My first work day on sabbatical: reflections on the cost of colonoscopies

Human digestive systemWell, today is the first “work” day of my sabbatical. Because I am in Milwaukee visiting my 92-year-old father there is a hint of vacation in the air, but my body’s muscle memory is telling me to dress for work.

I feel the Void. I must make this day worthwhile.

So I will applaud the new series in the New York Times reporting on “medical mammonism” (my term); otherwise known as The $2.7 Trillion Medical Bill.

The first article uses colonoscopy as an example of inappropriate billing practices. Now, colonoscopies are something I know a bit about, having performed them for 33 years in training and in practice. I have seen the evolution of the procedure and its associated components.

The addition of heavy sedation as delivered by an anesthesiologist is one of the most egregious expenses and is motivated purely by greed.

It is a practice started as an experiment to compare the use of propofol with the standard of “conscious sedation,” the blend of a narcotic and a sedative.

It became apparent that insertion of the tube could be performed a few minutes faster because no adjustment had to be made for the patient’s comfort. In addition, the patient’s memory returned fifteen minutes faster so they could be discharged more quickly. There was no demonstrable medical benefit.

Doctors with private surgery centers quickly embraced these findings because they could book more cases in a day and discharge the last case faster which reduces recovery room expenses.

The gastroenterologists also learned they could hire their own anesthesiologists for less than hospital OR rates and keep a percentage of the anesthesia reimbursements.

The three professional societies that monitor and guide the practice of gastroenterology have all evaluated the use of propofol as administered by anesthesiologists and they have concluded that the expense is not justified for the average patient and they recommend it be used only for exceptional cases.

Yet doctors continue to use it, and more doctors embrace it, because they can make money doing it and they sell it to their patients as “new” and “improved.” Some hospitals and health systems also embrace it for the same reasons.

Trying to maintain good and ethical practices becomes a slippery slope when paired with the commercialization of medicine.

Dr. Steven Nissen said it best in the documentary, Escape Fire: “When we made medicine a business, we lost our moral compass.”

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14 Responses to My first work day on sabbatical: reflections on the cost of colonoscopies

  1. Claudia Hall Christian June 3, 2013 at 11:18 am #

    We’re in this bizarre situation where no matter how much the colonoscopy costs, we are still charged the $1k deductible. Here in Denver, we can go to the fast, doctor recommended center where you go in, have the test, and to home for $818; or you can check into the the super luxury hospital outpatient center for most of the day at the low cost of $4,500. Either way, it costs us $1k.

    What patient would use the efficient $800 service over the luxury $4,500 service? (Well, I would but I’m a bit of a workaholic.) Because most people have some kind of insurance, there is no incentive for the doctors or hospital to make the procedure easy, and inexpensive for the patient. None.

    I realize this is a bit off your point, but it’s worth noting that these situations don’t occur in a vacuum. Doctors would not get away with “new” and “improved” if their patients couldn’t afford them.

    • Claudia Hall Christian June 3, 2013 at 11:19 am #

      It’s worth noting that this would be my FIRST colonoscopy – my husbands as well. This ridiculousness will continue for the rest of our lives on some regular basis, which frankly, makes the entire thing seem absurd.

    • Alice October 7, 2014 at 1:26 pm #

      As a frequent flyer for this procedure, the most bizarre billing practice I have found is that the procedure is listed as being no cost to me as it is preventative. Almost every time, they do a biopsy as I have a little polyp factory in my lower intestines. The fact that they biopsy it makes it into a medical procedure and they bill it accordingly, I.e., impose a deductible and I have to pay 20 percent of the approved charges. Think about it: I have had several adenomas (the kind that can turn to cancer) so the fact that they found and removed them prevented me from getting colon cancer so it was truly preventative. Any other time, the procedure did not prevent anything but that was paid at 100 percent??

      • Sam Harrington October 8, 2014 at 10:01 am #

        Alice, your comment highlights some incongruities in American health care that are not illogical financially but are morally inconsistent.

        Doctors are trained to do more and paid to do more. Colonoscopists rationalize that more tests and tissue biopsies reduce future colon cancer and “coincidentally” get paid to remove tissue and to schedule frequent-flyer follow-ups.

        Insurance companies profit by NOT paying for procedures. They have calculated that they make more money by making you pay for your deductible and 20% copay than by standing by their promise of paying for “preventative” services.

        These questionable values of doctors and insurers create your quandary.

        As an aside, I believe that medical science has overrated the benefits of colonoscopy to practitioners and patients. The exponential increase in cost and frequency of procedures is not justified by the small decrease in actual deaths by colon cancer
        (see my blog post of January, 2014, “The Law of Diminishing Returns”-or some variation on that theme).

        We need to “right size” the frequency of colonoscopies. We need to re-educate the consumers about the actual risk reduction of a given procedure. We need to stand up to insurance companies and demand that they pay more for fewer, and better, preventive services, including colonoscopies. Sam

  2. adfranklin June 4, 2013 at 12:50 pm #

    Just curious… does Obama Care do anything to help make it any easier for people will be able to make informed choices about their medical care? I recently chose to undergo a spinal injection for back pain without the benefit of conscious sedation because my insurance company would not pay for it. The injection didn’t hurt very much – but didn’t do much good either. I’m glad I didn’t waste money on the sedation.

    • Sam June 6, 2013 at 10:09 pm #

      No. I do not think it has any effect on your question but given thousands of pages of regulations no one can be sure.

      Sent from iPhone. Please excuse abbrvs and typoz (aged thumbs). SPH

  3. Debbie June 4, 2013 at 6:36 pm #

    Uh oh, I’m realizing we’re going to need a Comments Policy. Takes me back to my days of corporate blogging – the need for disclaimers and what not.

    I’ll say it informally for now. We’ll work on getting something up on the site that’s super official and legal.

    In the meantime, here goes:

    Sam, as an M.D., cannot offer specific recommendations for medical care or treatment to anyone posting a comment on the site. I hope everyone understands. Keep the comments coming. We love them!

  4. marciarossMarcia Ross June 18, 2013 at 9:08 am #

    Hi Sam,
    Don’t know if you’re familiar with David Sedaris’ writing? In case you’re not – he’s a brilliant, funny, astute, insightful essayist/story-teller. I went to see him speak a few weeks ago in Toronto, and bought his new book “Let’s Explore Diabetes with Owls.”

    The first story, “Dentists Without Borders” is the most dead-on indictment of American medical care that I’ve ever read. Barely reaching seven pages, 100% anecdotal, and taking place entirely in France, it nonetheless gets right to the heart of many of the issues. Do take a look, I guarantee enjoyment. Bizarre that the French would have have done such a good job on national health care, but there it is, they have, who knew. (You may not like the last story as much, about his colonoscopy, but it’s still a great read.)

    • Sam June 18, 2013 at 1:38 pm #

      Thank you. I will look them up.


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