How to minimize the costs of surgery

Surgery is expensive, there are no doubts about that. However, there are a few things a patient without insurance who desires surgery can do to minimize the costs as much as possible. Before going into cost-cutting measures, you first need to understand where the costs come from.

In rank order, the costs of surgery come from (highest to lowest):

  • Hospital Charges (most expensive charges)
    • Use of OR Room
    • Paying the Circulating Nurse
    • Paying the Scrub Nurse
    • Paying for the medications used during surgery including anesthesia
    • Paying for the OR room cleaning
    • Paying for administrative overhead
    • Use of surgical instruments including cleaning/sterilization after use
    • All disposable used for the surgery (masks, drapes, wires, IV tubing, gauze)
  • Anesthesiologist Fees (excluding anesthesia medications)
  • Surgeon’s Fees (least expensive charges)

The hospital charges run into the many thousands of dollars (typically charges start at around $3000 and goes up from there). The surgeon’s fees can be as low as $100 to around $1000 depending on the surgery. The anesthesia’s fees are between the hospital charges and the surgeon’s fees (anesthesiologists are paid similarly or more than the surgeons per case).

So now that you know where the costs come from, what are some ways to reduce them? Please be aware that the surgeon has no control/authority/influence over the anesthesia and hospital charges which the patient needs to individually deal with each separately.

  • Have the surgery done in an Ambulatory Surgery Center if possible. Oftentimes, the costs are almost 50% lower than the same surgery done in a hospital. If possible, the hospital charges can be completely avoided if the surgery is done in the surgeon’s office.
  • Ask the hospital about self-pay discounts/payment plans.
  • Ask the surgeon about self-pay discounts/payment plans.
  • Ask about further fee discounts if the total cost is paid all at once up front in cash rather than a payment plan.
  • Do get referred by a free clinic if your income level qualifies you. Free clinic referral pretty much means (for most patients), the care including surgery will be provided completely for free.
  • If possible, request only local anesthesia which is cheaper than MAC anesthesia (twilight anesthesia) which is cheaper than general anesthesia which is the most expensive.
  • Request medication samples (ie, antibiotics for after surgery).

Christopher Chang is an otolaryngologist who blogs at Fauquier ENT Consultants blog.

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  • Doc99

    Here’s another – Ask about the Hospital/Anesthesia charges upfront & Get it in writing.

  • http://collectingmythoughts.blogspot.com Norma

    So each nurse costs more than the surgeon fees? Interesting. All the disposables cost more than the anesthesiologist (who is an MD right?) or the surgeon? Why is anyone bothering to go to medical school?

  • http://onsurg.com/about Chris Porter MD

    Great patient info here. I learned a lot too.

    Another possible savings: not having surgery. Many common operations in general surgery have arguable indications: hernia, gallbladder, sigmoidectomy for diverticulitis – even colon cancer (absence of bleeding/obstruction in presence of multiple mets.)

    If each specialty published a list of conditions where surgical indications are not clear-cut, patients and the system could save a lot by not rushing to surgery. Second opinions and observation are good management alternatives to many operations.

    • Hexanchus

      You can add antibiotic treatment instead of surgery for mild to moderate cases of appendicitis to that list….

  • J P

    I find it very interesting that “Surgeon’s Fees” are at the absolute bottom of the list of costs. Yet, many people blame surgeons and other physicians for getting paid too much when in reality many of the healthcare costs have less to do with physicians’ salaries and more to do with bureaucracy and supplies.

  • http://fertilityfile.com IVF-MD

    Many years ago, for one day, I got the opportunity to do surgery in Taiwan. It was at a small missionary hospital and I was in the country giving a lecture. (Because the attendings there vouched for me that I was a practicing US doctor, it was simply assumed that it would be fine for me to assist them on surgery. I found it interesting that there weren’t mountains of credentialing papers involved.)

    Anyway, it was a great learning experience for me, as I witnessed all the smart practical non-wasteful things they did, such as using as many non-disposables as possible. Anyone who routinely operates in the US must take for granted by now the tremendous amount of environmental waste that is generated with each surgery. Disposable gowns, drapes, instruments etc etc.

    Even today, I find a contrast between small for-profit surgery centers vs large public hospitals. In the former, there is much thought given to cutting waste. In the latter, there is not much thought given to this. There are certain trays that are opened for a certain type of case that include things on there that I don’t personally use, but are put on there just because my colleagues use them.

    Often, I will ask for certain instruments to be “in the room” and available if I should need it, but not to open it. Half the time, the techs don’t listen and in a misguided effort to be accommodating to me, as the surgeon, they’ll open it immediately and drop it onto the tray. -_-

    What can we do to incentivize smart conservation rather than cookbook tray preparation?

