As a gastroenterologist in Colorado Springs, I help patients with digestive tract problems. My partners and I work hard to provide the care our patients need as efficiently as possible. This article explains how we do it, and how we could do it better without government interference.
Patients are individuals who have different needs. I have to listen closely to each person’s history in order to figure out what is wrong and how best to treat them. Rather than sitting in a room on a committee discussing ways to improve “population health,” I sit two feet from my patients listening to accounts of their struggles, and trying to use the tools at my disposal to solve their individual health problems. Sometimes I use an endoscope, a long, flexible tube with cameras and lights, to look inside their body.
I believe that each person deserves personalized care in a setting which respects his time and his financial situation. Unlike remote policy makers prescribing untested health care reforms to reduce poorly measured costs for theoretical “populations” of faceless people they have never met, I care for individual patients who have real medical problems and need real medical care.
My patients are often concerned about the cost of the medical care they need. We work together to figure out the least expensive way to provide it. This includes choosing the best, least expensive, setting for their care, one that takes patient living situations into account and balances physician and patient costs, preferences, and risks.
Some patients have an array of problems that require treatment in a hospital. Others can be safely treated in a less expensive outpatient center. Hospitals are excellent at taking care of sicker people who may need post-procedural monitoring or those who need more complex procedures. Outpatient centers are a better value for basically healthy individuals who need a straightforward procedure to address a more limited group of ailments.
After years of treating patients, my partners and I decided that our practice, and many of our patients, would be better off if we built our own endoscopy center. We knew we could reduce procedure costs. Hospitals focus on stabilizing the seriously ill and making them better. This means that a hospital must be able to do many things well. It carries more equipment, hires more people, and needs more space to house everything. It also needs multiple levels of bureaucracy to coordinate patients, facilities, and staff. One person may be accountable to several bosses. This affects productivity because it makes it more difficult to create stable teams of people who work well together. It also makes it harder to distinguish between those who are good at their job and those who need to do better.
Providing lower cost, high quality health care requires a team of people who work well together. My partners and I are picky about who we work with. Our staff is directly accountable to us. We hire people who are good at their jobs, think about better ways to do them, and like the working environment. Our turnover is low, because we have a different mission than a hospital and our focus is narrower; we have smaller, more efficient, teams with higher productivity in our specialty.
Physical design can either facilitate or hinder efficient and effective care. In a hospital, the same rooms are often used for surgery, pain injections, and endoscopic procedures. Procedure rooms turn around more slowly, and patients and staff may spend valuable time traveling from offices and patient rooms to procedure rooms.
In building our endoscopy center, my partners and I strove to minimize the number of steps from the patient’s bed to the endoscopy room. Our patients move in and out of rooms quickly and safely. The rooms are designed to require minimal time to prepare for the next patient. Fewer steps and faster turnover means that patients wait less, spending less time in the center. It means that physicians and staff wait less, travel less, and have more time to spend with patients.
Some policy makers deride our efforts as increasing volume rather than value. What we are really doing is increasing our productivity. At a time when there is a significant shortage of physicians, we work to ensure that our working environment is designed to let us properly care for as many patients as we can.
Government pricing also hinders our efforts. Government sets Medicare reimbursement for various services. Commercial insurance companies usually set their reimbursement as a percentage of Medicare reimbursement. If the government lowers what Medicare will pay, commercial payment falls as well. With this type of price fixing, government sets the price for all services. Unfortunately, government pricing often makes little sense for individual patients and their physicians.
At an endoscopy center, Medicare pays a flat rate for a specific procedure. At a hospital, it pays separately for almost every piece of equipment used. If a patient’s procedure requires multiple maneuvers or pieces of equipment which will be paid for at a hospital but not at an endoscopy 
center, physicians do the procedure at a hospital rather than risking a loss on the fixed endoscopy center payment. But if a patient is well enough to be seen at an endoscopy center, why not offer an incentive to be treated there? It would be a much more efficient use of resources.
Medicare includes conscious sedation with Versed or Fentanyl in the bundled payment for endoscopy. But like the equipment used in a hospital, Medicare pays separately for sedation with Propofol. Propofol causes deeper sedation, requires more training to administer safely, and increases procedure costs. Medicare policies encourage the use of Propofol even though conscious sedation works well for most patients.
Interventional policies can sacrifice quality care for supposed cost savings as seen in the national policies in Japan, Korea, France, Norway, Germany, and Spain. Those countries do not pay for colonoscopy sedation at all. They reduce health care spending by saving the cost of the anesthesia and by reducing the number of people who volunteer for colon cancer screening.
If government interference continues to make things more difficult for private practices like ours, physicians will close them. Patients will become faceless populations, innovations like our endoscopy center will dry up, health care costs will increase, and health care quality will fall.
Dr. Krishnan is a gastroenterologist in Colorado springs.
