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“A billion here, a billion there …”

“… and pretty soon you’re talking real money.” The late Senator Everett Dirksen (R-IL), a politician who often spoke passionately about the debt ceiling, federal spending and the growth of government, is rumored to have made this statement to reporters about the way Congress thinks about the federal budget.  Well, the Rand Corporation may have found a billion dollars that can be taken off our nation’s yearly health care tab.

In a study published by the Journal of the American Medical Association a year ago, researchers at Rand concluded that $1.1 billion in savings per year could be generated by eliminating the discretionary use of anesthesia providers during gastroenterology procedures.  The key findings of their study included the following:

  • The use of anesthesia providers to deliver sedation during routine gastroenterology (GI) procedures is seen as medically justifiable only for high-risk patients who require intensive monitoring.
  • But between 2003 and 2009, the proportion of GI procedures involving anesthesia providers doubled, and overall payments for GI anesthesia tripled.
  • The use of anesthesia providers varied by almost a factor of four across U.S. regions.
  • The majority of patients who received sedation from an anesthesia provider rather than the endoscopy team were not high-risk patients.
  • Eliminating potentially discretionary use of anesthesia providers for low-risk patients could generate $1.1 billion in savings per year.

Hardly seems worth talking about, given the reality that we will spend more than $2.4 trillion dollars on health care in the U.S. this year, right?  Nay, I think it should be talked about because this practice speaks to a kind of wasteful thinking in the delivery of medical care that needs to change, and because I also agree with Benjamin Franklin, who said, “Watch the pennies and the dollars will take care of themselves.” 

More importantly, this study serves as an example of the comparative effectiveness goals embodied in health care reform that I wrote about in a previous blog.  This federal cost-cutting initiative calls for the government to study hard data associated with health care delivery to determine where the greatest savings can be made that will improve overall quality and outcomes.  In that regard, I hope the Patient Centered Outcomes Research Institute set up to oversee this initiative will not shelve the benefits to be derived from research like the Rand study on routine GI procedures in its quest to save big bucks.

Your thoughts?

Comments

response to "A billion here, a billion there"

Submitted by Visitor (not verified) on February 28, 2013 - 9:14am.
First let me say, Jim I love your blog and read each one, frequently tempted to chime in but generally i totally support your angle. This time i'm going to provide a different perspective. Use of anesthestics during routine outpatient GI procedures has substantially enhanced the patient experience and reduced the length of stay for the procedure. Before fairly routine use of short-activing anesthetic agents a GI procedure with the usual procedural sedation caused patients to have a prolonged post-procedural stay due to nausea and more lengthy recovery of full mental clarity. In addition, although I certainly can't prove it, the more pateint friendly experience may well increase screening colonscopies and catch more disease earlier which clearly has both a cost and an outcome benefit. Again, i can't prove it. However, I can give just one woman's perspective: I personally am far more likely to volunteer for this procedure knowing I will be fully knocked out, awake with clarity and speed and no nausea. Procedural sedation has always been a bit of a hit or miss procedure as balancing the right amount of sedation versus too much can and definately has resulted in many unpleasant patient experiences. One other perspective on this: As anesthesiologists find their incomes declining having one more revenue stream stripped from them will eventually create other issues related to adequate anesthesiologists of quality and coverage for emergencies 24/7. If the revenue stream provides a meaningful improved patient experience, outcomes and possibly reduces cost through early diagnosis and quicker recovery I would hope we go somewhere else for the $1B. Just my thoughts. Thanks for the opportunity and keep writing these thoughtful blogs. Nancy Carlson Chief Exeuctive Providence Little Company of Mary Medical Center San Pedro

billion here and there

Submitted by Michael Hunn (not verified) on February 28, 2013 - 11:46am.
Thanks Jim.

