet equally safe, method. or if the GI team is going to demand propofol sedation for quicker turnover and fewer PACU stays, then they have to supplement the anesthesia costs. is this how most outpatient ASCs work?
 

Dirtball

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Dr. Idiopathic - Is Mac for endo no safer than consc. sedation by RN/GI doc ? Does it provide a more motionless patient, less wretching/aspiration with EGD and less Pt. movement during tortuous colons? I've practiced anesthesiology for almost 20yrs continously in both the OR and GI lab every week. I do my own cases- everyday. you are insulting me. I have had highly skilled GI docs (and their pts) drive past an ASC that provides an RN only, 20 more miles to my center where the endo pts all get MAC.
"Equally safe" ???? You are a fellow in what ? I used to go to too many GI lab codes in a hospital that had the consc. sedation method. The poor RN's hands shaking as the GI yells at her to draw up Narcan/ROmaz. when an oral airway and a couple breaths with the bag would have done it, No, they turn the nasal cannula from 2>4>6 lpm , then when the heart starts to slow, they cry uncle and pull the cord for help. I wish I could type faster, I'd be goin Ann Coulter on ya here. If HCVA(MCR) would police the billion dollar MCR fraud annually from the criminals out there, they could pay me a junior lawyers hourly wage to safely get our sick elderly through a GI case. ...AND YEAH I supplement the cost by not being a pig like NY Doc in the NY Times ....$400.00 is OK for a 7 unit case I don't care how much parking cost in NYC. I let 2-4 pts per week pay me ZERO cause there's more to life than a fancy house. Come spend a week with me, I'll take you into the trenches. Better yet need need a scope? I'll give you MDZ3mg + maybe 2 mg more if you flinch with Meperidine 75mg......the the next day I'll give you MDZ 0.5mg/Fent 25ug/Prop 100mg/Lido 60mg- then you tell me what was nicer........Nothing personal here you just hit a nerve, you know how that goes if you've touch a nerve.
 

Idiopathic

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Dr. Idiopathic - Is Mac for endo no safer than consc. sedation by RN/GI doc ? Does it provide a more motionless patient, less wretching/aspiration with EGD and less Pt. movement during tortuous colons? I've practiced anesthesiology for almost 20yrs continously in both the OR and GI lab every week. I do my own cases- everyday. you are insulting me. I have had highly skilled GI docs (and their pts) drive past an ASC that provides an RN only, 20 more miles to my center where the endo pts all get MAC.
"Equally safe" ???? You are a fellow in what ? I used to go to too many GI lab codes in a hospital that had the consc. sedation method. The poor RN's hands shaking as the GI yells at her to draw up Narcan/ROmaz. when an oral airway and a couple breaths with the bag would have done it, No, they turn the nasal cannula from 2>4>6 lpm , then when the heart starts to slow, they cry uncle and pull the cord for help. I wish I could type faster, I'd be goin Ann Coulter on ya here. If HCVA(MCR) would police the billion dollar MCR fraud annually from the criminals out there, they could pay me a junior lawyers hourly wage to safely get our sick elderly through a GI case. ...AND YEAH I supplement the cost by not being a pig like NY Doc in the NY Times ....$400.00 is OK for a 7 unit case I don't care how much parking cost in NYC. I let 2-4 pts per week pay me ZERO cause there's more to life than a fancy house. Come spend a week with me, I'll take you into the trenches. Better yet need need a scope? I'll give you MDZ3mg + maybe 2 mg more if you flinch with Meperidine 75mg......the the next day I'll give you MDZ 0.5mg/Fent 25ug/Prop 100mg/Lido 60mg- then you tell me what was nicer........Nothing personal here you just hit a nerve, you know how that goes if you've touch a nerve.
so back to my analogy, there are many ways to get this procedure done. just like you can elect to have a tooth pulled rather than a root canal, you can have a colonoscopy done without any sedation, if you wish. there are costs associated with each decision. im not sure we allow patients the chance to make decisions when it comes to anesthesia.
 

