The more President Obama speaks off the cuff in the Great Health Care Debate, the less he seems to know. Recently, President Obama contended that surgeons are paid “$30,000, $40,000, $50,000″ to amputate a foot. (Hit YouTube clip, above.) But, that doesn’t seem to be true. I looked up New York State’s Medicaid reimbursement fee for a foot amputation. Guess what? Surgeons fees for most amputation procedures are in the hundreds, not tens of thousands of dollars. Here’s an example from Med NY Physician Manual, (hit the “Fee Schedules Surgery” Link):
NYS Medicaid Physician Surgery Services Fee Schedule Effective Date: April 1, 2009
AMPUTATION, FOOT; MIDTARSAL (EG, CHOPART 335.31
AMPUTATION, FOOT; TRANSMETATARSAL 424.57
AMPUTATION, FOREARM, THROUGH RADIUS AND 459.98
AMPUTATION, FOREARM, THROUGH RADIUS AND 451.12
AMPUTATION, FOREARM, THROUGH RADIUS AND 403.46
AMPUTATION, FOREARM, THROUGH RADIUS AND 449.18
AMPUTATION, THIGH, THROUGH FEMUR, ANY LE 468.10
AMPUTATION, THIGH, THROUGH FEMUR, ANY LE 524.50
AMPUTATION, THIGH, THROUGH FEMUR, ANY LE 397.09
AMPUTATION, THIGH, THROUGH FEMUR, ANY LE 290.96
You get the picture. Now, unless the surgical fee schedule isn’t really the surgical fee schedule, that is a long way from $30,000, $40,000, or $50,000 to amputate a foot! And why isn’t the media fact checking the president? I mean, can you imagine if Bush had made such a huge mistake?
I have no doubt private insurance companies pay more than Medicaid for amputations, perhaps thousands more. But I truly doubt it is 100 times more! If anyone has any information on that, please let me know.
President Obama has a Web site to report “myths” being spread about health care: Physician–er, POTUS–heal thyself.
August 12th, 2009 | 10:15 pm
This same brief snippet contains another example of presidential medical ignorance. Obama says, “Let’s take the example of something like diabetes, a disease that’s skyrocketing, partly because of obesity, and partly because it’s not treated as effectively as it could be.” It’s true that the prevalence of diabetes in increasing in part because of the increased prevalence of obesity. But it’s manifestly NOT true that diabetes is “skyrocketing” because it is inadequately treated. Since treatment of diabetes is not curative, proper treatment simply prolongs survival of diabetics. With proper treatment, diabetics don’t die as quickly of the disease as they otherwise would. They live longer. Thus, the prevalence of the disease in the population increases with proper treatment, not with inadequate treatment!
August 12th, 2009 | 10:57 pm
This is absolutely stunning. At first I thought these had to be the medical codes. The reimbursement rate is too low. But, no, you are correct and that is the actual reimbursement. Which leads me to a couple of thoughts:
1. No wonder more doctors don’t want to take Medicaid! Medicaid doesn’t even begin to cover the costs involved.
2. These costs have to be borne by someone. If they aren’t borne by the patient, and the government isn’t paying the full cost, then the uninsured wind up paying higher costs because the physicians have to recoup it from somewhere or they can’t stay in business. (Insurance companies have contract rates with doctors, so they aren’t allowed to charge their patients over that rate.) But even contract rates ultimately have to go up because these costs have to be borne by someone. So the price of medical care goes up, precisely because of the lack of a free market.
The bottom line is that Medicaid hurts the uninsured more than it helps.
August 12th, 2009 | 11:03 pm
I’m beginning to feel sorry for our President. He has made way too many blunders of late.
August 12th, 2009 | 11:05 pm
From a physician friend:
I think that Medicare reimburses about $800 to $1000 for a below-the-knee amputation, the type most commonly performed for a gangrenous diabetic foot. Don’t quote me on it, because I’m not sure. (Some surgeon reader of yours will doubtless give you details.) Keep in mind that that fee covers not just the operation itself, but also the followup care post operatively for, I believe, about a month.
August 13th, 2009 | 12:50 am
(I posted this comment also on your post on First Thoughts. I won’t be offended if you don’t post it twice.)
