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To Bundle or not to Bundle payments

August 30, 2015

Who decides who gets how much and based on what? Usually the doctors who fix patients and do the real work, now get paid the least. To give and example of how much, if a patient gets a heart attack and comes to the hospital by an ambulance they first go to the Emergency Room then to the Catheterization-Lab and is then evaluated for open-heart surgery. Post operation the patient may need repeated trips to the operating room whether to stop bleeding or to remove blood clots or to end manage cardiac arrhythmia which is very common as up to 50% of cases go through this. Some patients may need device therapy such as pace-makers for very slow heart rhythm which is common in the elderly who have diseased electrical systems as well as clogged arteries (plumbing). So the average stay of a patient with no complications is 5-7 days which could extend with minor complications to 10 days. If there are more complications such as recurrent fluid build-up (congestive heart failure) or fluid in the lungs (pleural effusion) that needs to be drained by using a chest tube for a few extra days so that may push the hospital stay up to three weeks or beyond. 

If God forbids, the patient develops a stroke post operatively or goes into acute renal failure, requiring dialysis or can not even get off the ventilator because of bad lungs or bad heart or a combination of both then you are talking about long-term care as well as a huge bill as a consequence.

Let us say the average bill for the above patient would range between $200,000-250,000 however guess how much the surgeon gets? $1500 if lucky and with bundle payments this amount is likely to decrease for the doctors as most payments go to the hospital. This pushes independent physicians to go out of business or pushes them to be an employed physician with almost zero job security as reported by many colleagues, they could be fired for any cause (reasonable or unreasonable). Even worse, there could be no notice and they could be fired on the spot only adding to their devastation of those great talented physicians who we already are suffering a shortage in. 

My humble suggestion for the future of care delivery to have a fair compensation that should be secured for those in charge of delivering the care,  i.e doctors. And not those who are controlling the flow of money and are getting paid with the top dollars according to recently published CMS (Center of Medicare Service) are the business executives, CEOs, administrators as physicians pay lag behind. Similar scenarios in patients who may have a slip and fall accident, sustain a fracture call EMS, go to the ER, are seen by the orthopedic surgeon, get surgery, get in hospital and post discharge rehab with all their bills being bundled. 

The best model to date that should be considered as a solution is offered by the Surgery Center of where a patient/ consumer shops for the best services and the best prices. To given an example

Arthroscopy bilateral knee - $5,300

Femoral-Popliteal bypass graft with vein- $10,700

Inguinal Hernia Repair- $3,060

Pace-maker placement includes device/leads- $11,400

Cataract Surgery (one eye)- $4,000

Hip Replacement surgery- $19,400

Simple fracture requiring open reduction - $4,455

Simple fracture, closed reduction with cast- $1,925

Laser varicose veins therapy upper or lower (one side)- $2,700

Adenoidectomy- $2,695

I remember very well about 14 years ago I was charge 24,000 for a six hour stay for an Adenoidectomy surgery for my daughter and insurance denied payment (citing it was a pre-existing condition!). Which I had to fight and they finally paid to the hospital.  There is a breaking point which is about to happen in the current healthcare system as it is unsustainable and would require adapting these models mentioned for the future practice of medicine. 

Dr Adel Eldin,MD, FACC,FACP
Board Certified Cardiologist
President, Clinical Appeals Services
Founder, CEO
Affordable Quality Healthcare Program
Founder, CEO
Wesley Chapel , Florida
President ,Society of Physician Entrepreneur, Tampa Bay Chapter

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