jetproppilot

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Dr. Idiopathic - Is Mac for endo no safer than consc. sedation by RN/GI doc ? Does it provide a more motionless patient, less wretching/aspiration with EGD and less Pt. movement during tortuous colons? I've practiced anesthesiology for almost 20yrs continously in both the OR and GI lab every week. I do my own cases- everyday. you are insulting me. I have had highly skilled GI docs (and their pts) drive past an ASC that provides an RN only, 20 more miles to my center where the endo pts all get MAC.
"Equally safe" ???? You are a fellow in what ? I used to go to too many GI lab codes in a hospital that had the consc. sedation method. The poor RN's hands shaking as the GI yells at her to draw up Narcan/ROmaz. when an oral airway and a couple breaths with the bag would have done it, No, they turn the nasal cannula from 2>4>6 lpm , then when the heart starts to slow, they cry uncle and pull the cord for help. I wish I could type faster, I'd be goin Ann Coulter on ya here. If HCVA(MCR) would police the billion dollar MCR fraud annually from the criminals out there, they could pay me a junior lawyers hourly wage to safely get our sick elderly through a GI case. ...AND YEAH I supplement the cost by not being a pig like NY Doc in the NY Times ....$400.00 is OK for a 7 unit case I don't care how much parking cost in NYC. I let 2-4 pts per week pay me ZERO cause there's more to life than a fancy house. Come spend a week with me, I'll take you into the trenches. Better yet need need a scope? I'll give you MDZ3mg + maybe 2 mg more if you flinch with Meperidine 75mg......the the next day I'll give you MDZ 0.5mg/Fent 25ug/Prop 100mg/Lido 60mg- then you tell me what was nicer........Nothing personal here you just hit a nerve, you know how that goes if you've touch a nerve.
When I initially read your post I was

COCKED AND LOCKED

and about to go off on your a s s.

I mean, your screen name is DIRTBALL,

you've got like 13 posts here,

etc etc etc.


Plus I know Idiopathic is a quality dude so you, MISTER DIRTBALL,

going off on Idio pissed me off.

I've been in this game for sixteen years so I think I've got a pretty good feel for

THE GAME.

BUT you may have a point. On the other hand, you may not.

I just don't know.

The G.I. SUITE?

DUDE...


You gotta admit theres alotta

AMBIGUITY THERE.

Judging from my experience I dunno if an anesthesia provider is necessary all the time. I've seen conscious sedation performed by RNs better than some CRNAs I've worked with. Procedural sedation is

COMPLETELY AND TOTALLY OPERATOR DEPENDENT.

In other words, if the RNs providing sedation aren't cutting the mustard,

I can assure you...because I've seen it....that there are others out there.

My opinion on anesthesia's presence in the GI suite is

AMBIVALENT.

I'm not convinced we need to be there...

I do pain procedures under conscious sedation provided by an RN, btw...transforaminal ESIs, cervical ESIs, etc etc...

I think skilled RNs can provide conscious sedation for certain procedures...and this is an HONEST opinion, since if I took the other side my pocket book would be fatter....most things are

ALL ABOUT THE BENJAMINS, BRAH.

I'm not convinced our absence increases morbidity.

Yeah, I read your post...

GI docs driving further where the anesthesia was better.

I don't believe that.
 