Perhaps he was not speaking only of the surgeon’s fee but also of the cost of anesthesia, hospitalization (probably this is not outpatient!), rehabilitation (a lot must be needed), and so on and so on…
A year ago, I had laparascopic hernia surgery. Surely this is less major surgery than a foot amputation. It is outpatient. I was in the hospital maybe six hours.
Here is what the hospital charged my insurance company, and what the insurance company paid (that is their contracted reduced charges; at this point we had reached our family out of pocket limit and we paid nothing):
charges:
30,194.21
paid by insurance:
9666.11
These charges are just for the day of surgery, and include items such as “medical/surgical supplies,” “anesthesia,” “drugs,” “operating room,” etc (according to my insurance co’s explanation of benefits).
August 13th, 2009 | 1:27 am
(This comment won’t make sense without the previous one.)
From the Med NY Physician Manual link:
49520 REPAIR RECURRENT INGUINAL HERNIA, ANY AG 339.34
49521 REPAIR RECURRENT INGUINAL HERNIA, ANY AG 413.60
I am not sure what the difference is between these two. But that is what I had: repair of a recurrent inguinal hernia.
What relation these numbers bear to what was actually charged to my insurance for my repair, and what my insurance actually paid, is opaque to me.
But it at least suggests that you can’t judge what physicians are typically paid for such surgeries just by going by the Medicaid schedule.
The figures I gave in my first comment above for my surgery are from my insurance co’s eob’s, which do not separate out the surgeon’s fee. The largest charge was for “operating room” at about $14,000, for which the insurance co apparently paid about 4000-5000 (the eob gives a total for charges and a total for amount paid — they seem to pay at about 1/3 of the official “charges”).
August 13th, 2009 | 1:47 am
A bit more:
from the International Diabetes Foundation:
“In developed countries diabetic foot care accounts for up to 20% of total healthcare resources available for diabetes. In developing countries, it has been estimated that foot problems may account for as much as 40% of the resources available. In western countries, the economic cost of a diabetic foot ulcer is thought to be between US$7,000 and US$10,000. Where healing is complicated and amputation required, this cost may increase to as much as US$65,000 per person.”
http://www.idf.org/Position_statementsdiabetic_foot
and from another site:
“The cost of a lower extremity amputation has been estimated to be $30,000 to $60,000, with an additional $43,000 to $60,000 for subsequent care for 3 years.”
http://www.helphealdfus.com/diabeticfootwoundsandamputations.html
(they give a reference to: http://www.ncbi.nlm.nih.gov/pubmed/17901338
That leads only to an abstract of an article I can’t obtain without paying.)
August 13th, 2009 | 9:01 am
Citing Medicare/Medicaid reimbursement amounts as the representative cost of specific amputations is downright dishonest. Medicare/Medicaid reimbursements are notoriously low compared to the fee the doctor normally bills. Furthermore, those who aren’t old enough (or poor enough) to be covered by Medicare/Medicaid are billed the full amount; and to the extent their insurance providers don’t cover it, they’re stuck with the balance.
August 13th, 2009 | 10:13 am
My hunch is that the President’s comments accurately reflect what someone with no medical insurance would be forced to pay for an amputation. Hospitals and doctors charge what in the world of consumer sales is called “full list price” to the uninsured for any procedure, and it typically is an unlandish amount such as the $30+K that Obama cited. And the hospital will pursue you for that amount. No, you may not negotiate it. At least not as an insurance company–or Medicaid or Medicare–gets to do.
August 13th, 2009 | 10:44 am
Michael, the President does not know what he’s talking about. Watch the video, for goodness sake, before you write. Obama did not claim that 30k-50k is what the total cost is of the amputation and all related procedures.
He simply said that $30k-50k is what the surgeon is immediately reimbursed, and that is significant because he was explicitly contrasting what a primary care physician is paid versus a surgeon.
The total cost of an amputation and all related costs could be in the $30k-$50k range. But until someone gives the breakdown in costs and declares exactly how he has come to the judgment that one or more parts costs more than it ought to, it’s irrational to simply assume that a $30-$50k cost is excessive. It may very well be. But, there’s no evidence, so far, that it actually is.
All that is besides the point that the President is, intentionally or not, spreading false information in his quest to rule healthcare.