  • Vox Rusticus

    Free clinic referral should not presume that all specialty follow-on care will also be free or on the same terms, unless the specialist has agreed to take the case on those terms beforehand (and usually that means each individual cases will be considered on a case-by-case basis.) Free clinics are charities that receive tax-favored donations and donations of time from willing professionals. Of course, free clinics have expenses, but specialists also have expenses, and often considerably greater than those of a free clinic. So it is reasonable for specialists to decide whether to accept free clinic referrals on reduced terms or not, and those specialists are within their rights to apply their own means test to a request or even outright decline to accept the patient. That might seem harsh, but it really isn’t. Many free clinics do not necessarily require significant evidence for eligibility or means to pay beyond the declarations of patients seeking their care, and few have the means to properly sort those with legitimate need from those without. The free clinic in turn doesn’t have the requirement to pay market rate for its labor and even its supplies, and enjoys charitable financial support, so it is under less pressure to extract payment from those able to pay. Not so with the private practice.

  • Patient

    Re: anesthesia fees – double-check the ASA patient status classification both pre- and post-op. I was once upgraded for a semi-elective surgery from ASA status 1 (healthy) to ASA status 3 (systemic disease), with a corresponding upgrade in fees. This took time to rectify, but eventually was done because I was in fact ASA status 1.

    I’ve since learned this type of “mistake” is not uncommon. I think it’s fraud.

  • emes

    An idea is this. Many procedures in general surgery can be safely performed by Family Practitioners, with the proper training. Appendectomy, cholecystectomy, tonsillectomy and addenoidectomy, hernia repairs, carpal tunnel surgery, tenotomy, lumpectomy, mastectomy, biopsies/FNA, thyroidectomy/parathyroidectomy, lysis of adhesions, anorectal surgery, etc. can be performed by FP’s. In fact, many PA’s are now doing some of thes procedures solo. Specialists could see the more complex cases, with FP doing the bulk of these more basic operations. With a 1-2 year fellowship in General Surgery and Operative Obstetrics, preceded by a more procedurally-focused residency, interested FP’s can perform at the level of a 3rd year general surgery resident. This would result in increased access and reduced costs. Canada, Australia, and more rural and developing areas already use this model. What makes a Congolese appendix or thyroid any different than an American appendix or thyroid? Make the increased training opportunities available and they will come. This may also help alleviate the primary care shortage.

    • surgical resident

      I think this is a terrible idea.

      There is a saying that patients pay for results, but surgeons are paid to think of complications. You say that a fellowship trained fp could operate at the level of a third year resident, which might be true. I, however, would never let a third year resident take out my gb without supervision.

      We also often say that you can teach a monkey to operate . The point isn’t that a pa or fp can operate. The point is that they shouldn’t.

  • asdf

    i understand fp’s performing surgery in places where there is a dire need of surgeons, say some rural places. i can understand fp’s doing some surgery in african countries where patients will die if they don’t have the surgery.

    but to have fp’s perform the operations above? ridiiiiculous. it’s a cop out for fp’s that didn’t want the intensity of a gen surg training program. i would not want a one-year fellowship performing any surgeries on me. that would be akin to a 1st year med student operating on me.

    a congolese thryoid has used up all options.. a US thyroid has better options.

  • http://onsurg.com/about Chris Porter MD

    I doubt training FP’s to do surgery will solve any problems. Instead it would give PCPs more to do and distract a great deal from their clinic practices. My bias as a surgeon says a great difference exists between removing an appendix in a pinch and removing one to the standard attained by a five-year surgical training program.

  • http://clinician1.com Bob Blumm PA-C, DFAAPA

    This was an interesting article and many of the comments were applicable and especially those that questioned the reimbursement of the surgeon at the bottom of the list.
    In the past I have been hired by hospitals as a consultant in the OR to observe where I saw waste and to document this and perhaps suggest a treatment approach. Sure, I made a few dollars but I saved institutions millions.
    When we speak of disposables we are creating a devastating problem for future generations as our pile of waste continues to grow. Why seperate bottles and cans from our garbage if hospitals continue to only use disposables. I worked in the era where our Central Supply Department did much of that work and they can he hired as around the clock technicians.
    Secondly, because some fear the wrath of a surgeon they open droves of sutures and other materials so that the “scrub” does not have to wait. If the scrub technologist observes and antisipates as we were trained years ago they can ask the surgeon if he will need 4- nylon for closure and any special instrumentation.
    Lastly, as this could contain 15 cost savers, we do far too many laproscopic cases which increase the bottom line for an appendectomy or cholecystectomy and the younger surgeons have almost forgotten how to do an open gallbladder. Yes, I know the reasons for laproscopic approach but many patients will take weeks off post-op in any case as they feel that this is their right and there are more complications from closed procedures because it is two dimensional and pathology is sometimes missed because we can see but not “feel” the tissue. Laproscopic supplies and equipment are budget breakers and should be utilized with far more discretion.
    These are not just the comments of a PA with almost fifty years in surgery but are supported by the surgeon that I work with who are ancient (meaning fifty or above).
    This is my effortless overview of a problem that is costly and helping to create the health care problems that we are currently confronting.

