Letters to the Editor is a periodic Kaiser Health News characteristic. KHN welcomes all comments and can publish a variety. We edit for size and readability and require full names.
Surgery Centers: The Bigger Picture
Here is my response—as a #journalist and #anesthesiologist–to the @KHNews/@USATODAY report on #surgerycenters. ANY dying is horrific. But context issues–and makes for stronger #reporting. @ASCAssociation @By_CJewett @markalesia https://t.co/UURkzdtivN
— Dr. James Lozada (@DrJLozada) March 2, 2018
Surgery and anesthesia carry with them small however recognized dangers, together with dying. The thrust of the story was that ASCs are extra harmful than hospitals. However, the information as we at present realize it don’t assist that declare. It’s doable that higher reporting of opposed occasions from ASCs will present new info. And I absolutely assist the push for extra info. Still, contextual reporting is necessary.
— Dr. James Lozada, Chicago
Last yr, greater than 20 million Americans put their belief in ambulatory surgical procedure facilities (ASCs) for outpatient surgical procedures and coverings starting from cataract surgical procedure to whole joint substitute. They did so as a result of the surgeons, nurses and different well being professionals who follow in ASCs have the identical training, coaching and expertise as their friends who work solely in hospitals.
Regrettably, the Kaiser Health News-USA Today Network article “As Surgery Centers Boom, Patients Are Paying With Their Lives” (March 2) by Christina Jewett and Mark Alesia targeted on a comparatively small variety of opposed occasions, whereas ignoring the greater than 100 million profitable procedures that ASCs offered throughout the identical time-frame.
Despite the innuendo and conjecture on this article, there isn’t a empirical proof that helps the inference that surgical procedure facilities pose danger to sufferers. The opposed occasions highlighted within the story had been tragic anomalies.
Here are a couple of different important details about ASCs that the story doesn’t cowl:
Hospital Transfers. ASCs, like hospital outpatient departments, have all of the medical gear and coaching wanted to answer unanticipated emergencies. In uncommon cases, a hospital switch turns into obligatory, and surgical procedure facilities work with their native hospitals to have protocols in place to offer for these. More importantly, a current examine within the January problem of the Journal of Health Economics concluded: “We find that patients treated in an ASC are less likely to be admitted to a hospital or visit an emergency room a short time after outpatient surgery.”
Regulatory Approval For Outpatient Surgery. ASCs are an integral a part of a particularly risk-averse well being care system on this nation. As such, new procedures transfer into the ASC setting solely after the medical neighborhood is satisfied that the surgical approach, anesthesia, ache management and restoration time related to these outpatient procedures assist the identical outcomes as when these procedures are carried out within the hospital.
Transparency. ASCs have lengthy supported significant well being care high quality reporting throughout all websites of service and proceed to work for enhancements in these techniques to assist sufferers make knowledgeable selections. Patients deserve higher entry to information on the protection, high quality and price of the care they’re to obtain, no matter the place they go for the process.
Cost Savings. ASCs even have a superior report of offering actual worth to sufferers, because the funds for procedures carried out in surgical procedure facilities are usually a lot decrease than the identical procedures carried out in hospital outpatient departments. For Medicare beneficiaries, for example, ASC charges are roughly 50 p.c of those who hospital outpatient departments obtain. A evaluate of economic claims information discovered that U.S. well being care prices are decreased by greater than $38 billion per yr as a result of availability of ASCs as an applicable setting for care. More than $5 billion of these financial savings profit sufferers by means of decrease deductible and coinsurance funds.
The tales these reporters informed had been, certainly, tragic, and can little question be deeply regarding to your readers. As well being care professionals devoted to serving to sufferers, the docs, nurses and different well being professionals in ASCs share within the loss and remorse that accompanies any opposed medical occasion. But we additionally know these occasions are each uncommon and happen throughout all websites of care, together with hospitals.
While severe opposed occasions are uncommon in each setting, they’re even rarer in ASCs as a result of the mannequin of care is predicated on utilizing every affected person’s well being historical past to make sure that they are often seen safely as an outpatient. Patients contemplating surgical procedure ought to discuss to their docs about their well being, ask questions and do their very own analysis on the websites of care accessible to them. When they do, we’re assured that, for many sufferers, the details will make them the conclusion that an ASC is the correct selection for the outpatient surgical care they want.
— William Prentice, CEO of the Ambulatory Surgery Center Association, Alexandria, Va.
My father was a type of sufferers… the gastroenterologist who botched his colonoscopy inflicting his dying the following day was additionally part-owner of the Surgery Center the place the colonscopy was carried out…it was like a cattle name…get em in & get em out?
— Cynthia S. Brown (@cyndiblaw1) March 21, 2018
— Cynthia Brown, Cincinnati
As medical director and director of anesthesia companies on the Montefiore Hutchinson Campus, one of many largest ambulatory surgical facilities within the New York metropolitan area, I used to be dissatisfied in your investigation. It is deceptive to painting all outpatient surgical facilities as being inferior to hospital care.
The Hutch Ambulatory Surgery Center is a standalone hospital outpatient facility, accredited by the Joint Commission and held to the identical requirements as hospitals. We present the very best high quality care throughout our 1,000 surgical instances every month. We have skilled excessive affected person satisfaction charges and our hospital switch fee is zero.three p.c, effectively beneath the nationwide common.
