Letters to the Editor is a periodic Kaiser Health News feature. KHN welcomes all comments and will publish a selection. We edit for length and clarity 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 death is horrific. But context matters–and makes for stronger #reporting. @ASCAssociation @By_CJewett @markalesia https://t.co/UURkzdtivN
— Dr. James Lozada, Physician Journalist (@DrJLozada) March 2, 2018
Surgery and anesthesia carry with them small but known risks, including death. The thrust of the story was that ASCs are more dangerous than hospitals. However, the data as we currently know it do not support that claim. It’s possible that better reporting of adverse events from ASCs will provide new information. And I fully support the push for more information. Still, contextual reporting is important.
— Dr. James Lozada, Chicago
Last year, more than 20 million Americans put their trust in ambulatory surgery centers (ASCs) for outpatient surgical procedures and treatments ranging from cataract surgery to total joint replacement. They did so because the surgeons, nurses and other health professionals who practice in ASCs have the same education, training and talent as their peers who work only 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 focused on a relatively small number of adverse events, while ignoring the more than 100 million successful procedures that ASCs provided during the same time frame.
Despite the innuendo and conjecture in this article, there is no empirical evidence that supports the inference that surgery centers pose risk to patients. The adverse events highlighted in the story were tragic anomalies.
Here are a few other essential facts about ASCs that the story does not cover:
Hospital Transfers. ASCs, like hospital outpatient departments, have all the medical equipment and training needed to respond to unanticipated emergencies. In rare instances, a hospital transfer becomes necessary, and surgery centers work with their local hospitals to have protocols in place to provide for those. More importantly, a recent study in the January issue 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 part of an extremely risk-averse health care system in this country. As such, new procedures move into the ASC setting only after the medical community is convinced that the surgical technique, anesthesia, pain control and recovery time associated with these outpatient procedures support the same outcomes as when those procedures are performed in the hospital.
Transparency. ASCs have long supported meaningful health care quality reporting across all sites of service and continue to work for improvements in these systems to help patients make informed decisions. Patients deserve better access to data on the safety, quality and cost of the care they are to receive, regardless of where they go for the procedure.
Cost Savings. ASCs also have a superior record of providing real value to patients, since the payments for procedures performed in surgery centers are typically much lower than the same procedures performed in hospital outpatient departments. For Medicare beneficiaries, as an example, ASC fees are approximately 50 percent of those that hospital outpatient departments receive. A review of commercial claims data found that U.S. health care costs are reduced by more than $38 billion per year due to the availability of ASCs as an appropriate setting for care. More than $5 billion of those savings benefit patients through lower deductible and coinsurance payments.
The stories these reporters told were, indeed, tragic, and will no doubt be deeply concerning to your readers. As health care professionals dedicated to helping patients, the doctors, nurses and other health professionals in ASCs share in the loss and regret that accompanies any adverse medical event. But we also know these events are both rare and occur across all sites of care, including hospitals.
While serious adverse events are rare in every setting, they are even rarer in ASCs because the model of care is based on using each patient’s health history to ensure that they can be seen safely as an outpatient. Patients considering surgery should talk to their doctors about their health, ask questions and do their own research on the sites of care available to them. When they do, we are confident that, for most patients, the facts will lead them to the conclusion that an ASC is the right choice for the outpatient surgical care they need.
— William Prentice, CEO of the Ambulatory Surgery Center Association, Alexandria, Va.
https://twitter.com/cyndiblaw1/status/976538231582969856
— Cynthia Brown, Cincinnati
As medical director and director of anesthesia services at the Montefiore Hutchinson Campus, one of the largest ambulatory surgical centers in the New York metropolitan region, I was disappointed in your investigation. It is misleading to portray all outpatient surgical centers 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 same standards as hospitals. We provide the highest quality care during our 1,000 surgical cases each month. We have experienced high patient satisfaction rates and our hospital transfer rate is 0.3 percent, well below the national average.
Outpatient surgery centers exist in many forms, and in many ways represent a safer, more convenient option for people seeking care. Instead of lumping all surgical centers together, I hope to see a future focus on what patients should expect when seeking ambulatory surgical care. For example, we have an on-site board-certified anesthesiologist who does not leave the surgery center until the last patient does — this should be the standard of care. By educating people about what to look for in ambulatory surgery centers, the unfortunate tragedies recounted in your article may cease to exist.