TrustMe

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I am not sure what the GI guys can and can't bill for regarding sedation, but I found out that some of them are dirtballs as well. I am still freshly minted so there is a lot I don't know (especially about billing). I was covering a small community hospital a few weeks ago on a Friday and was told by the nursing that the GI guy had added on an EGD in the afternoon that wanted me to provide sedation for. While the CRNA is our last morning case (delay between this and the EGD), I head up to the ICU to see the patient. From nursing home, CHF (MI, CABG, MVR), COPD (continuous home O2), COPD (CPAP), morbidly obese, PVD, IDDM, etc., upper GI bleed, admitted with Hct. of 17%. Small place so nothing else going on in the afternoon. I tell the nursing staff that I want to do this in the OR (which is across the hall) and not the GI suite (which is the size of a YuGo). They call the GI guy to tell him this while I am down the hall and he decides that he doesn't need my help anymore. Nurses told me it has to do with billing (which I assume is true) but I had no desire to ask the GI dude about it. Anyone have any thoughts about this?
 

ssmallz

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I am not sure what the GI guys can and can't bill for regarding sedation, but I found out that some of them are dirtballs as well. I am still freshly minted so there is a lot I don't know (especially about billing). I was covering a small community hospital a few weeks ago on a Friday and was told by the nursing that the GI guy had added on an EGD in the afternoon that wanted me to provide sedation for. While the CRNA is our last morning case (delay between this and the EGD), I head up to the ICU to see the patient. From nursing home, CHF (MI, CABG, MVR), COPD (continuous home O2), COPD (CPAP), morbidly obese, PVD, IDDM, etc., upper GI bleed, admitted with Hct. of 17%. Small place so nothing else going on in the afternoon. I tell the nursing staff that I want to do this in the OR (which is across the hall) and not the GI suite (which is the size of a YuGo). They call the GI guy to tell him this while I am down the hall and he decides that he doesn't need my help anymore. Nurses told me it has to do with billing (which I assume is true) but I had no desire to ask the GI dude about it. Anyone have any thoughts about this?
I've been in a similar spot. Had a case I felt the pt needed to be tubed, GI guy said "No tube or I'll do it w/out you", I said fine. We are fee for service so I def cost myself some $$ but I slept well that night. You should always do the same. They are calling you not the other way around. You are the expert at what you do, not them, and don't ever forget that b/c when the $hit hits the fan, the GI doc will sit there on the stand and say "That's why I had an anesthesiologist covering me, because I knew badness was going to happen and he was supposed to handle it". Do what you think is right for the pt and what you are comfortable doing. If you feel the pt needs to be done in the OR, then he goes to the OR. I've tubed a few pts in the GI suite but they didn't have a difficult airway so I just bagged em w/a bit of propofol. Trust your training and don't ever second guess yourself because someone else who is not an anesthesiologist tells you what he/she knows best.
 

TrustMe

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I've been in a similar spot. Had a case I felt the pt needed to be tubed, GI guy said "No tube or I'll do it w/out you", I said fine. We are fee for service so I def cost myself some $$ but I slept well that night. You should always do the same. They are calling you not the other way around. You are the expert at what you do, not them, and don't ever forget that b/c when the $hit hits the fan, the GI doc will sit there on the stand and say "That's why I had an anesthesiologist covering me, because I knew badness was going to happen and he was supposed to handle it". Do what you think is right for the pt and what you are comfortable doing. If you feel the pt needs to be done in the OR, then he goes to the OR. I've tubed a few pts in the GI suite but they didn't have a difficult airway so I just bagged em w/a bit of propofol. Trust your training and don't ever second guess yourself because someone else who is not an anesthesiologist tells you what he/she knows best.
Thanks for the support smalz. Being new I just didn't feel comfortable doing this lady in the GI suite without my equipment close by. And the fact that no other OR's were running and the OR I wanted to use was literally right across the hall from the GI suite made my decision very easy. The fact that he was a greedy douche made me feel even better about wanting to do it in the OR because if something had happened, it sounds like he would have been the first to point the finger.
 

yappy

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Dentists don't need to do extractions as it's their dental license. Likewise, physicians have the right to offer whatever services they want to. Medicine doesn't need to be al acarte, neither does dentistry. If there is a great enough demand for other methods they will be searched out and providers will respond. However, if they're doing what they believe are best practices what's the big deal and patience keep coming what's the big deal?

