When Billing for Services, Location Matters

Hospitals' charging of facility fees for off-site surgical care is drawing scrutiny from Medicare and other insurers as well as the ire of consumers, who see the practice as confusing, unfair or an attempt to generate revenue that is driving up healthcare costs, according to a report in the Boston Globe (free registration required).

The article recounts the story of a man who had cryotherapy to remove 3 precancerous spots in his dermatologist's office, then received a bill for the physician's services — and a $1,525 bill for "operating room" and "facility" fees. Physician offices cannot charge facility fees, but this one had because it is owned by the Lahey Hospital and Medical Center in Burlington, Mass. An article published in the Seattle Times notes that hospitals have justified the charges as defrayment for "overhead such as equipment, staff, medical-records systems, diagnostic imaging and care not covered by insurance or underpaid by Medicare or Medicaid," and "because integrating clinics with hospitals improves care."

As the practice has proliferated, consumers have begun to complain that the fees are unfair and that they drive up the cost of care. MedPAC has therefore decided to have a closer look. In its 2012 Report to the Congress: Medicare Payment Policy, the independent advisory panel recommended that the Medicare payment system allow for a single fee rate for various procedures performed in offices and for basic office visits, regardless of how the site is designated.

Stephanie Wasek

Spine Repair Outcomes Slight Obese Patients

Obese patients experience less successful outcomes from lumbar disc herniation treatments than non-obese patients do, researchers say, even when other post-treatment factors are similar.

For their study, published in the January 2013 issue of the Journal of Bone and Joint Surgery, the researchers compared the cases of 336 lumbar disc herniation patients with body-mass indexes greater than 30 against those of 854 patients with BMIs of less than 30. Some of the patients had undergone surgery, and others non-surgical treatment.

Four years after the treatments, assessments showed less of an improvement in function among the obese patients. Interestingly, though, obese patients did not report statistically greater pain scores on average, nor did they exhibit higher rates of infections, intraoperative complications, herniation recurrences or the need for re-operations. (Researchers noted that the absence of higher recurrence rates runs counter to earlier studies in medical literature.) Their analysis also found no evidence that body-mass index influenced whether surgery was more successful than non-surgical options.

"The results of this study may be helpful in educating patients about their treatment options and expected outcomes," says Jeffrey Rihn, MD, a co-author of the study and an associate professor at Philadelphia's Thomas Jefferson University Hospital and Rothman Institute. "These findings may suggest that weight loss should be encouraged in patients with this condition. However, this study does not specifically address whether weight loss in obese patients would affect their clinical outcome with non-surgical or surgical treatment."

David Bernard

SSIs Linked to Blood Clot Dangers

Patients who suffer surgical site infections after abdominal surgery are 4 times more likely to develop deep-vein thrombosis in the legs and pulmonary emboli in the lungs, according to researchers at Johns Hopkins School of Medicine in Baltimore, Md.

While only 4% of the 615 patients who underwent colorectal surgery at Johns Hopkins between July 2009 and July 2011 developed DVT, 92% of those who did had received prophylaxis measures - low-dose blood thinners and the use of compression devices to keep blood flowing in the legs - believed to prevent the potentially deadly complication.

A little more than half of the patients with pulmonary emboli also had post-op infections, compared to less than 30% of patients who did not have blood clots. Sixty-four percent of the infections occurred before or on the same day as the pulmonary emboli, according to the study's findings, which are published in the Journal of the American College of Surgeons. The researchers say the increase of inflammatory protein molecules present during infections impact the functioning of blood platelets, which could increase blood clot risks.

"We need to think beyond the prophylaxis we are already giving these patients," says Susan L. Gearhart, MD, an associate professor of surgery at Johns Hopkins and the study's lead author. "We need to think smarter."

She advises, for example, aggressive monitoring and prophylaxis administration for abdominal surgery patients who develop SSIs, including ultrasound screening for blood clots and prescribing blood thinners for 30 days post-op.

Daniel Cook

InstaPoll: How Do You Perform Your Initial Pre-Anesthesia Screening?

Phone call, patient visit or online questionnaire? Help us get a snapshot of how surgical facilities perform their initial pre-anesthesia screenings in this week's InstaPoll.

Nearly 7 out of 10 (69%) of the 516 facility managers who took last week's poll feel that robotic surgery is more marketing hype than clincial benefit. Here's how they answered that question:

  • Strongly agree: 41%
  • Agree somewhat: 28%
  • Neither agree nor disagree: 9%
  • Disagree somewhat: 10%
  • Strongly disagree: 12%

Dan O'Connor

News & Notes
  • B&L ophthalmic cannula recalled Bausch & Lomb is recalling certain lots of its 27G sterile viscosurgical cannulas packed in Amvisc 1.2% sodium hyaluronate (models 59051, 59081, 59051L and 59081L) and in Amvisc Plus 1.6% sodium hyaluronate (models 60081, 60051, 60051L and 60081L). The cannulas may leak viscoelastic or detach from the syringe during injection, which has reportedly injured patients.
  • Anesthesia's inflammation risk? A new study in the journal Anesthesiology may have identified why children younger than 4 years old who undergo repeated surgeries requiring general anesthesia are at increased risk for learning disabilities. Researchers at the Massachusetts General Hospital in Boston report that sevoflurane - but not desflurane - elevated brain tissue inflammation in mice and negatively impacted their learning and memory function, suggesting that some inhalational anesthetics may be safer than others for young children.
  • HIPAA bulks up In a final omnibus rule issued earlier this month, the federal Department of Health and Human Services amended HIPAA's health information privacy provisions. Among the changes: expanded requirements on business associates handling private data, greater control of patients over their information, increased enforcement and higher penalties.