August 13th, 2009 | 11:14 am
The American Medical Association disagrees with the President’s “facts” as well:
Hospital stay, rehab, prosthesis, yes I’m sure we should be confident in politician and would-be social engineer determinations of how much those things really should cost. After all, they base those judgments on whatever they happen to feel is right, and our feelings can’t be wrong!
August 13th, 2009 | 12:51 pm
Albert,
I have watched the video. For crying out loud. In my judgment it was ambiguous.
Here is exactly what POTUS said:
“All I’m saying is let’s take the example of something like diabetes, one of — a disease that’s skyrocketing, partly because of obesity, partly because it’s not treated as effectively as it could be. Right now if we paid a family — if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they’re taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000 — immediately the surgeon is reimbursed. Well, why not make sure that we’re also reimbursing the care that prevents the amputation, right? That will save us money.”
The words “the surgeon is reimbursed” are the debatable words. I think this is at least ambiguous; it could mean — the cost of this is $30k or more, and it is immediately paid for, for example by reimbursing the surgeon (etc). But you may not think this can be read that way. We can disagree about that.
But the reality is this:
it does cost $30k or more to have a foor amputated. (I have links on this on secondhand smoke comments.) The surgeon is not the one getting most of the money, granted. But this outlay is still a lot more (wherever it is going) than what we pay the primary care physician for preventative care. And that is a situation we might want to address. I don’t think Obama was saying 30k was excessive when amputation is necessary, I think he was saying we could do more to prevent this.
As to what the total costs are, they are in line with what Obama said — as you can see if you just go over to secondhand smoke and check out my links.
August 13th, 2009 | 2:22 pm
Well I hate to defend the President but I think it is correct that what he probably meant was total cost of the amputation. His mistake was letting his fight the “evil rich” rhetoric get the best of him in trying to pin the entire fee on the “rich” doctor.
My 10 year old daughter recently had out patient surgery, albeit for a very serious condition, the surgeon’s charge was a shadow of the other costs which I believe totaled over $40,000. That’s for outpatient surgery.
I suspect that under Obama’s Health System the care she received would have been greatly restricted. As we were waiting for her after surgery it was pretty obvious that we were one of the few parents in the waiting room at one of the best hospitals in Los Angeles, who had insurance. The thought came to me, that our insurance was probably paying for part of their kid’s treatments for the same life threatening condition, and I was happy about that. I thought, thank God we live in a country where even poor people can get the very best medical care. I suspect that under Obamacare, neither my daughter nor the children of the poor parents would have received the same quality of care.
One of the Doctor’s assistants was explaining to my wife that they often see patients whose condition has been made radically worse because they were first treated by a general care physician who did the simple and obvious but absolutely wrong thing. That I suspect is what awaits us all under Obamacare.
August 13th, 2009 | 3:34 pm
[...] Ethicist extraordinaire Wesley Smith does a fact check on something President Obama recently said, about doctors overcharging for amputating feet (what [...]
August 13th, 2009 | 3:43 pm
I never did think that Medicare or Medicaid were a good idea. But then, I’ve always been a Republican or a Conservative except for a brief stint as an Independent during which I still didn’t approve of Medicare or Medicaid then either.
I’ll never feel sorry for Obama.
I don’t care what the actual figures are. He still has to be impeached.
August 13th, 2009 | 3:44 pm
K-man,
In my experience, you can negotiate with the hospitals. It’s a pain, and you have to push past your first contacts to those in the business office, but a little persistence goes a long way – especially before a procedure is done.
August 13th, 2009 | 5:20 pm
>>The more President Obama speaks off the cuff in the Great Health Care Debate, the less he seems to know. Recently, President Obama contended that surgeons are paid “$30,000, $40,000, $50,000″ to amputate a foot.<<
Hey Wesley! Are you sure that he really was not simply talking about "The Fourth Dimension" which is not exactly "Reality" as we know "IT" cause some of my MPD cells have heard them ask on occasions where they could buy an arm and/or leg so they could multiply themselves! :)
I hear ya! sinner vic might have gotten hold of a few of The Presidents brain cells and sold them to these alien gods!