I dont plan to pull peoples teeth just because they think it's cheaper in the short term. I'll do whatever I think is best for their oral health and educate them along the way. If they're adamant about something I'm sure there will be a shady dental practice that will do whatever they desire.


so back to my analogy, there are many ways to get this procedure done. just like you can elect to have a tooth pulled rather than a root canal, you can have a colonoscopy done without any sedation, if you wish. there are costs associated with each decision. im not sure we allow patients the chance to make decisions when it comes to anesthesia.
 
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jetproppilot

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I've been in a similar spot. Had a case I felt the pt needed to be tubed, GI guy said "No tube or I'll do it w/out you", I said fine. We are fee for service so I def cost myself some $$ but I slept well that night. You should always do the same. They are calling you not the other way around. You are the expert at what you do, not them, and don't ever forget that b/c when the $hit hits the fan, the GI doc will sit there on the stand and say "That's why I had an anesthesiologist covering me, because I knew badness was going to happen and he was supposed to handle it". Do what you think is right for the pt and what you are comfortable doing. If you feel the pt needs to be done in the OR, then he goes to the OR. I've tubed a few pts in the GI suite but they didn't have a difficult airway so I just bagged em w/a bit of propofol. Trust your training and don't ever second guess yourself because someone else who is not an anesthesiologist tells you what he/she knows best.
There is a post of mine that exemplifies this.

After hours, CRNA in house, ICU pt with GI bleed, GI doctor wants to proceed immediately, I was at home, had to fend him off, "Yeah dude it's all good but you can't start until I get there!"
case turned out it was prophetic we waited and intubated the patient,

THANK GOD

I'm hoping one of you young, technically savvy

MO FOES

out there can

Find that post.

TECH SAVVY DUDES,

PLEASE HELP.


Love,

JET
 

ssmallz

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Thanks for the support smalz. Being new I just didn't feel comfortable doing this lady in the GI suite without my equipment close by. And the fact that no other OR's were running and the OR I wanted to use was literally right across the hall from the GI suite made my decision very easy. The fact that he was a greedy douche made me feel even better about wanting to do it in the OR because if something had happened, it sounds like he would have been the first to point the finger.
I'm new out as well and this is my least favorite situation to be in because the GI doc/surgeon will inevitably say "Dr. XXXX would do it and I'm going to tell your boss about this." :eek::thumbdown: Other docs who have been around longer than us may feel more comfortable doing certain things but in the end you are the one making the decision and you're the one who will have to defend it to yourself, your patients, and the lawyers.
 

ssmallz

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There is a post of mine that exemplifies this.

After hours, CRNA in house, ICU pt with GI bleed, GI doctor wants to proceed immediately, I was at home, had to fend him off, "Yeah dude it's all good but you can't start until I get there!"
case turned out it was prophetic we waited and intubated the patient,

THANK GOD

I'm hoping one of you young, technically savvy

MO FOES

out there can

Find that post.

TECH SAVVY DUDES,

PLEASE HELP.


Love,

JET
Jet,

I def remember that post and every time I'm up in the GI suite it runs through my head. I've really only had a problem with one GI doc, the other ones are smart enough to defer to my expertise and are happy to have us there to handle the airway and sedation. Had a scenario on call about a month ago where I was called for an EGD on a pt who was actively vomiting all day. I decided to tube him, nursing staff is not happy b/c this is "GA in the endo suite and we don't normally put tubes in these people" but GI doc had my back. Tube goes in successfully, GI doc puts the scope in and we suction 600cc of gastric contents outta the stomach. He was very happy we tubed him that day and the case proceeded much more uneventfully than what could have happened.
 

