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!