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The Price is Right: Gynecology Clinic Costs


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teaching didactic lecture prepared by Dr. Shipla Iyer at Brigham & Women’s Hospital, Harvard Medical School

Published in: Health & Medicine
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The Price is Right: Gynecology Clinic Costs

  1. 1. The Price is Right! Shilpa Iyer, MD MPH 12/27/11 Gyn style
  2. 2. The Goals <ul><li>There is little research about resident/provider cost awareness </li></ul><ul><li>Some research looks at cost awareness w/ ordering and impact on ordering frequency </li></ul><ul><li>To create awareness of costs associated with decision making in common scenarios </li></ul><ul><li>To better understand the components of associated costs of routine care and the broader health care system </li></ul>
  3. 3. The Rules <ul><li>There will be 2 teams (each half of the room) </li></ul><ul><li>For each case presentation there will be pauses in the story when management action is taken </li></ul><ul><li>Teams will then work together to submit a price bid for the cost BWH charges for that action </li></ul><ul><li>The team that comes the closest to the actual price wins a point! </li></ul><ul><li>You cannot win if you overbid! </li></ul><ul><li>The team with the most points at the end of the game wins </li></ul>
  4. 5. National Health Expenditures per Capita, 1960-2009 Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http:// / (see Historical; NHE summary including share of GDP, CY 1960-2009; file
  5. 6. 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 ; 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:// . Data accessed on 01/06/11.
  6. 7. The Costs The Patient The Hospital Insurance companies
  7. 8. The Costs <ul><li>Costs in this game are the costs to BWH Hospital </li></ul><ul><li>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 </li></ul><ul><li>Costs were obtained from: </li></ul><ul><ul><li>BWH billing (Diana Perkins, Hematology Lab, Microbiology Lab, Pharmacy, OR Billing, Dr. Delli-Bovi) </li></ul></ul><ul><ul><li>Advice from Neel Shah </li></ul></ul>
  8. 9. Case 1: SD with menorrhagia <ul><li>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. </li></ul>
  9. 10. The case of SD Cont. <ul><li>OB/Gyn Hx: G3P2012 (SVDx2, TAB x1) </li></ul><ul><li>Regular menses, no STIs, no abnl Pap, 6 lifetime partners, not currently sexually active, no future fertility desired </li></ul><ul><li>PMedHx: htn controlled </li></ul><ul><li>PSurgHx: </li></ul><ul><li>Ovarian cystectomy 20yrs ago </li></ul><ul><li>2009 lap band </li></ul><ul><li>Left breast lumpectomy </li></ul><ul><li>Meds: MVI, Calcium </li></ul><ul><li>Allergies: NKDA </li></ul><ul><li>FamHx: no familial cancers </li></ul><ul><li>SocHx: Working, single, lives with 2 daughters </li></ul><ul><li>Denies tobacco/EtOH/illicits </li></ul>
  10. 11. The case of SD cont. <ul><li>PE: </li></ul><ul><li>VS:BP 118/80 Wt 198 lbs Ht 66.5 cm </li></ul><ul><li>gen: NAD </li></ul><ul><li>CV: RRR S1S2 </li></ul><ul><li>Lungs: CTAB no r/r/w </li></ul><ul><li>breast: symmetric, no abnormal masses palpated, no adnexal masses/LN palpated </li></ul><ul><li>abd: soft, NT, no rebound, no guarding </li></ul><ul><li>SSE: os visualized, no bleeding or discharge noted </li></ul><ul><li>BME: external genitalia wnl, no erythema, lesions, or atrophic changes in skin, mobile 9wk sized uterus, mid position, no adnexal masses or tenderness </li></ul>
