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
1960 1970 1980 1990 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
National Health Expenditures per Capita, 1960-2009
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
Per Capita Total Current Health Care Expenditures, U.S. and Selected Countries, 2008
^OECD estimate.
*Differences in methodology.
**Based on 2007 data.
Notes: Amounts in U.S.$ 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 ago2009 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 susceptibilityOr $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 1st 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 AssociatesIf the fetus has any abnormalities, the fee may be as high as $370
How about 1st 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!