Does Medicare Overpay for Cataracts and Colonoscopies?

The skyrocketing cost of health care in the United States may be attributable in part to a huge discrepancy between what Medicare pays physicians for common surgical procedures and what it pays them for primary care visits, say researchers.

In a study published online by JAMA Internal Medicine on Aug. 12, they calculate that Medicare pays surgeons performing cataract extractions 486% of the revenue it pays primary care physicians who treating patients for the same amount of time. Surgeons performing colonoscopies earned 368% of the primary care amount.

"Two common specialty procedures can generate more revenue in 1 to 2 hours of total time than a primary care physician receives for an entire day's work," write Christine A. Sinsky, MD, of Medical Associates Clinic in Dubuque, Iowa, and David C. Dugdale, MD, of the University of Washington in Seattle.

This gap is due in part to the complexities of Medicare's relative value unit-based payment system and in part to the agency's overestimation of the amounts of time that surgeons spend on a case, they argue. The end result is rising costs, especially since commercial insurers often follow Medicare's cues, and demands a revision of the RVUs.

"Historically, U.S. physicians have been paid more for performing costly procedures that drive up spending and less for cognitive services that may conserve costs and promote population health," they write.

David Bernard

Replaced Knees Pay Financial Dividends

Knee-replacement surgery is a good investment, both for individuals and for society as a whole. That's the finding of a study published in the Journal of Bone and Joint Surgery, which found that the average knee replacement costs $20,700 but results in an indirect savings of $39,700 as a result of increased time in the workforce, fewer missed days and reduced disability payments.

Researchers, who reviewed literature and Medicare claims and collected patient-reported data, estimate that the 600,000 total knee-replacement surgeries done in the U.S. in 2009 netted about $12 billion in savings, mostly to working patients and employers. With the population aging and obesity rates rising, demand for the surgery is expected to exceed 3 million by 2030.

"We know that when a knee replacement is done on patients at the appropriate time … it improves their quality of life and allows them to be productive and active again," said John R. Tongue, MD, the past president of the American Academy of Orthopaedic Surgeons. "But until now, that value has been hard to quantify. This study allows patients to see the big picture of the effect on their daily lives and in the long term."

Jim Burger

Help Patients Stop Smoking

Spending just a few minutes during pre-admission assessments to warn patients about the dangers of lighting up decreases smoking rates on the day of surgery and promotes abstinence a month later, according to a study in the journal Anesthesia & Analgesia.

Researchers at the University of Western Ontario divided 168 patients evenly into a group who received no smoke cessation interventions and a group who was counseled to stop smoking 3 weeks before surgery, given anti-smoking brochures, referred to a smokers' helpline and supplied with a 6-week supply of nicotine replacement therapy.

According to the study, 12 of the patients who received interventions quit smoking before they arrived for surgery, compared to 3 patients in the non-intervention group. At 30 days post-op, 22 of the patients who were educated about the dangers of smoking still hadn't smoked, compared to 8 patients who did not receive pre-op counseling.

Patients who smoke are more likely to suffer major complications and even die within 30 days of surgery, according to a study published online in JAMA Surgery.

The study's authors say patients who smoke should be encouraged to kick the habit before undergoing procedures to lower complication risks and realize the long-term benefits of surgery. Patients should be encouraged to kick the habit before surgery, say the study's authors, because that's when the message will have the most impact.

Daniel Cook

InstaPoll: Would You Post Your Prices Online?

What do you think of hospitals and ASCs that post their all-inclusive prices for surgery online? Transparency in health care is the subject of our September issue's cover story. Tell us your thoughts on the topic in this week's InstaPoll, then check here next week for the results.

Nearly three-fourths (72%) of the 439 respondents to last week's InstaPoll feel they are paid adequately, but more than half of those satisfied with their salary feel they're overdue for a raise. The results:

Which best describes your feelings about your compensation?

  • I am paid adequately and overall satisfied: 34%
  • I am paid adequately but overdue for a raise: 38%
  • I am paid handsomely; I can't complain! 4%
  • I am grossly underpaid; time to update the resume: 14%
  • I am happy that I have a job: 10%

Dan O'Connor

News & Notes
  • Treat all patients like children? Even those who provide surgical care to adults can learn a lot from the way pediatric hospitals treat their patients, says medical student Mark Attiah in the Aug. 21 issue of JAMA. From better environments to more sensitive interactions with patients, children's hospitals get it right. "The truth is that without help, most people, regardless of their age, aren't naturally good at being patients," he writes. "Could approaching the patient with this mindset actually the make the experience more tolerable?"
  • Measure readmission risk with EMRs An automatically calculated health risk score based on EMR data may help to predict and reduce avoidable hospital readmissions, says a study in the September issue of the journal Medical Care. The Rothman Index, which is based on vital signs, nursing assessments, skin condition, heart rhythms and laboratory tests, gauges the likelihood of a patient's readmission. A retrospective study found that patients who scored the highest risks were more than 2.5 times as likely as those with the lowest to be readmitted within 30 days.
  • Sleep apnea, glaucoma linked Patients who have been diagnosed with obstructive sleep apnea are 1.67 times more likely to also be diagnosed with open-angle glaucoma within the 5 years following their OSA diagnosis, say Taiwanese researchers in the journal Ophthalmology.