OPINION
GASTROENTEROLOGY & ENDOSCOPY NEWS • MAY 2013
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Can Hospital-Owned Practices Survive in the Long Run? Arthur Gale, MD Internal Medicine St. Louis, Missouri Contributing Editor, Missouri Medicine
[Editor’s Note: The following article was originally published in Missouri Medicine, January/February 2013;110:21.] Doctors are becoming hospital employees.
Private practice, which has been the dominant way physicians have practiced since the country was founded, may be a thing of the past. Doctors are closing their offices for the simple reason that hospitals give them a hefty signing bonus for the first year or two, and the government and insurance companies reimburse them at higher levels as hospital employees than they can obtain in private practice. Hospitals buy doctors’ practices in order to lock
in referral sources for inpatient and outpatient services. How long can this costly state of affairs last? The government is under tremendous pressure to reduce Medicare costs. Over the past 30 years, health care expenditures have increased from 7% to 16% of the gross national product (GNP). The number of uninsured people has increased from 30 to 50 million (Wikipedia, Health Care in the United States). For a family of
four, the cost of health care has increased to $20,000 annually according to a recent report from the Milliman Medical Index ((Am Med News, June 4, 2012). And the public is asking if all these expenditures are worthwhile. The health of the U.S. population is no better than the health of citizens of many countries that spend far less on health care than the United States. Hospitals comprise the nation’s largest single health care expenditure, at about 30% of the total cost. Both the government and employers are finding it increasingly difficult to pay for skyrocketing health care costs. And they are finally beginning to scrutinize hospital costs.
Currently a mid-level office visit for a hospital-owned doctor is $124.40. The same visit in a private physician’s office is $69.97, or 44.6% less.
SUPREP Bowel Prep Kit. Because the quality of cleansing matters. • Effective bowel cleansing2,3 in all bowel segments1
• Low volume
• ACG-recommended split-dose regimen
• No sodium phosphate
References: 1. Rex DK, DiPalma JA, Rodriguez g R, McGowan J, Cleveland M. A randomized clinical studyy comparing p g reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage g solution as ppreparation p for colonoscopy. py Gastrointest Endosc. 2010;72:328-336. 2. DiPalma JA, Rodriguez g R, McGowan J, Cleveland MvB. A randomized clinical study evaluatingg the safety and efficacy of a new, reduced-volume, oral sulfate colon-cleansing preparation for colonoscopy. Am J Gastroenteroll. 2009;104:2275-2284. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2010.
BRIEF SUMMARY: Before pprescribing, g please p see full Prescribing Information and Medication Guide for SUPREP® Bowel Prepp Kit (sodium sulfate, ppotassium sulfate and magnesium g sulfate) Oral Solution. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansingg of the colon as a ppreparation p for colonoscopy py in adults. CONTRAINDICATIONS: Use is contraindicated in the followingg conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, g ggastric retention, ileus, known allergies g to components p of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prepp Kit is an osmotic laxative indicated for cleansingg of the colon as a ppreparation p for colonoscopy py in adults. Use is contraindicated in the followingg conditions: ggastrointestinal (GI) obstruction, bowel pperforation, toxic colitis and toxic megacolon, g ggastric retention, ileus, known allerggies to components of the kit. Use caution when pprescribingg for patients p with a historyy of seizures, arrhythmias, y impaired p ggagg reflex, regurgitation g g or aspiration p , severe active ulcerative colitis, impaired p renal function or ppatients takingg medications that mayy affect renal function or electrolytes. y Pre-dose and post-colono p scopy ECG’s should be considered in ppatients at increased risk of serious cardiac arrhythmias. y Use can cause temporary p y elevations in uric acid. Uric acid fluctuations in ppatients with ggout mayy pprecipitate p an acute flare. Administration of osmotic laxative products p mayy pproduce mucosal aphthous p ulcerations, and there have been reports of more serious cases of ischemic colitis requiring q g hospitalization. p Patients with impaired p water handlingg who experience p severe vomitingg should be closelyy monitored includingg measurement of electrolytes. y Advise all patients p to hydrate y adequately q y before, during, g and after use. Each bottle must be dilutted with water to a final volume of 16 ounces and ingestion g of additional water as recommended is important p to patient p tolerance. Pregnancy: g y Pregnancy g y Category g y C. Animal reproduction p studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive p capacity. p y Pediatric Use: Safetyy and effectiveness in ppediatric ppatients has not been established. Geriatric Use: Of the 375 ppatients who took SUPREP Bowel Prepp Kit in clinical trials, 94 (25%) were 65 years of age g or older, while 25 (7%) were 75 years of age g or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose p (2-day) y regimen g were observed between geriatric g patients p and yyounger g patients. p DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP mayy not be absorbed completely. p y ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal ppain, nausea, vomitingg and headache. Oral Administration: Split-Dose p (Two-Day) y Regimen: g Earlyy in the eveningg pprior to the colonoscopy: ppy Pour the contents of one bottle of SUPREP Bowel Prepp Kit into the mixingg container pprovided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume onlyy a light g breakfast or have onlyy clear liquids q on the dayy before colonoscopy. py Dayy of Colonoscopy py (10 to 12 hours after the eveningg dose): Pour the contents of the second SUPREP Bowel Prepp Kit into the mixingg container provided. p Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least one hour prior to colonoscopy.y Consume only clear liquids until after the colonoscopy. STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185 For additional information, please call 1-800-874-6756 or visit www.suprepkit.com ©2012 Braintree Laboratories, Inc.
SU-13280T
January, 2012
An article published last year in the St. Louis Post-Dispatch ( June 14, 2012) listed the costs of magnetic resonance imaging (MRI) at various hospitals and outpatient imaging centers. There was at least a threefold difference in pricing. A private for-profit hospital was the least expensive. The largest hospital system in the area refused to reveal its prices for MRIs. Competition is supposed to be the hallmark of managed care, under which our current health system operates and which was supposed to reduce health care costs. How can there be competition when there is no price transparency? Why does this marked disparity in hospital pricing exist? MRIs aren’t the only overpriced hospital service. Hospitals strongly urge their employed physicians to refer their patients to hospital imaging centers for other types of x-rays and to high-priced, hospital-owned clinical laboratories and outpatient surgical centers.
Reimbursements Vary The influential governmental nonpartisan Medicare Payment Advisory Commission (MedPAC) has recommended cuts in hospital reimbursement. One major cut would be in primary care services. Currently a mid-level office visit for a hospital-owned doctor is $124.40. The same visit in a private physician’s office is $69.97, or 44.6% less. MedPAC has recommended the elimination of this disparity ((Am Med News, March 26, 2012). MedPAC has recommended uniform see Hospitals, page 4