The Price is Right: Gynecology Clinic Costs

The Price is Right! Shilpa Iyer, MD MPH 12/27/11 Gyn style

The Goals
There is little research about resident/provider cost awareness
Some research looks at cost awareness w/ ordering and impact on ordering frequency
To create awareness of costs associated with decision making in common scenarios
To better understand the components of associated costs of routine care and the broader health care system

The Rules
There will be 2 teams (each half of the room)
For each case presentation there will be pauses in the story when management action is taken
Teams will then work together to submit a price bid for the cost BWH charges for that action
The team that comes the closest to the actual price wins a point!
You cannot win if you overbid!
The team with the most points at the end of the game wins

National Health Expenditures per Capita, 1960-2009 Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http:// www.cms.hhs.gov/NationalHealthExpendData / (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).

Per Capita Total Current Health Care Expenditures, U.S. and Selected Countries, 2008 ^OECD estimate. *Differences in methodology. **Based on 2007 data. Notes: Amounts in U.S.$ Purchasing Power Parity, see www.oecd.org/std/ppp ; includes only countries over $2,500. OECD defines Total Current Expenditures on Health as the sum of expenditures on personal health care, preventive and public health services, and health administration and health insurance; it excludes investment. Source: Organisation for Economic Co-operation and Development. OECD Health Data 2010, from the SourceOECD Internet subscription database updated October 2010. Copyright OECD 2010, http:// www.oecd.org/health/healthdata . Data accessed on 01/06/11.

The Costs The Patient The Hospital Insurance companies

The Costs
Costs in this game are the costs to BWH Hospital
This is because costs to patients vary by insurance status and depend on individual plans as well as negotiated rates between BWH and insurance companies
Costs were obtained from:
BWH billing (Diana Perkins, Hematology Lab, Microbiology Lab, Pharmacy, OR Billing, Dr. Delli-Bovi)
Advice from Neel Shah

Case 1: SD with menorrhagia
HPI: 47yo G3P2012 w/ h/o fibroids presents with menorrhagia and dysmenorrhea x 8 months. She has regular menses that has increased in frequency from 1 x/mos to 2 x/mos, lasting 8 days, & changing her pad every hour most days. She has passed large clots, is fatigued, and has had a few accidents bleeding through her clothes. No interval bleeding.

The case of SD Cont.
OB/Gyn Hx: G3P2012 (SVDx2, TAB x1)
Regular menses, no STIs, no abnl Pap, 6 lifetime partners, not currently sexually active, no future fertility desired
PMedHx: htn controlled
PSurgHx:
Ovarian cystectomy 20yrs ago
2009 lap band
Left breast lumpectomy
Meds: MVI, Calcium
Allergies: NKDA
FamHx: no familial cancers
SocHx: Working, single, lives with 2 daughters
Denies tobacco/EtOH/illicits

The case of SD cont.
PE:
VS:BP 118/80 Wt 198 lbs Ht 66.5 cm
gen: NAD
CV: RRR S1S2
Lungs: CTAB no r/r/w
breast: symmetric, no abnormal masses palpated, no adnexal masses/LN palpated
abd: soft, NT, no rebound, no guarding
SSE: os visualized, no bleeding or discharge noted
BME: external genitalia wnl, no erythema, lesions, or atrophic changes in skin, mobile 9wk sized uterus, mid position, no adnexal masses or tenderness

SD Workup?
CBC
TSH, free T4
Pap smear
Endometrial Biopsy
Pelvic ultrasound
Office Hysteroscopy in BWH gyn clinic

New Gyn Patient Clinic Visit $317

CBC $85

TSH, +/- free T4 TSH: Free T4: $179 $95

Pap Smear $161

Endometrial Biopsy $566

Pelvic Ultrasound $ 700 In the ED: $1400

Office Hysteroscopy $3338

The case of SD: Results
CBC: 4.93 > 12.5/ 35,5 < 247
TSH: .921
Pap smear: neg, consistent with atrophy
Endometrial Biopsy: inactive endometrium, fragements of stromal polyp
PUS: uterus 12.5 x 9.1 x 6.7 cm, 14mm stripe, 4.6cm subserosal fibroid, 5 intramural fibroids: 2, 4.8, 2.1, 2.3, and 5 cm, ovaries not seen
Office hysteroscopy: no intracavitary lesions seen

If we couldn’t do an office hysteroscopy or saw something… To the OR! Diagnostic hysteroscopy/D&C: Hysteroscopy w/ polypectomy $13,621 *Dr. Federschneider $12,466 *Dr. Federschenider

SD Cont.
She returns 1 year later with contiued menorrhagia and severe dysmenorrhea
On repeat PUS, areas near her fundus appear consistent with adenomyosis.
On BME, her uterus is noted to be 16 wk size
After discussing her options, she opts for a hysterectomy as she does not want to deal with dysmenorrhea and menorrhagia anymore

