What the time limits on Anesthesia were really about

Investment Analysis Clubs Macro Economic Trends and Risks
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{{ Americans have many justified grievances with insurance companies, which often refuse to cover necessary care.

But this particular fight was not actually about putting the interests of patients against those of rapacious corporations. Anthem’s policy would not have increased costs for their enrollees. Rather, it would have reduced payments for some of the most overpaid physicians in America. And when millionaire doctors beat back cost controls — as they have here — patients pay the price through higher premiums. }}

About 10 years ago, I had a small gold weight implanted in my left eyelid to force the eyelid to close some more. The middle of my cornea was getting dried out because when I blinked, it wasn’t covering the whole eye.

This procedure required about a 1/4" to 3/8" incision to place the weight just under the skin. If I had that kind of wound on my eyelid for any other reason, I’d put a bandaid on it, and be on my way.

I asked the surgeon if he could do the procedure in his office. He said “No”. Since it was an “implant” it had to be done in a hospital and the hospital would keep any records in case of a recall, etc. So I said “Fine”. Then I said, 'Since this is such a simple procedure, can you do it under local anesthetic? I don’t want to accept the risks of sedation or anesthesia for something this small. He said, “OK”.

About a week before the surgery, I get a call from “Anesthesiology Services” and they start asking me all kinds of questions. So I ask them “Doesn’t the surgical order say that this is being done under local anesthetic? She confirms that it does?
I ask, “Why am I even talking to you guys?” She said that an anesthesiologist had to be there in case something went wrong”. I said, “It’s like a 1/4” incision. I’m not going to pay you guys thousands of dollars to stand there as spectators."

Then she asks me “How are you getting home”. I said, “I’m driving myself home since I’m not getting any anesthesia or sedation.” She said that’s not permitted.

I said, OK. I’ll call the surgeon’s office and cancel the procedure.

When I called the surgeon’s office to cancel since I was unwilling to pay an anesthesiologist as a spectator. They said, "Oh, no. Don’t do that. We’ll straighten out “Anesthesiology Services”.

I didn’t get a bill from an anesthesiologist. But somehow the hospital still charged me $1,800 for “Anesthesiology Services”. When I alerted the insurance company to the fact that I got no sedation or anesthesia, they told me that “The hospital gets to charge us for “Anesthesiology Services” whether you get anesthesia or not.”

It may well be that Anesthesiology is our most financially fraudulent medical specialty. {{ LOL }}

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Decreased reimbursement

Medicare reimbursement has decreased in the last 20 years when adjusted for inflation.

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But specialist doctor’s incomes have not. Primary care physicians (Internal Medicine, Pediatrics, Family Medicine, etc.) have taken a hit because of the so-called Relative Value Committee that advises Medicare on doctor’s payments. It’s stacked with surgeons, anesthesiologists, dermatologists, ophthalmologist and radiologists who have protected their incomes while screwing other specialties.

This is one of the biggest frauds in Medical Finance.

My favorite is the magic words you’ll see in your ophthalmologist’s visit notes. “All testing was done by a medical assistant trained by me.”

For about 10 years, I was getting my eye exams from a very smart Korean optometrist at Walmart who did all her own tests. You had her attention for the full 45 minutes of an exam for about a $100 charge.

When Obamacare started, I went to see an ophthalmologist since I no longer had a high deductible policy. All the tests were done by a young lady who seemed to be a high school intern and the ophthalmologist looked at for about 5 minutes at the end of the hour long visit and said I was fine. The charge for the same suite of tests and exam done at Walmart for $100 was now over $800. It seemed like the minimum wage intern’s time was being billed at specialist MD rates. {{ LOL }} That’s the value the “Specialty Society Relative Value Scale Update Committee” provides to the patient.

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So much to dissect and doubt much makes sense to an outsider/patient.

Have no idea why “anesthesia services” showed up. Main possibility, you used an OR and OR monitoring equipment (BP cuff, EKG, pulse oximeter, etc.,) that are standard monitors used in ANY case in the OR. Or office for that matter.

Why an anesthesia person got involved, I have no idea. When ever a surgeon posted an OR case as “local anesthesia” (just a shot of lidocaine with no sedation), I never got involved. And the surgeons knew that if they got themselves/their patient in trouble, they are on their own. IF the patient coded I would step in but everything else is SOL. Can’t tell you the number of times the you know what has hit the fan over a “simple procedure” usually from one of two sources: an overconfident surgeon or a spendthrift patient pinching pennies. Had a co-worker nurse die because of the former and knew of an arrogant ENT surgeon have a patient die in his office.

Now to the heart of the headline, trying to pay anesthesia less. Had that fight my entire career. Never had an insurance company call up and said we are giving you a raise. Why pick on anesthesia? Because they think they are an easy target. Hospital based and not mobile (can’t pack up and move somewhere else). Our pay is mostly base on time but difficulty of procedure and physical health of the patient play a role as well.