jetproppilot

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Dr. Idiopathic - Is Mac for endo no safer than consc. sedation by RN/GI doc ? Does it provide a more motionless patient, less wretching/aspiration with EGD and less Pt. movement during tortuous colons? I've practiced anesthesiology for almost 20yrs continously in both the OR and GI lab every week. I do my own cases- everyday. you are insulting me. I have had highly skilled GI docs (and their pts) drive past an ASC that provides an RN only, 20 more miles to my center where the endo pts all get MAC.
"Equally safe" ???? You are a fellow in what ? I used to go to too many GI lab codes in a hospital that had the consc. sedation method. The poor RN's hands shaking as the GI yells at her to draw up Narcan/ROmaz. when an oral airway and a couple breaths with the bag would have done it, No, they turn the nasal cannula from 2>4>6 lpm , then when the heart starts to slow, they cry uncle and pull the cord for help. I wish I could type faster, I'd be goin Ann Coulter on ya here. If HCVA(MCR) would police the billion dollar MCR fraud annually from the criminals out there, they could pay me a junior lawyers hourly wage to safely get our sick elderly through a GI case. ...AND YEAH I supplement the cost by not being a pig like NY Doc in the NY Times ....$400.00 is OK for a 7 unit case I don't care how much parking cost in NYC. I let 2-4 pts per week pay me ZERO cause there's more to life than a fancy house. Come spend a week with me, I'll take you into the trenches. Better yet need need a scope? I'll give you MDZ3mg + maybe 2 mg more if you flinch with Meperidine 75mg......the the next day I'll give you MDZ 0.5mg/Fent 25ug/Prop 100mg/Lido 60mg- then you tell me what was nicer........Nothing personal here you just hit a nerve, you know how that goes if you've touch a nerve.
is that you zippy?
 

okayplayer

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Great case, Jet. What is your induction agent of choice in this type of patient who is nonobtunded but whose hemodynamics are clearly being maintained by her sympathetic drive? Etomidate 0.2 mg/kg? A wimpy dose of propofol 0.5-1 mg/kg with neo ready to push as needed? I think ketamine (2 mg/kg) would be a nice choice, but since it is not in our airway bag and not accessible by pyxis outside of the OR it doesn't seem to be what I reach for.

If this patient is obtunded I think the decision gets easier: RSI dose paralytic +/- a little midaz.

Just curious what other people with more experience do in this scenario to avoid the inevitable hemodynamic collapse (besides all the other things you did like getting real access, getting blood, opening up fluids, etc).
 

Idiopathic

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Dentists don't need to do extractions as it's their dental license. Likewise, physicians have the right to offer whatever services they want to. Medicine doesn't need to be al acarte, neither does dentistry. If there is a great enough demand for other methods they will be searched out and providers will respond. However, if they're doing what they believe are best practices what's the big deal and patience keep coming what's the big deal?

I dont plan to pull peoples teeth just because they think it's cheaper in the short term. I'll do whatever I think is best for their oral health and educate them along the way. If they're adamant about something I'm sure there will be a shady dental practice that will do whatever they desire.
seriously...if i have a painful second molar thats going to need an expensive restoration, and i cant or dont want to pay for it, are you going to do it for free? or send me away until i can save the money for it? i hope not. hopefully you will extract the tooth if thats what i want, is that a shady request?
 

PMPMD

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This is a good thread, in addition to JPP's past post which was referenced above (that I also remember from back in the day). I didn't do many of these cases in residency but will be doing tons in my new gig. In training, we would only be called for very sick pts or certain procedures (ERCPs), and even then, these cases usually went to anesthetists.
 