GI and anesthesia

Submitted by Jim (not verified) on March 1, 2013 - 9:43am.
I completely agree with Nancy. I too like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

GI and anesthesia

Submitted by Jim (not verified) on March 1, 2013 - 9:48am.
I completely agree with Nancy. I too, like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

I completely agree with

Submitted by Jim (not verified) on March 1, 2013 - 9:51am.
I completely agree with Nancy. I too like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

I completely agree with

Submitted by Jim (not verified) on March 1, 2013 - 10:26am.
I completely agree with Nancy. I too like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

I completely agree with

Submitted by Jim (not verified) on March 1, 2013 - 3:28pm.
I completely agree with Nancy. I too like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. What's happened to patient choice? How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

Comments

response to "A billion here, a billion there"

Submitted by Visitor (not verified) on February 28, 2013 - 9:14am.
First let me say, Jim I love your blog and read each one, frequently tempted to chime in but generally i totally support your angle. This time i'm going to provide a different perspective. Use of anesthestics during routine outpatient GI procedures has substantially enhanced the patient experience and reduced the length of stay for the procedure. Before fairly routine use of short-activing anesthetic agents a GI procedure with the usual procedural sedation caused patients to have a prolonged post-procedural stay due to nausea and more lengthy recovery of full mental clarity. In addition, although I certainly can't prove it, the more pateint friendly experience may well increase screening colonscopies and catch more disease earlier which clearly has both a cost and an outcome benefit. Again, i can't prove it. However, I can give just one woman's perspective: I personally am far more likely to volunteer for this procedure knowing I will be fully knocked out, awake with clarity and speed and no nausea. Procedural sedation has always been a bit of a hit or miss procedure as balancing the right amount of sedation versus too much can and definately has resulted in many unpleasant patient experiences. One other perspective on this: As anesthesiologists find their incomes declining having one more revenue stream stripped from them will eventually create other issues related to adequate anesthesiologists of quality and coverage for emergencies 24/7. If the revenue stream provides a meaningful improved patient experience, outcomes and possibly reduces cost through early diagnosis and quicker recovery I would hope we go somewhere else for the $1B. Just my thoughts. Thanks for the opportunity and keep writing these thoughtful blogs. Nancy Carlson Chief Exeuctive Providence Little Company of Mary Medical Center San Pedro

billion here and there

Submitted by Michael Hunn (not verified) on February 28, 2013 - 11:46am.
Thanks Jim.

GI and anesthesia

Submitted by Jim (not verified) on March 1, 2013 - 9:43am.
I completely agree with Nancy. I too like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

GI and anesthesia

Submitted by Jim (not verified) on March 1, 2013 - 9:48am.
I completely agree with Nancy. I too, like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

I completely agree with

Submitted by Jim (not verified) on March 1, 2013 - 9:51am.
I completely agree with Nancy. I too like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

I completely agree with

Submitted by Jim (not verified) on March 1, 2013 - 10:26am.
I completely agree with Nancy. I too like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.

I completely agree with

Submitted by Jim (not verified) on March 1, 2013 - 3:28pm.
I completely agree with Nancy. I too like most of your columns, Jim, but you are too much in lock step with bean counters and bureaucrats on this one. Nancy is correct- we should look elsewhere for the $1B in savings. The argument that it is 'wasted' on anesthesia services for these procedures is superficial, and there are indeed several advantages as nicely narrated above. Faster turnover and shorter procedure times due to shorter acting anesthetics (allowing for more procedures), avoiding side effects of 'traditional' sedatives and narcotics, improved patient experiences (this has been documented), and possibly other improved outcomes far, far outweigh the costs. What's happened to patient choice? How about the bureaucrats looking to eliminate the waste and fraud so rampant in the system: too many bureaucrats, especially at the government level, too many middlemen siphoning money from the actual providers of medical care like physicians and hospitals? Rand, in my opinion, has a very government oriented outlook and bias. And to me, this type of 'conclusion' is exactly what is wrong with 'comparative effectiveness' studies: just like statistics, the 'hard facts' can be used to support almost any point of view. There is an inherent conflict of interest in the government sponsoring this supposed Patient Centered Outcomes Research Institute. It will ultimately feed their 'conclusions' into the Independent Payment Advisory Board, and voila, payments will be controlled or eliminated for procedures and treatments they deem 'less valuable' despite patient experiences or preferences, as with the GI procedures.