Hospital-Based Practice Versus Physician Private Practice

The other day, an astute patient of mine asked what the difference is between a physician who works for a hospital (hospital-based practice) versus a physician run private practice.

After all, a patient still sees a physician in either case…

Is there an actual difference from a patient’s perspective???

Assuming all things equal whereby a private practice physician and a hospital-based physician are equally competent and the supporting staff for each are both equally good (such assumptions are debatable in some circles, but will be ignored here), it all comes down to money.

When a patient sees a private practice physician, the fee schedule only incorporates payments to the physician.

When a patient sees a hospital-based physician, the fee schedule not only incorporates physician payments, but also additional payments to the hospital.

Now, the patient doesn’t pay what insurance covers in either scenario, but typically there is a copay or coinsurance payment that the patient is responsible for that typically is 20% of the total charges.

Here’s an example using the Medicare fee schedule from 2002. I elected to provide “old” 2002 data as this information can be found easily and corroborated, but rest assured, the numbers are starkly different and perhaps more lopsided today. Medicare was selected as it is the bar to which all other insurance plans are typically based on.

In a physician run private practice, the only charges that are incurred is from the “Physician Fee Schedule”. In a hospital-based practice, a patient incurs not only the physician fee schedule, but also additional charges based on the “Outpatient Prospective Payment System”.

As you can see, the physician fees are slightly higher in the private practice setting compared to hospital-based practice… BUT, given the additional hospital charges involved with a hospital-based practice, the patient ends up being charged more per service for a simple clinic visit ($16.48) than if they had been seen in the private practice office ($10.06).

The cost differential for the patient is far worse with any procedures ($62.62 versus $342.47).

For the same exact procedure or service, a patient automatically ends up paying more to be seen in a hospital-based practice.

This payment system is the same whether you go to a tertiary care teaching hospital like Massachusetts General Hospital or a tiny 98-bed community hospital.

As an aside… for any physicians employed by a hospital, it behooves you to consider this differential payment in terms of how a hospital determines your salary and productivity. Do they consider ONLY the physician fee schedule or do they also take into account the outpatient prospective payment system?

I should also mention that for 2012, Congress is considering abolishing the outpatient prospective payment system for clinic visits only. Click here for more info.

Source:
Elimination of Differential in Medicare Payment for Clinic E&M Services Furnished in Hospital-Based Outpatient Departments Proposed. Martinedale 12/10/11

Medicare rules for hospital-based clinics. American College of Surgeons. Vol 87, No 4

Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System. Congressional Research Service. 8/6/2010

New Video on “Where” Snoring Comes From and Treatment

Our office has produced a new video describing “where” snoring comes from determined by a simple procedure known as sedated or sleep endoscopy.

At its most basic definition, snoring is noise produced from a vibrating mucosal surface in the upper airway.

Though snoring can be defined simply, the tough question is WHERE are these vibrating mucosal surfaces? Because unless one can define WHERE the snoring is coming from, successful treatment can’t be pursued definitively.

An office exam performed while a patient is awake is suboptimal as the patient is awake… and not snoring. As such, it is an educated guess where the snoring problem is stemming from.

To this end, there are three main levels where snoring can be produced and the best way to localize a snore is to perform the exam while the patient is asleep (induced by anesthesia) and snoring!

1) Nose
2) Mouth
3) Throat
4) All of the above

Watch the video to see how each of these areas can contribute to a person’s snore as well as treatment options.

Why Does the Nose Whistle in Some People?

Though most people like the professional nose whistler shown here require an instrument to enable the nose to whistle, in others it occurs naturally due to unique anatomic features within the nose.

Why might someone’s nose whistle?

Septal Perforation

The most common reason it may occur constantly is due to a hole in the septum (septal perforation). The septum is a wall that divides the right nasal cavity from the left side. Normally, it should be straight and without any openings.

However, when a hole is present in the septum and it is in just the right size and place, whenever air is breathed in and out the nose, it will whistle. In this situation, the hole is the “window” of the whistle and the nose itself is the mouthpiece.

Correction of this problem is by either closing the hole (septal button or surgery) or making it bigger such that the aerodynamics eliminate the conditions conducive to nasal whistling. As an FYI, surgical correction of a septal perforation is quite difficult.

Septal Deviation and Some Nasal Congestion

The other situation when the nose may whistle, but only intermittently, is when there is a deviated septum. In this scenario, the septum rather than being straight, it is slightly crooked to one side making one side more narrow than the other.