  11. 12. SD Workup? <ul><li>CBC </li></ul><ul><li>TSH, free T4 </li></ul><ul><li>Pap smear </li></ul><ul><li>Endometrial Biopsy </li></ul><ul><li>Pelvic ultrasound </li></ul><ul><li>Office Hysteroscopy in BWH gyn clinic </li></ul>
  12. 13. New Gyn Patient Clinic Visit $317
  13. 14. CBC $85
  14. 15. TSH, +/- free T4 TSH: Free T4: $179 $95
  15. 16. Pap Smear $161
  16. 17. Endometrial Biopsy $566
  17. 18. Pelvic Ultrasound $ 700 In the ED: $1400
  18. 19. Office Hysteroscopy $3338
  19. 20. The case of SD: Results <ul><li>CBC: 4.93 > 12.5/ 35,5 < 247 </li></ul><ul><li>TSH: .921 </li></ul><ul><li>Pap smear: neg, consistent with atrophy </li></ul><ul><li>Endometrial Biopsy: inactive endometrium, fragements of stromal polyp </li></ul><ul><li>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 </li></ul><ul><li>Office hysteroscopy: no intracavitary lesions seen </li></ul>
  20. 21. 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
  21. 22. SD Cont. <ul><li>She returns 1 year later with contiued menorrhagia and severe dysmenorrhea </li></ul><ul><li>On repeat PUS, areas near her fundus appear consistent with adenomyosis. </li></ul><ul><li>On BME, her uterus is noted to be 16 wk size </li></ul><ul><li>After discussing her options, she opts for a hysterectomy as she does not want to deal with dysmenorrhea and menorrhagia anymore </li></ul>
  22. 23. TAH? $78,812
  23. 24. Summary of TAH Costs: Dr. Federschneider case from 10/11 <ul><li>Total hospital cost $78, 812 (no physician costs) </li></ul><ul><li>OR charge (15 min increments): $58,164 </li></ul><ul><li>Anesthesia: $6,402 </li></ul><ul><li>Recovery Room: $1,335 </li></ul><ul><li>Semi-private room for 3 days: $10,257 </li></ul><ul><li>Pharmacy: $295 </li></ul><ul><li>Surgical supplies: $675 </li></ul><ul><li>Laboratory: $921 </li></ul><ul><li>Extra chemistry: $90 </li></ul><ul><li>Extra hematology: $255 </li></ul><ul><li>Bacterial Microbiology: &87 </li></ul>
  24. 25. TLH? $26,403
  25. 26. Summary of TLH with Dr. Einarsson 11/11 <ul><li>Total hospital cost: $26, 403 (50 min OR time) </li></ul><ul><li>OR charge: $15,553 </li></ul><ul><li>Surgical supplies: $3,154 </li></ul><ul><li>Anesthesia: $1,455 </li></ul><ul><li>Recovery Room: $1580 </li></ul><ul><li>Semi-private room for 1 night: $3,419 </li></ul><ul><li>Pharmacy: $1,042 </li></ul>
  26. 27. Case #2: NK with Vaginal Discharge <ul><li>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. </li></ul><ul><li>Otherwise negative review of symptoms, but she’s unsure if she has dysuria </li></ul>
  27. 28. NK Cont. <ul><li>POBHx: G0 </li></ul><ul><li>PGynHx: menarche @ 13yo, regular menses </li></ul><ul><li>No past STIs, 5 lifetime sexual partners, 1 current partner for the past 5 months, uses the Nuvaring for BC </li></ul><ul><li>PMedHx: none </li></ul><ul><li>PSurgHx: tonsillectomy at 6 yo, uncomplicated </li></ul><ul><li>No current medications </li></ul><ul><li>NKDA </li></ul>
  28. 29. NK Cont. <ul><li>PE: VS: BP 110/70 Wt 135 lbs </li></ul><ul><li>Gen: NAD </li></ul><ul><li>CV: RRR, Lungs: CTAB </li></ul><ul><li>Abd: soft, NT, no rebound, no guarding </li></ul><ul><li>BME: uncomfortable, but no CMT or adnexal tenderness </li></ul><ul><li>SSE: normal genitalia w/o erythema, some thin white discharge, no strawberry cervix </li></ul>