    • surgical resident

      I agree with some of your premise. I do think you sell the benefits of laproscopy a little short.

      For example, a lap chole vs open is probably cost effective as an open chole spends 3days in the hospital and has ~10% chance of a hernia which will require another surgery and expensive mesh.

      On average a lap chole is probably cheaper. Of course,there is no study that I’m aware of to support my statement. :)

  • http://nomidazolam.blogspot.com Jackie

    I’ll tell you one thing that will DRAMATICALLY cut costs. Dispense with the sedation for nearly everything. It does nothing but add cost to any procedure. Most sedation is not only un-called for, but is dangerous for the patient. As I read the posts, some are not possible. Try getting any kind of cost analysis from a hospital. They won’t tell you. In writing? Not even. Try stopping them from using g/a and sedation. You will probably be unsuccessful. They want the money that those items generate. CRNA’s were supposed to cut costs… Think they have? Demand an anesthesiologist.

    • Hexanchus

      Jackie,

      It’s actually not that hard to do – you simply write “I do NOT consent to the use of general anesthesia or sedation of any form without my specific written prior approval.” on the surgical/anesthesia consent form. Now that you have established the ground rules, you can have a dialog on what possible anesthesia interventions might be applicable under specific circumstances, what the potential risks and benefits are, and decide on a modified consent based on specific triggers or events based on what you feel comfortable with.

      It helps if you have discussed it with your surgeon ahead of time and can tell the anesthesia provider that. You can also do the same with any other procedure/intervention such as intubation or catheterization if you wish.

      FWIW, I agree with with you on the overuse of sedation (and will add amnesic drugs such as midazolam to that). Bottom line, they are going to want to do what’s easiest for the OR team – not necessarily what’s best for the patient. Unfortunately, if you leave it up to them, most providers will revert to doing what they are used to and most comfortable with – that’s just human nature. I think that if providers would truly take the time to discuss the risks and potential side effects of these drugs, more patients would opt out.

      With the advent of better regional anesthesia techniques, the real need for G/A, along with it’s inherent risks, should be significantly reduced. In India, for example, they have done well over 1000 successful open heart procedures of various types (CABG, valve repair, etc.) on awake, non-intubated patients using thoracic epidural anesthesia. They’ve been doing it there for years – unfortunately it hasn’t caught on here yet….. I believe that areas like this is another place where both the costs and the risks to the patient could be reduced.

  • Frank Castle

    Dr. Kevin,

    Readers should really drill into the URL. While I might concur with the generalized theory — a closer review appears to be more buck-passing and self-interest.

    That is: the MD involved appears to run an ambulatory surgical center (ASC). And, he recommends ASCs.

    Those facts should be right at the top of the post. The public has a right to know.

    • http://fauquierent.blogspot.com Dr. Chris Chang

      Just to set the record straight… I do not own or even have access to an ambulatory surgery center. In fact, the county I live and work in (Fauquier) does not have an ambulatory surgery center.

      Out of patient-interest, I have referred patients to other ENTs who DO have ambulatory surgery center access in Culpeper, VA and Manassas, VA.

  • stitch

    One cost not included in this analysis: the waste of most pre-operative exams. There is very little data to support pre-operative physicals and especially testing for young people, for those on no meds or without significant medical history, or for certain procedures such as cataract removal. The routine ordering of blood counts, chemistries, EKGs and imaging does almost nothing to reduce the risk and adds significantly to the costs. Not to mention it takes up time for primary care physicians, which is limited to begin with.

    • surgical resident

      Best post on this thread!

  • MissPriss

    Surgeons “fees” are very low compared to the astronimical amount the hospital charges. This is a somewhat misleading article, because it fails to mention the salary most surgeons receive from the hospital in addition to the small professional fee. The huge price the hospital charges should cover the nurses salary as well. Don’t be fooled, surgeons still make disproportionately more than PCP’s and please let’s not compare this to a nurses salary, come on….

    • Anon

      Actually, private practice surgeons do NOT receive a salary or any money from hospitals.

      Only surgeons (or any doctor) EMPLOYED by a hospital receive a hospital salary.

      Also, the blog article bundles the nurses salary into the hospital charge… so there is no direct comparison between the surgeon fee and nursing salary. Just a bundled “hospital charge” which includes the nurse’s salary along with a number of other costs. Let’s face it… when a hospital comes up with a charge, it will include all the direct and indirect costs related to a surgical case… which does add up to an astronomical amount.

  • MissPriss

    * astronomical -oops

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