Dirtball

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IF the NY Times writer was talking to a Pt. not in NY there probably wouldn't even be an article worth writing. NOW I WISH THIS WASN'T A PUBLIC FORUM. But if the pt in the article came to me who charges $75/unit and the insurance paid $400 there would be no further billing to the pt. ...BUT some pretty aggressive NY billing dept took the take no prisoners approach. We don't make friends this way. The Pt tells the GI doc what we are asking for ($$) , he says to himself I only get $300-400 for that scope what's going on here? Look, occaisionally I'll get almost paid in full by an insur co. , and get double the surgeon fee ,, but on any MCR Pt. we are getting $70/hr.....that's my #1 beef with the system. The NY metro area fee of $200/unit is ???????? kinda ridiculous in my little mind. The bill should be the bill should be the bill --- end of story. You don't negotiate with the dentist.
Dr JetPilot, which anesthetic would you prefer in my post above? btw how does one make those BIG letters in a post ?? I was one of the original contributers to Gasnet when it was created. We had no college students to appease, wines or car talk, it was mostly " I had this challenging case..." And you would get amazing feedback from around the globe the--- next day... vs a letter to the editor in a journal getting published in 6 mos. btw Gasnet was kinda private, the public could not lurk and difficult cases were easier to discuss. It still exits but not like the original, Dr K. Ruskin pioneered.
* There aren't enough anesthesia providers in the US to give all GI scopes Prop.
* Many countries do EGD's with Lido 4% soln 10cc swallow, no IV, no sedation.
* Some pilots watch sweeping hands on dials, some stare at glass cockpits.
* Canadair RJ , Left seat guy with 3000hrs, Rt seat guy with 300 hrs.. Rt seat can "Fly the plane alone, why doesn't he? It's only a 90 min flight. ...... FAA used to mandate safety upgrades basing the cost of retrofit vs insurance payout on a $700,000/ life figure x miles flown x chance of failure x # passengers etc. etc..... My point- sadly, everything has a price these days.
I send maybe 10 people annually to collections and only when they are rude to my billers on the phone. Send me $50-100 over a year(no interest) on a $500 bill and I am OK. But rudeness to my girls, no more nice guy.
BTW I have never asked any member of the armed services, police or fireman for a penny for my anesthesia services- my way of saying thanks for their sacrifice. Try to pass it on guys.
Excuse my digression from the original topic , I'll post more here when inspired.
 

yappy

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I would just put you at ease, man:

"Idiopathic. I understand your concern; however, as your dentist I must warn that by simply removing your tooth you'll put excessive wear on your surrounding teeth and have bone loss in that area as you age. In the long run this will cause other dental problems that will inhibit your quality of life and will be very costly. Now as you know, I pride myself on providing the highest level of care to my patients, that's why I'm suggesting the safest, most therapeutic restoration for you.

I'm going to have my office manager come in and talk about some financing options that we can provide you so that all your health goals are meet and it's not going to be too much of a financial burden for you.

Take care :cool:"

**leaves the room**

After that you're going to see the light and get the procedure done. No need to seek out a shady dentist lol. In all seriousness pulling teeth isn't a terrible practice if the patient wants it due to financial reasons. It's just when I've been shadowing dentists dont like to do it because it sets up the patient for problems down the road. They would rather give them something that will last a long time and save the tooth. Another problem I have seen is when the patients solution is always to pull the teethl... I once saw a 14 y/o with only 2 molars left... kinda sad.


seriously...if i have a painful second molar thats going to need an expensive restoration, and i cant or dont want to pay for it, are you going to do it for free? or send me away until i can save the money for it? i hope not. hopefully you will extract the tooth if thats what i want, is that a shady request?
 
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Mman

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My favorite request from the GI people was an ERCP on a little old lady with critical aortic stenosis who was also anemic. They seemed to think it was no big deal and a little propofol would help her hold still.

After I stopped laughing, we were able to do the case MY way and not with their little bit of propofol.

But seriously. Why in the hell would the gastroenterologist care how we went about anesthetizing the patient (MAC vs GA)? All they should really care about is having a patient that holds still and is alive at the end of it.
 

cincincyreds

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My favorite request from the GI people was an ERCP on a little old lady with critical aortic stenosis who was also anemic. They seemed to think it was no big deal and a little propofol would help her hold still.

After I stopped laughing, we were able to do the case MY way and not with their little bit of propofol.

But seriously. Why in the hell would the gastroenterologist care how we went about anesthetizing the patient (MAC vs GA)? All they should really care about is having a patient that holds still and is alive at the end of it.
This sounds like a comedy routine. Did you refuse to do this case prone?