  29. 30. Wet Prep $46
  30. 31. Urine dip in the office $27
  31. 32. UA $23
  32. 33. Urine Culture $87 w/ Susceptibilities: $73 per isolate
  33. 34. Cervical probe for gonorrhea and Chlamydia $277 each! billed separately
  34. 35. Vaginal culture $91 for aerobic bacterial + $73 for each susceptibility Or $91 for gram negatives because of different MIC cards used
  35. 36. Vaginal fungal culture $89
  36. 37. Urine Hcg in the office $67 (test & MA time) Serum Hcg... for all of the Ectopic List players... $160
  37. 38. NK Results <ul><li>Wet prep: no Clue cells, Trich, only 1-2 hyphae, no leukocytosis </li></ul><ul><li>Urine Hcg neg </li></ul><ul><li>Urine dip wnl </li></ul><ul><li>UA wnl </li></ul><ul><li>UCx 5,000 mixed flora </li></ul><ul><li>Cervical probe for Gonorrhea/Chylamidia: positive for Gonorrhea, neg for Chylamidia </li></ul>
  38. 39. Office IM ceftriaxone RN IM Injection Drug cost: $212 $1 + 4x hospital markup
  39. 40. Case #3: SD in need of TAB and birth control <ul><li>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 </li></ul><ul><li>SVD x1 uncomplicated, TAB at 8wga 2009 uncomplicated, SAB ~6 wga at home </li></ul><ul><li>No PMedHx, PSurgHx, Meds, or Allergies </li></ul>
  40. 41. SD cont. <ul><li>She has been with the same partner for 10 years, the father of her daughter. </li></ul><ul><li>She smokes ½ pack of cigarettes/day, denies EtOH or illicits </li></ul><ul><li>Has never had an STD, and was tested 4 months ago at her annual exam </li></ul><ul><li>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 </li></ul>
  41. 42. Early 1 st trimester D&C at FPC $3,022 (for 8-12 wga) Includes: hospital charge & $141 US fee
  42. 43. The FPC Actual Breakdown for 2 cases: 17-23 wga <ul><li>Total actual costs: $5,470 (global ? $7,855) </li></ul><ul><li>Laminaria placement + visit: $1,724 </li></ul><ul><li>Procedure: $2,520 </li></ul><ul><li>Pathology: $667 </li></ul><ul><li>Pharmacy: $559 </li></ul>
  43. 44. & For the pathology? $120 from Pathology Associates If the fetus has any abnormalities, the fee may be as high as $370
  44. 45. How about 1 st trimester D&E at Lolly’s?? $600 Self Pay
  45. 46. What if she were 18 wga and needed laminaria at FPC? $3490
  46. 47. 18 wga with laminaria at Lolli’s? $1450 Between 14-through 16 weeks it's $950 and through 17 weeks it's $1065
  47. 48. Birth Control options counseling… <ul><li>Mirena IUD </li></ul><ul><li>Paraguard IUD </li></ul><ul><li>Implanon </li></ul><ul><li>Depo Provera </li></ul><ul><li>Or if she was older and interested in permanent sterilization…. Essure </li></ul>
  48. 49. Mirena Paraguard IUDs IUD: $700 ($2800) Insertion: $1038 IUD: $568 ($2400) Insertion: $1038
  49. 50. Depo Provera RN IM Injection in clinic: $212 Medication Cost: $21 (x4 = $84)
  50. 51. Implanon: Device only... $660 (x4 = $2640)
  51. 52. Essure in gyn clinic: Device: $4,820 Procedure: $4,071 $8,891
  52. 53. The Tally!
  53. 54. Thank You! <ul><li>All FPC staff </li></ul><ul><li>My fellow residents </li></ul><ul><li>Lab Control, Microbiology lab, Pharmacy, OR billing, Nancy Falconer, Lolly, Neel Shah, Diana Perkins for their help in obtaining costs! </li></ul>