Why would anyone believe that cheap surgery is a good choice?

If you live in southern California, you can’t miss the billboards advertising laparoscopic gastric banding at “1-800-GET-THIN” outpatient surgery centers.  They feature happy people who’ve lost 100 pounds or more, and urge you to “let your new life begin” by having a “lap band” inserted.  Fees at these centers are much lower than they are at university medical centers or other major hospitals.

Recently, however, those surgery centers and their owners have been in a lot of trouble.  Patient deaths have been reported in detail by the Los Angeles Times.  Whistleblower lawsuits by former employees have accused the surgery centers of performing gastric banding with unqualified staff and unsanitary, malfunctioning equipment.   Members of Congress are calling for hearings to question the aggressive advertising that failed to disclose “lap band” risks.

Why would anyone believe that cheap surgery is a good choice?  Think about it for a moment.  If you buy a knock-off Rolex watch from a street vendor, are you really surprised if tarnish rubs off on your wrist?

Yet we hear little else these days but criticism of the high cost of health care, and demands for better quality at less expense.  No doubt there’s waste in any system that can be trimmed.  When my life is on the line, though, I’d prefer for my doctors and nurses not to be chintzy with my care.  The push to move procedures from the inpatient to the outpatient setting to save money has reached dangerous extremes.

Outpatient centers do a wonderful job at making it easy and comfortable for patients to have simple procedures done.   There’s little reason to go to a major hospital to have a routine breast biopsy, cataract extraction, or carpal tunnel release, unless you’re an exceptionally high-risk patient.

But far more invasive procedures are being done at outpatient surgery centers today, and they’re being done on patients who are sicker and at higher risk.  Most microdiskectomies go smoothly, but occasionally the aorta is nicked.  How many patients realize that no blood is available for transfusion at an outpatient surgery center, no matter how desperate the need?

The whole concept of cut-rate surgery centers ought to raise eyebrows and inspire questions.  They’re unlikely to have good equipment to manage a difficult airway, or the drugs to treat a rare but deadly complication such as malignant hyperthermia. Are first-rate physicians and nurses likely to seek employment at such a place?  The pay isn’t going to be top notch, because that would raise costs.  Perhaps these places attract personnel who can’t find work elsewhere.

“Suboptimal” care by the anesthesiologist contributed to a woman’s death after weight-loss surgery at a Beverly Hills clinic connected to the 1-800-GET-THIN advertising campaign, according to an autopsy report by the Los Angeles County coroner.  At the time of the incident, the anesthesiologist was on probation—and ordered to participate in an anger management program—after the state medical board determined that he had assaulted a process server with a meat cleaver.

Many outpatient surgery centers are owned in part by surgeons. It’s possible that profit can motivate them to schedule procedures there that exceed the bounds of safety.  Many morbidly obese patients have other health problems such as hypertension, reflux, and asthma that can raise their risk of complications from general anesthesia.  It can be difficult to intubate or ventilate them. Though the patient might be safer at an inpatient hospital, the surgeons will lose the facility fee if the procedure isn’t done at their own outpatient center.

Once, I was doing a preoperative exam on a slim, healthy young patient, and I was surprised to see a 12-inch midline scar on her abdomen.   What happened?  At the start of a previous laparoscopic procedure, the Veress needle punctured a major artery.  Since she was in a hospital at the time, a vascular surgeon was available to repair the injury at once.  The patient recovered uneventfully and went home only a few days later.  Had the same injury occurred at an outpatient center, the outcome might not have been as happy.

This is not to say that ambulatory surgery centers shouldn’t exist.  Many are excellent, are located close to major hospitals, and can transfer a patient rapidly in the rare cases when that becomes necessary.  At the medical towers adjacent to my hospital, several plastic and hand surgeons have state-of-the-art operating rooms in their office suites.  There’s a connecting bridge directly to the hospital, and the same MD-only anesthesiology group staffs both facilities.

Recently I noticed a magazine ad for “cheap” helicopter tours over the Hawaiian Islands.  To me, that seems like an unwise way to save money.  If I were going to book a tour, I’d like some assurance that the helicopter pilot was well paid and happy, and that all the equipment was modern and scrupulously maintained.

First-rate surgery is never going to be able to compete financially with the care at cut-rate surgery centers, but patients should understand that you get what you pay for.  Your life could depend on it.