— Dr. Curtis Choice, Bronx, N.Y.
I used to defend medical providers in mal practice actions and would do everything to avoid a surgery center. Despite what many think, doctors are not infalliable, so I’d want to be where mistakes can be corrected. Also, if you are really concerned after, go to an ER.
— John Laurens (@RealJohnLaurens) March 5, 2018
— John Laurens, Louisville
Side Effects From ‘Bill Of The Month’
Substance abuse, and opioid abuse in particular, is a dominant public health crisis in America, and the news keeps getting worse. In “Pain Hits After Surgery When A Doctor’s Daughter Is Stunned By $17,850 Urine Test” (Feb. 16), Fred Schulte reports on medical professionals seeking excessive profits from vulnerable patients who have become dependent on opioids or currently use them. The business arrangements used, such as markups and self-referral, vary but at their core involve a perverse financial incentive that puts profits ahead of patient care.
The American Society for Clinical Pathology (ASCP) is opposed to these business practices and does not believe that patients should have to pay such exorbitant rates. These abusive business practices raise deeply troubling legal, ethical and moral concerns about the way patients, many of whom have a history of drug abuse, are being treated by some providers. It would be wonderful if the judicial system could effectively hold these providers accountable. Unfortunately, federal and state laws are often weak and ineffectual. We urge Congress, and state legislatures, to explore ways to prevent unscrupulous health care providers from exploiting patients for financial gain.
—Dr. E. Blair Holladay, CEO of the American Society for Clinical Pathology, Chicago
Aside from the cost and the multiple issues Shefali Luthra raised in “Bill Of The Month: For Toenail Fungus, A $1,500 Prescription” (March 16), it is very concerning that the cure rate 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 total cost of treatment would be about $16.5K. If these numbers are correct, why would any practitioner prescribe the medication? This sounds like a placebo effect more than an actual pharmacological effect. I hope that the physician assistant who prescribed the medication was given a copy of your report to learn about the issues and how it affected the patient.
—Bruce Gilman, RN, BSN, CCM, Natick, Mass.
Patients always come first at Braun Dermatology & Skin Cancer Center. We would never knowingly prescribe a medication that would take $1,500 out of a patient’s pocket.
When patients have a condition requiring prescription treatment, our first thought is always: “What medication will work best?” If there is an adequate generic medication, we are happy to prescribe it. If a brand-name medication is needed, we do our best to find a coupon or specialty pharmacy to find the lowest cost for the patient. If a patient tells us that a medication is too expensive, we are happy to work toward finding an alternative.
We do not have access to pharmacy pricing: Different pharmacy companies have different pricing schedules, and those prices can vary by ZIP code and day to day. When patients ask us what a drug will cost, we tell them they must ask their pharmacist.
There is no generic for the Kerydin that was prescribed for this patient. Your article mentioned alternative medication for toenail fungus: There is indeed an older topical medication available, but it does not work as well as Kerydin. And there are oral medications, available as generics, but they carry the risk of (potentially severe) liver damage, so we do not generally prescribe these as first-line treatments.
We are disappointed that the use of this specialty pharmacy, which has been very helpful to our other patients in the past, resulted in such a high cost to this particular patient. While we yearn for more transparency at the pharmacy level regarding drug costs, we encourage all patients to know the rules of their insurance policy, ask questions of us and their pharmacist, and alert us of any problems they encounter.
— Xavier Davis, Braun Dermatology & Skin Cancer Center, Washington, D.C.
Multitasking Medics
As an anesthesiologist and a recent intraocular lens implant recipient, I think I have an intimate familiarity with this issue (“Anthem Calls On Eye Surgeons To Monitor Anesthesia During Cataract Surgery,” Feb. 20).
I find it contradictory that, in their justification statement, 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,” while they declare in their specific criteria for having an anesthesia provider present, that all patients who do not fit those specific criteria requirements, will have no anesthesia services reimbursed by the company.
This issue has been addressed before, in the late 1990s and early 2000s in Florida by one of my former practice partners, regarding anesthesia providers attending for endoscopies. When gastroenterologists were allowed to do “double duty” as surgeon and anesthesia provider, intra-operative deaths skyrocketed. Once that “privilege” was rescinded, deaths went to almost zero.
— Dr. Michael T. Grier, Anderson, S.C.