Outpatient surgical procedure facilities exist in lots of types, and in some ways symbolize a safer, extra handy possibility for folks in search of care. Instead of lumping all surgical facilities collectively, I hope to see a future concentrate on what sufferers ought to count on when in search of ambulatory surgical care. For instance, now we have an on-site board-certified anesthesiologist who doesn’t depart the surgical procedure heart till the final affected person does — this ought to be the usual of care. By educating folks about what to search for in ambulatory surgical procedure facilities, the unlucky tragedies recounted in your article could stop to exist.
— Dr. Curtis Choice, Bronx, N.Y.
I used to defend medical suppliers in mal follow actions and would do every thing to keep away from a surgical procedure heart. Despite what many assume, docs are usually not infalliable, so I’d wish to be the place errors might be corrected. Also, in case you are actually involved after, go to an ER.
— John Laurens (@ActualJohnLaurens) March 5, 2018
— John Laurens, Louisville
Side Effects From ‘Bill Of The Month’
Substance abuse, and opioid abuse specifically, is a dominant public well being disaster in America, and the information retains getting worse. In “Pain Hits After Surgery When A Doctor’s Daughter Is Stunned By $17,850 Urine Test” (Feb. 16), Fred Schulte stories on medical professionals in search of extreme income from weak sufferers who’ve develop into depending on opioids or at present use them. The enterprise preparations used, comparable to markups and self-referral, differ however at their core contain a perverse monetary incentive that places income forward of affected person care.
The American Society for Clinical Pathology (ASCP) is opposed to those enterprise practices and doesn’t consider that sufferers ought to must pay such exorbitant charges. These abusive enterprise practices increase deeply troubling authorized, moral and ethical considerations about the best way sufferers, lots of whom have a historical past of drug abuse, are being handled by some suppliers. It could be great if the judicial system might successfully maintain these suppliers accountable. Unfortunately, federal and state legal guidelines are sometimes weak and ineffectual. We urge Congress, and state legislatures, to discover methods to forestall unscrupulous well being care suppliers from exploiting sufferers for monetary achieve.
—Dr. E. Blair Holladay, CEO of the American Society for Clinical Pathology, Chicago
Aside from the fee and the a number of points Shefali Luthra raised in “Bill Of The Month: For Toenail Fungus, A $1,500 Prescription” (March 16), it is vitally regarding that the treatment fee is so poor. “Yearlong treatment of Kerydin completely cured toe fungus in 6.5 percent of patients for one trial, and 9.1 percent of patients in another.” The whole value of remedy could be about $16.5K. If these numbers are right, why would any practitioner prescribe the remedy? This feels like a placebo impact greater than an precise pharmacological impact. I hope that the doctor assistant who prescribed the remedy was given a replica of your report back to be taught concerning the points and the way it affected the affected person.
—Bruce Gilman, RN, BSN, CCM, Natick, Mass.
Patients at all times come first at Braun Dermatology & Skin Cancer Center. We would by no means knowingly prescribe a medicine that may take $1,500 out of a affected person’s pocket.
When sufferers have a situation requiring prescription remedy, our first thought is at all times: “What medication will work best?” If there’s an ample generic remedy, we’re completely satisfied to prescribe it. If a brand-name remedy is required, we do our greatest to discover a coupon or specialty pharmacy to seek out the bottom value for the affected person. If a affected person tells us that a remedy is just too costly, we’re completely satisfied to work towards discovering an alternate.
We do not need entry to pharmacy pricing: Different pharmacy corporations have completely different pricing schedules, and people costs can differ by ZIP code and day after day. When sufferers ask us what a drug will value, we inform them they need to ask their pharmacist.
There is not any generic for the Kerydin that was prescribed for this affected person. Your article talked about various remedy for toenail fungus: There is certainly an older topical remedy accessible, nevertheless it doesn’t work in addition to Kerydin. And there are oral medicines, accessible as generics, however they carry the chance of (probably extreme) liver injury, so we don’t typically prescribe these as first-line therapies.
We are dissatisfied that the usage of this specialty pharmacy, which has been very useful to our different sufferers prior to now, resulted in such a excessive value to this specific affected person. While we yearn for extra transparency on the pharmacy stage relating to drug prices, we encourage all sufferers to know the principles of their insurance coverage coverage, ask questions of us and their pharmacist, and alert us of any issues they encounter.
— Xavier Davis, Braun Dermatology & Skin Cancer Center, Washington, D.C.
Multitasking Medics
As an anesthesiologist and a current intraocular lens implant recipient, I feel I’ve an intimate familiarity with this problem (“Anthem Calls On Eye Surgeons To Monitor Anesthesia During Cataract Surgery,” Feb. 20).
I discover it contradictory that, of their justification assertion, Anthem states “there is no one definitive approach regarding the use of anesthesia for cataract surgery and patient-specific needs should be taken into consideration,” whereas they declare of their particular standards for having an anesthesia supplier current, that each one sufferers who don’t match these particular standards necessities, could have no anesthesia companies reimbursed by the corporate.
This problem has been addressed earlier than, within the late 1990s and early 2000s in Florida by one in all my former follow companions, relating to anesthesia suppliers attending for endoscopies. When gastroenterologists had been allowed to do “double duty” as surgeon and anesthesia supplier, intra-operative deaths skyrocketed. Once that “privilege” was rescinded, deaths went to nearly zero.
— Dr. Michael T. Grier, Anderson, S.C.
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