TAH? $78,812

Summary of TAH Costs: Dr. Federschneider case from 10/11
Total hospital cost $78, 812 (no physician costs)
OR charge (15 min increments): $58,164
Anesthesia: $6,402
Recovery Room: $1,335
Semi-private room for 3 days: $10,257
Pharmacy: $295
Surgical supplies: $675
Laboratory: $921
Extra chemistry: $90
Extra hematology: $255
Bacterial Microbiology: &87

TLH? $26,403

Summary of TLH with Dr. Einarsson 11/11
Total hospital cost: $26, 403 (50 min OR time)
OR charge: $15,553
Surgical supplies: $3,154
Anesthesia: $1,455
Recovery Room: $1580
Semi-private room for 1 night: $3,419
Pharmacy: $1,042

Case #2: NK with Vaginal Discharge
31yo G0 followed in gyn clinic for contraception presents for a problem visit with vaginal discharge x3-4 days, thin- thick in consistency, white-yellow in color, itching at times. It’s very bothersome and non responsive to Monistat. She’s never had this before. She was also late to put in her Nuvaring by 1 week and is concerned about being pregnant.
Otherwise negative review of symptoms, but she’s unsure if she has dysuria

NK Cont.
POBHx: G0
PGynHx: menarche @ 13yo, regular menses
No past STIs, 5 lifetime sexual partners, 1 current partner for the past 5 months, uses the Nuvaring for BC
PMedHx: none
PSurgHx: tonsillectomy at 6 yo, uncomplicated
No current medications
NKDA

NK Cont.
PE: VS: BP 110/70 Wt 135 lbs
Gen: NAD
CV: RRR, Lungs: CTAB
Abd: soft, NT, no rebound, no guarding
BME: uncomfortable, but no CMT or adnexal tenderness
SSE: normal genitalia w/o erythema, some thin white discharge, no strawberry cervix

Wet Prep $46

Urine dip in the office $27

UA $23

Urine Culture $87 w/ Susceptibilities: $73 per isolate

Cervical probe for gonorrhea and Chlamydia $277 each! billed separately

Vaginal culture $91 for aerobic bacterial + $73 for each susceptibility Or $91 for gram negatives because of different MIC cards used

Vaginal fungal culture $89

Urine Hcg in the office $67 (test & MA time) Serum Hcg... for all of the Ectopic List players... $160

NK Results
Wet prep: no Clue cells, Trich, only 1-2 hyphae, no leukocytosis
Urine Hcg neg
Urine dip wnl
UA wnl
UCx 5,000 mixed flora
Cervical probe for Gonorrhea/Chylamidia: positive for Gonorrhea, neg for Chylamidia

Office IM ceftriaxone RN IM Injection Drug cost: $212 $1 + 4x hospital markup

Case #3: SD in need of TAB and birth control
27yo G4P1021 (SVD x1, TAB x1, SAB x1) presents to FPC with 11+4 wga undesired pregnancy. She was using OCPs inconsistantly and cannot take care of another child
SVD x1 uncomplicated, TAB at 8wga 2009 uncomplicated, SAB ~6 wga at home
No PMedHx, PSurgHx, Meds, or Allergies

SD cont.
She has been with the same partner for 10 years, the father of her daughter.
She smokes ½ pack of cigarettes/day, denies EtOH or illicits
Has never had an STD, and was tested 4 months ago at her annual exam
She is not good at remembering to take pills every day, has heard about weight gain with Depo provera from a friend, but is curious about the IUD

Early 1 st trimester D&C at FPC $3,022 (for 8-12 wga) Includes: hospital charge & $141 US fee

The FPC Actual Breakdown for 2 cases: 17-23 wga
Total actual costs: $5,470 (global ? $7,855)
Laminaria placement + visit: $1,724
Procedure: $2,520
Pathology: $667
Pharmacy: $559

& For the pathology? $120 from Pathology Associates If the fetus has any abnormalities, the fee may be as high as $370

How about 1 st trimester D&E at Lolly’s?? $600 Self Pay

What if she were 18 wga and needed laminaria at FPC? $3490

18 wga with laminaria at Lolli’s? $1450 Between 14-through 16 weeks it's $950 and through 17 weeks it's $1065

Birth Control options counseling…
Mirena IUD
Paraguard IUD
Implanon
Depo Provera
Or if she was older and interested in permanent sterilization…. Essure

Mirena Paraguard IUDs IUD: $700 ($2800) Insertion: $1038 IUD: $568 ($2400) Insertion: $1038

Depo Provera RN IM Injection in clinic: $212 Medication Cost: $21 (x4 = $84)

Implanon: Device only... $660 (x4 = $2640)

Essure in gyn clinic: Device: $4,820 Procedure: $4,071 $8,891

The Tally!

Thank You!
All FPC staff
My fellow residents
Lab Control, Microbiology lab, Pharmacy, OR billing, Nancy Falconer, Lolly, Neel Shah, Diana Perkins for their help in obtaining costs!

The Price is Right: Gynecology Clinic Costs

by Neel Shah on Dec 30, 2011

Accessibility

Categories

Tags

Upload Details

Usage Rights

Statistics

The Price is Right: Gynecology Clinic Costs — Presentation Transcript