Karen S. Sibert is an Associate Professor of Anesthesiology, Cedars-Sinai Medical Center.  She blogs at A Penned Point.

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  • Anonymous

    “Why would anyone believe that cheap surgery is a good choice?”

    I suppose the question could be turned on its head:  Why does surgery (and other procedures, medications, etc) cost SO MUCH when you have it done at a university medical center or major hospital?

    • http://profile.yahoo.com/5SKBCI5RBBKC6WFBEQ45K4WTWA rich

       because the anesthesiologist has to be paid $500k/year for passing gas…

      • Anonymous

        Well, I guess it’s because people–and especially American people–have a very strong impulse to not be dead.  If we could take the same approach to surgery and anesthesiology as we do to air travel or highway construction, then we would have a system that:
        1. Costs less
        2. Guaranteed a minimum safety standard
        3. But also guaranteed a minimum fatality rate–yes, that’s right, almost everything in engineering has a margin of error and that usually translates to some sort of fatality rate.  The regulators look that over and then weigh those lives with the additional cost associated with making those people live, and then decide whether or not it’s worth it to taxpayers to keep those people alive.
        If you are ok with “rollin the dice” when you go in or your family goes in, then go for it–get bottom dollar.  Ever eat at a gourmet Chinese banquet restaurant and then have Chinese buffet at Panda Express?  Go knock yourself out.

        BTW: Ever wonder why a baseball player gets paid millions a year to bat 30-35%?  What happened if surgeons and anesthesiologists had a success rate of 30-35% (ie major complications 65-70%?)  We make some pretty stupid decisions as a society when we pump that kind of money into entertainment and then complain about professionals with almost a decade of post-doctoral hands-on malpractice-exposed training trying to bat 1000 making 300-500K a year.

        Please wake up.

  • Anonymous

    Most of the local advertisements I see on TV and billboards in Florida are from doctors and lawyers.  One billboard got my attention, they advertise vasectomies with no needle or scalpel.  My question is what do they use? A hammer.

    • John Henry

       Laser or RF.

  • Christine Doyle

    The cost of healthcare is multifactoral — but a large part of it is driven by people costs.  Healthcare is a “service industry” just like retail or food.  The single largest budget item of any hospital is paying the staff — and I don’t mean the doctors.  An experienced RN in our hospital makes anywhere between $50-90/hour for straight time, which of course goes up for overtime and call.  Add 30% to that for the associated benefits (health insurance for them, retirement, social security, PTO, etc).  Add the assorted support staff — housekeeping, engineering, medical records, cafeteria — and you can see how the budget increases.  Not to mention the mortgage, utilities, regulatory burdens (both state and federal), etc — which have to be paid whether or not you have patients.

    Surgical charges are based, in part, on the time spent in the operating room and recovery room.  So university hospitals may have higher charges because the residents are slower as they learn how to assist and operate.  Some major hospitals cost shift, with more than 50% of the patients having only a governmental insurance (Medicare or Medicaid) — which pays about 13 cents on the dollar!  

    jyd13 is correct — perhaps another way to look at it is what is our “tolerance for fault” — and in healthcare, most people consider it pretty much zero.  

  • http://www.threehourmidlifecrisis.com/ Dike Drummond MD

    Great post Karen … and the short answer to your title is “because money sometimes matters more than quality”. The key here is the ads (and the procedure) you are talking about are not covered by insurance. This is a for-profit business plan that takes cash for the Lap Band. Their “special sauce” is obviously “low price” which means their business model is based on high volume.

    All I have to do is lay that out there … and ad in that it takes outpatient surgery with an anesthetic to complete the procedure and you know there is going to be trouble with this business.

    Low cost (and low margins) + high volume + surgery = constant pressure to cut corners and speed up

    When this procedure is paid for by insurance there is still some pressure to cut costs, but it is far less and quality is being monitored by the payor.

    This is the same as outpatient Lasik for $700 “an eye”. Except in that business no one needs a general anesthetic so the risks are far less. That is a better procedure for this business model.

