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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