In my career, did numerous c-sections, many schedule, many emergencies, patient health from fitness instructor to Jabba the Hut. If you were to pay me by the case, i.e. $X per c-section, over time things would wash out assuming you over paid me for the healthy patients but under paid me for the sick ones. The biggest factor becomes time. Had many surgeons do a section in under an hour. Had a couple that took 3 hours assuming no complications. Total nightmare. Eventually, this surgeon would have a hard time finding someone to do anesthesia for non-emergency cases because why get paid less?

I could go on and on about all the simple cases I did that should have taken less than an hour but 6 hours later we are finally headed to recovery room/ICU. Time is how I was primarily paid. Try asking your plumber, lawyer, etc., to charge a flat case rate when time can be a highly unknown factor.

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Did they actually get reimbursed $800??? I was often shocked at how little some of my doctors actually received from the insurance company after the contract discount was applied. Especially surgeons!

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Oh, I have an idea. {{ LOL }}

The "Anesthesia Services” at the local hospital is U.S. Anesthesia Partners (USAP) , the big private equity funded group that buys up doctor’s practices, and then strip mines the charts for billing opportunities.

I’m pretty sure they expected to collect a “toll” on every patient that flowed through the operating room, whether they needed anesthesia or not.

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I think they billed about $1,100 and the insurance company paid $800. It just depends on the contract that the doctor or hospital is able to get from the insurer. Sometimes they get paid a seemingly small amount, sometimes it’s crazy large for what they’re doing.

I went to a dermatologist in Houston about 30 years ago and a medical assistant spritzed me in three spots with a can of liquid nitrogen to “freeze off” some pre cancerous lesions – maybe it took 2 minutes. The charge was $60 per spritz.

I noticed today that the Medicare billing codes have one charge for 1-10 spritzes, and another for spritzes 11-15. And it isn’t anywhere near “$60 per spritz.”

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If a different group that constantly harps on pay was going on this way you’d be completely on the other side.

The dam the other guy stuff does not serve us.

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Not at all. Most of my professional career was in “Cost Engineering” – looking at where the company was getting screwed by unusually high costs or low productivity. Like most things in life, it’s just arithmetic.

Applying that metric to my personal expenses, especially in health care, has proven to be a bonanza over the past 40 years. It’s amazing you successful you can be, by merely avoiding getting screwed.

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Then you agree with TFG cutting $1 tr?

I was going to open another thread on this but in a neutral way lets begin that discussion.

First some numbers $1 tr, mid tier layoffs 650k guys, equals $100 billion not $1 tr.

Why $100 billion only? Because the workforce to cut is not big enough.

Why $1 tr?

Because there are one year budgets and 10 years of budgets. TFG did not say $1 tr over 10 years but he may mean that.

The austerity will be rude. The bond market will do a UK.

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Not if it means you’ll be spending $2 Trillion if you turn these tasks over to the private market. Again, I’m only looking at the arithmetic. I don’t care who does the work (private or public), only that it’s being done with acceptable quality and in a cost effective manor.

For example, there’s absolutely no way you’re going to make health care cheaper by adding a private insurance company’s overhead & profit to a doctor’s bill or hospital charge. The arithmetic just doesn’t add up. Either the doctors have to take less, or you have to pay more to cover the insurance company’s costs.

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True

The doctors can take a haircut. Not much of one but yes.

The insurance carriers are unnecessary. Outside of supplementals.

Pharma is nuts. Medical equipment is nuts.

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Even the Medigap supplemental policies are a fraud. Medicare is doing all the benefit administration and accounting for the Medigap insurer. All the Medigap insurer does is pay what Medicare tells them to pay, and they get skim off 20% of premiums collected for basically doing nothing. Medicare could provide this service at a 1.2% cost to you, why are you being forced to pay a 20% haircut for it?

Because somebody bought off a Member of Congress (or a whole bunch of them.)

https://www.manchin.senate.gov/newsroom/press-releases/manchin-leads-63-bipartisan-senators-in-urging-support-for-medicare-advantage-program

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MA is not a supplemental policy. That argument is different.

The supplementals set up a two tier solution. Allowing people with money more coverage. That is not without some merit. We do not live in a perfect world.

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Medigap is a supplemental policy. It pays “the 20% that Medicare doesn’t cover”, or so the advertising goes. Anytime you’re bringing in a private insurer to do something at a much higher cost than Medicare itself, you’re screwing both patients and taxpayers.

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Could be part of the “bundling of services” that the government/talking heads were trying to enforce for “simplification”. Typically ER, anesthesia, radiology, and maybe another that got all thrown together per patient per admit. Say each admit was $100 (totally made up number) that went into the bundling pool then divided up regardless of usage.

Politicians creating a solution without foreseeing unintended consequences.

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