    My two cents

    Dike Drummond MD

  • James Sinnott

    Great article I’m a GI doctor and have a surgical center.  We are able to provide high quality care at an affordable price.  We are certified by both Medicare and AAAHC which is a commitment of time and resources.  Patients can have procedures done with less hassel than the hospital and they have a more personal experience.  Is there a role for surgical centers yes with out a doubt.  But be an informed consumer see if they have certifications,  check out your doctors on the state board website; ask questions if they dont want to answer go somewhere else.  Ask for statistics data number of cases and emergency transfers; in fact ask to see the transfer agreement with the hospital (certified centers are required to have one).  

    Use the same diligence you would in any major purchase. Cavat Emptor 


  • Anonymous

    It’s not as though health care costs are even remotely transparent, so the difference between “expensive” and “cheap” may not be quality at all, but things like age, tradition, and bureaucracy.  In a large hospital, no one at all in a clinical role can tell you what anything costs.  In such a setting, it’s hard to argue that patients are paying for quality — no one has any idea what their services are even worth in any real sense!  There are hospital horror stories out there, as well as surgery center horror stories.  Dreadful anecdotes never really prove a point. 

    In the simplest economic terms, if you can increase demand for elective surgeries, you can charge a lower per-unit cost, without necessarily changing equipment or standards or anyone making less money.  With absolutely no cost transparency, the “going rate” may be grossly inflated, which is in many cases, the status quo that large hospital centers would like to preserve, and will spend a lot of lobbying and advertising money to maintain.  If you can interview mechanics and consider multiple factors including cost for car repair, why argue that the same procedure should be taboo when talking about elective surgery?  You touch on the issue of case selection, which is a legitimate concern, but don’t throw out the baby with the bathwater.

  • Anonymous

    Well, in business school I learned there is no correlation between price and quality.

    Price is merely a signalling tool of quality and most consumers *assume better quality with the higher price. Maybe consumers are just getting savvy to the fact that Insurance companies pay 20% of the quoted price??? In my case I was able to negotiate a reduction from $20K to $4K for a necessary surgery when I didn’t have medical insurance. Doesn’t this seem wrong that the MD had such a high initial gross margin???

  • http://twitter.com/KarenSibertMD Karen Sibert MD

    Interesting business school!  Generally, most of us would expect to have a nicer stay in a four-star hotel than in one that costs a fourth as much.  You are absolutely correct that the pricing model of our current system is grossly inflated, because hospitals and physicians know that insurance will only pay a fraction.  However, in any enterprise, if you cut costs past the point of reason and safety, quality will certainly suffer.

  • Anonymous

    Really! I was given Redman’s syndrome in an outpatient surgical center, while prepping for a colonscopy. My doctor didn’t order the antibiotic, the surgery center director did, to increase the complexity of the procedure. Of course, they nearly killed me. And then, to add insult to injury, they tried to bill my insurance $7000 for the colonoscopy. They settled for less but they dragged in about a thousand more than the local hospital would have received for the procedure. (And they lied about the cost, when I called for the estimate.) And when I was nearly stroking out from my mast cells degranulating, all over my body, I was very aware that these fools didn’t even have a tray prepared, they were operating out of a closet. I was very aware, at that point, that there was no emergency room, no trained personnel and no ethics. The nurses refused to give me the sugar water I needed as I went into acute hypoglycemia, as they still hoped to keep me in a dehydrated condition to go through the colonoscopy. 

    Why did I go to the center? My doctor suggested it. And in the interest of full disclosure he had also told me he was part owner. Actually, as a healthcare analyst I looked at it later and it’s a pitiful illusion that he thought he was part owner. He, and others like him, funded the build of the center and got some small benefit from it, but the majority of the profit went to the corporation that specialized in setting these centers up and running them. I didn’t sue my doctor, credit fifteen years of good service for that. I didn’t sue the center, because I thought they may have dragooned or conned my doctor’s partner or staff into rubber stamping the antibiotic decision. But I will tell you, I will never go to a so called surgical center again. 

  • http://twitter.com/EscorciaMD Erica Escorcia, MD

    Just a few points I’d like to make.  Many top notch physicians and nurses prefer to work or seek contracts in ASCs for a few reasons.  1.  More efficient pace of work.  2.  More cooperative environment. 3. Better lifestyle.  4.  No call. 5. Typically no holidays 6. Better compensation.  I have to disagree about the quality of the personnel.  Hospitals have some good and some bad.  In an ASC, they can be more selective (at least in the area where I live). 

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