Add some slight swelling of the nasal lining such that the opening of the nose is restricted to just right size and shape, and it may whistle.

This type of nasal whistling is akin to grass whistling (blowing between two thumbs holding a blade of grass).

Thankfully, the nasal conditions that lead to nasal whistling is quite rare and requires the perfect storm of just the right amount of septal deviation with just the right amount of nasal congestion.

As such, correction of this problem is fairly easy as one needs to change either the congestion causing the nasal lining to swell with a nasal spray or anti-histamine OR fix the deviated septum. If the inferior turbinates are enlarged, they can be reduced in size as well.

Of course, one can take this unusual condition and make it a positive feature worthy of a concert hall… WITHOUT the assistance of any instrument!

New Webpage on Vocal Cord Cysts and Vocal Cord Polyps

We have uploaded a new webpage describing what vocal cord cysts and vocal cord polyps are as well as how they are treated.

Vocal cord cysts are masses below the vocal cord lining whereas vocal cord polyps are masses involving the vocal cord lining.

Read more here!

New Webpage on Vocal Cord Nodules

Our office has created a new webpage on the evaluation and management of vocal cord nodules.

Vocal cord nodules also known as Singer’s nodules is a common cause of a painless raspy voice that mainly affects individuals who use their voice a lot. Such individuals include teachers, singers, cheerleaders, and people who simply just love to talk a lot.

Read more about this condition here and how to treat it!

Of note, the cartoon is by Dave Walker at We Blog Cartoons.

The Four Types of Patients Seen in a Surgeon’s Clinic

Over the years, I have found that patients can be loosely grouped into 4 different types. Nothing particularly wrong with any type, but it does help me to approach patients appropriately if I can get a sense of what type they are.

The four types are:

Type A:  If a surgery can “fix” or “cure” me such that I won’t have to take medications every day of my life, than let’s do it.

Type B: I will never consider surgery unless it is a life-threatening situation. If a medicine can help, why do it???

Type C: I will consider surgery only as a last resort when all else fails.

Type D: They thought they were Type B or C, but over time, they realize they are Type A.

Why is this important?

Because if a patient is Type B and surgery is recommended, the patient often develops an automatic distrust of the surgeon. The patient may see the surgeon as a “gun-slinger” who likes to cut people.

If a patient is Type A and the surgeon approaches them like Type B or C, such patients may come out of a visit quite disappointed and at worst, upset that the surgeon will not do what they want.

Ultimately, for a happy clinic encounter, a mutual understanding needs to quickly happen otherwise a mutual discord may snowball ultimately leading to a second opinion with another surgeon.

Of course, there is a more complex dynamic going on, but it’s a good over-simplification.

New Webpage on Vocal Cord Granuloma

Given the sudden interest patients have expressed in vocal cord granulomas ever since singer John Mayer announced a hiatus in concerts due to his voicebox granuloma, a new webpage has been developed to describe this unusual mass as well as treatment options.

Read all about it here!

Best Ballpoint Pen for Emergency Cricothyroidotomy?

I recently blogged about a man who choked to death on an airplane and the impossibility of saving this man’s life with a surgical airway like a cricothyroidotomy without a sharp object around inside the plane (ie, knife or scalpel).

 

I also stated that “Some surgeons would argue a strong, stiff ball-point pen could have been used to perform the cricothyroidotomy, but as someone who has performed a dozen emergency cricothyroidotomies and tracheotomies in the past, even under the best of circumstances with a knife and being on a hospital floor with help around, it is hard. Furthermore, skin and the windpipe is made of tough ‘fabric’ and trying to punch a ball-point pen through is laughable. Try doing it yourself on a chicken with the skin on.”

 

Well… it got me thinking… Let’s assume for argument’s sake that it IS possible to perform a cricothyroidotomy by literally punching through with a stiff ball-point pen into the airway. Would it actually work???

 

Believe it or not, there are two studies (listed below) I was able to find that tried to answer that very question. Contrary to popular belief… even IF a ball-point pen is able to secure an airway, the majority were found to be unsuitable due to inadequate internal diameter with too high an airway resistance for breathing.

 

In fact, the only TWO pens that might work (from a breathing standpoint) are the:

 

Baron retractable ballpoint

BIC soft feel Jumbo

 

I can’t even find these items on Amazon.com.

A sports bottle straw apparently works better than a pen.

