Colonoscopies: Raping the System?

This post may well be mis titled. 

The designation of "rape" incorporates an unwillingness on the part of someone. Any interaction which involves a willing buyer and a willing seller should not be designated a rape. But, in the case of medical services, there is this peculiar situation where the person most at stake is thrown out of the loop of negotiation. The service seller, the doctor, his facility and his business negotiates with an insurer for a service consumed by the patient, who is not consulted about the cost and payment.

In today's New York Times, front page, above the fold, is an important story about the factors which drive up American medical costs to astronomical levels seen nowhere else in the world. The example examined most closely is that of colonoscopy, but other examples are cited, including MRI exams, angiograms and hip replacements.

The Phantom has wondered for years when someone would blow the whistle on colonoscopies. This is a procedure which can be learned in a few months and mastered a year or two, which requires no special knowledge of anatomy or physiology beyond what could be taught over a short course to people with high school level educations. It's cost in most Western nations with national health systems or even with private systems falls somewhere between $450 and $750.  Across the United States the cost varies ranging from $665 in Utah to $8,577 in New York. 

The procedure, used to screen healthy people for colon cancer, has been around since the early 1970's and has provided a cash cow for gastroenterologists ever since.  These doctors, trained to diagnose and treat diseases of the intestines, stomach, gall bladder, liver and esophagus have given up the practice of medicine to focus on what returns the most dollars, namely a day filled with colonoscopies. 

The incentive factor was most famously illustrated by the NPR piece on a medical student who was at the top of his class at Mt. Sinai Medical School in New York City, who was called into the Dean's office because he had chosen to do his residency training at a community hospital in Florida rather than at a Harvard university hospital , where his grades and test scores would have assured him a place. 

"Look," the medical student said. "If I got to Harvard, I'll have to publish and I'll have to work on papers for the professors and it will be long hours and plenty of sweat. All I want to do is colonoscopies from 9 AM to 3 PM and be on my boat with my wife and kids by 4 PM. That I can learn to do in Florida."

So much for medicine as a calling. 

The procedure which would place this medical student on Easy Street has done the same for thousands of gastroenterologists before him over the decades. And, as the Phantom noted, it is remarkably simple to learn, and safe and easy to do.

The Phantom had a friend from internship who learned the procedure in a few months, got out into practice as quickly as he could, and borrowed money to buy his own office and his own colonoscope ($3600) and he did colonoscopies in his office and bought a beautiful Manhattan Coop within two years, and a home in the Hamptons, all based on this one procedure.

And he was a bargain, by today's standards, because he did the procedure in his office, and still does. As a result, his patients do no have to pay for an anesthesiologist, or a "facility fee" the way they would have to if he did not own his own instrument but instead did the colonoscopy at a "facility," either one owned by his practice or by a hospital.  Over time, everyone figured out how to get into the act:  the facility people got their cut; the anesthesiologist got his cut. And prices just kept climbing.

Of course, at any time, the insurance companies could have put an end to this legal exploitation by simply saying, "No."  Medicare eventually reduced the payment to $140, about what it is worth. But most colonoscopies are not done on Medicare patients.

Originally, the GI docs argued colonoscopy required 4 years of medical school, a year of internship, three years of GI fellowship, and they argued the procedure required high skill to avoid colonic perforation, and it required a doctor to administer intravenous "conscious sedation," usually Versed, so they somehow convinced insurance companies to fork over more for this procedure than Medicare was paying cardiac surgeons for doing coronary bypass procedures, where one mis-thrown suture literally would cost a patient his life.

Heaven only knows why the insurance companies were so pliable. Maybe they feared losing customers over this.

MRI's are another profit center. In Europe, patients have an MRI exam of a knee for $70; in the USA that exam runs $2500.  In Europe, the doctors who own the MRI machine, if doctors own the machine at all, will have to pay that machine off over 4-5 years. In the USA a $3 million machine runs 24 hours, 7 days a week, except for servicing and is paid off with 1,200 MRI studies, in about 12 months. 

Billing for medical services has become so Byzantine in these United States, there is little hope of unraveling this Gordian knot, to mix a metaphor. The only real way is to cut through it with a sharp sword, a la Alexander.  That sword would be a single payer, Medicare for All, as far as The Phantom can imagine.

Everything else, including Obamacare, where the insurance companies still do what they do, is just nibbling around the edges and doomed to fail.