 

Reference:

Bystander cricothyroidotomy performed with an improvised airway. Mil Med. 2002 Jan;167(1):76-8.Airflow efficacy of ballpoint pen tubes: a consideration for use in bystander cricothyrotomy. Emerg Med J. 2010 Apr;27(4):317-20.

At Home Laser Hair Removal That Works

Without going into TOO much detail of how I know this… I have personally observed that the TRIA Laser Home Removal System does work after observing its use and its effects over a 6 month period of time.

And before anybody asks… no… I was not paid to write this nor did I get a free one to try. Rather, someone I am close to bought it off Amazon.com and I was a skeptic on-looker.

In any case, the caveat being that I know it works  (admittedly anecdotal) as long as the hair is dark (ideally black or brown) on very light colored skin (ideally white).

The way laser hair removal works is that the laser beam is selectively absorbed by the hair follicle causing its death and destruction while preserving other skin structures. As such, the hair follicle needs to be as “different” a color to the skin around it in order for the laser to work. Otherwise, you end up burning the skin as well as the follicle. Depending on the laser used, different colored hair can be targeted on different colored skin. Because of this, the same laser can NOT be used for everybody.

In any case… back to the TRIA. This laser system ideally works best on dark colored hair on light colored skin. The greater the difference, the better it works; the best being black hair on white skin. In fact, the TRIA can’t be used at all if you don’t have the right hair/skin color combination (TRIA requires a skin check every time before use… unless you “pass,” the device will not work).

There are only a few real differences between this laser system and that used in medical offices.

The TRIA’s head is about 1/4 inch in size. The medical-grade laser head can be one inch or larger in size. What that means practically is that if you are using the TRIA for your leg, it’ll take a long time and a lot of zaps due to the large surface area.

Also, the TRIA can only be used for about 15 minutes on the highest power before it shuts off for 2 reasons: It “overheats” and needs to cool down or runs out of battery and needs to be recharged. On that last point, you can only use it on battery power (which I suspect is due to safety reasons). After letting it cool/recharge overnight, it is ready to use again by the next day.

Medical-grade lasers do not have these limitations.

Finally, for those technically inclined, the TRIA uses a pulsed diode laser (same as a medical grade laser) with five intensity settings. The highest fluence available is 22 with a wavelength of 810nm, which is lower than what is available from a laser used in the clinic.

Regardless of medical-grade laser hair removal or TRIA, it does require repetitive sessions as the laser only kills follicles that are in the growth phase. Unfortunately, hair are in different phases at any given moment (there are 3 phases) and as such, it may take numerous sessions spaced 1-2 weeks apart over a few months before all hair follicles have entered into the growth phase and thus be able to be amenable to death by laser.

And unlike brain cells… hair follicles CAN come back from the dead and start producing hair again. Hard to say when or why this happens, but is likely due to hormonal factors.

Overall, however, the TRIA can save you a lot of money (compared to getting it done by a physician) if you have the following characteristics:

1) Dark hair

2) Light skin

3) Patience (small laser head on large surface area takes a long time as well as the fact that a single session may need to be broken up over a few days due to device needing to recharge or cool overnight after about 15 minutes of use)

4) High pain threshold (even with a small head… it does hurt. And because it is a small head, there’s a lot more zaps to cover the same surface area)

You can buy it on Amazon.com here.

http://rcm.amazon.com/e/cm?lt1=_blank&bc1=FFFFFF&IS2=1&bg1=FFFFFF&fc1=000000&lc1=0000FF&t=fauentcon-20&o=1&p=8&l=as4&m=amazon&f=ifr&ref=ss_til&asins=B0029OSN4U

Sleep Endoscopy for Obstructive Sleep Apnea and Snoring

A new webpage has been created describing a procedure called “sleep endoscopy” or “sedated endoscopy.”

This procedure is performed on patients with obstructive sleep apnea (OSA) or severe snoring in order to determine where the source of their problem is anatomically located.

This special exam is needed in patients where such anatomic determination is not able to be made in the clinic while they are awake. As such, an anesthesiologist would put the patient to sleep using IV medications and when snoring or obstructive events happen, endoscopy is performed.

Areas that will be specifically examined during sleep endoscopy include:

• Behind the palate
• Uvula
• Back of Tongue
• Walls of the Throat
• Epiglottis
• Voicebox

Each of these areas may experience collapse during sleep causing obstructive or snoring symptoms.

Why is this information helpful? Well… once it is apparent where and what is the culprit causing a given patient’s problems, surgical treatment can be geared more specifically and directly to the area of concern seen during sedated endoscopy.

Read more here!