You Think Wesley? :(
God Bless
Peace
August 13th, 2009 | 5:34 pm
On the road and unable to formally post. Surgeons group has also criticized the POTUS’s ignorance. He wasn’t talking about total costs, if you listen to the quote, he was speaking about surgeons fees. This isn’t the first time he has exhibited appalling ignorance about how the health care system really works.
History Writer: Pretend he’s Bush, and you’ll get it.
August 13th, 2009 | 7:28 pm
And President Bush clearly said (listen to the clips!!) that people are working hard to put food on their families. My, what appalling ignorance! President Bush thought that people have jobs and earn wages to put food, not in their families’ mouths, but actually on top of them. He thinks we want to smear the food on our children! He really didn’t know anything about families, did he!! Just listen to that clip. What an imbecile!
Please stop the unfair posturing. Who do you think you’re serving with this kind of “analysis”? You even say Obama was speaking “off the cuff.” Are you error- or misstep-free in front of large crowds and many cameras? Yet you refuse to entertain the possibility that he misspoke and was in fact addressing overall costs. Under no circumstances are you prepared to be charitable to Obama, are you?
It’s not the mark of a serious and generous mind to seek to make your opponents look as stupid as possible. It’s the sign of someone who’d rather score cheap points in a battle for political power than deal reasonably and fairly with what’s actually on the table.
After all, do you really mean to suggest that there’s no point in what Obama was saying about preventative diabetic care, because even if the total costs of amputations run into the tens of thousands, he’s wrong about the surgeons, they only get 500 bucks? Is that really your point?
Why not be patient and generous and deal with the best interpretations of Obama’s words?
Why not deal with the best reasons for section 1233 of the healthcare bill? One of the biggest political advocates for end of life planning is a Republican from Georgia, Johnny Isakson. He was recently asked and responded to a series of questions on the topic (link to full interview below):
“[Q:]Is this bill going to euthanize my grandmother? What are we talking about here?
[A:]In the health-care debate mark-up, one of the things I talked about was that the most money spent on anyone is spent usually in the last 60 days of life and that’s because an individual is not in a capacity to make decisions for themselves. So rather than getting into a situation where the government makes those decisions, if everyone had an end-of-life directive or what we call in Georgia “durable power of attorney,” you could instruct at a time of sound mind and body what you want to happen in an event where you were in difficult circumstances where you’re unable to make those decisions.
This has been an issue for 35 years. All 50 states now have either durable powers of attorney or end-of-life directives and it’s to protect children or a spouse from being put into a situation where they have to make a terrible decision as well as physicians from being put into a position where they have to practice defensive medicine because of the trial lawyers. It’s just better for an individual to be able to clearly delineate what they want done in various sets of circumstances at the end of their life.
[Q:]How did this become a question of euthanasia?
[A:]I have no idea. I understand — and you have to check this out — I just had a phone call where someone said Sarah Palin’s web site had talked about the House bill having death panels on it where people would be euthanized. How someone could take an end of life directive or a living will as that is nuts. You’re putting the authority in the individual rather than the government. I don’t know how that got so mixed up.
[Q:]You’re saying that this is not a question of government. It’s for individuals.
It empowers you to be able to make decisions at a difficult time rather than having the government making them for you.
[Q:]The policy here as I understand it is that Medicare would cover a counseling session with your doctor on end-of-life options.
[A:]Correct. And it’s a voluntary deal.”
Of course, anyone is free to disagree with Isakson, let alone Obama. But let’s have a real debate about what’s actually being proposed. I haven’t seen you so much as mention Isakson’s conviction that the whole purpose of a provision like this is to stop wasting needless money.
August 13th, 2009 | 8:28 pm
Wesley: Thanks, but ONE George W. Bush was quite enough.
August 13th, 2009 | 9:14 pm
Perhaps this insurance industry study about the difference between what some doctors charge (out of network), and what Medicare pays, is a propos:
http://www.ahipresearch.org/PDFs/ValueSurvey/AllStatesReport.pdf
A quote from p. 1:
“Some out‐of‐network providers are charging exorbitant prices – several hundred or even
over a thousand percent of the Medicare reimbursement for the same service in the same area. $4,500 for an office visit when Medicare would have paid $134; $14,400 for removal of a gallbladder when Medicare would have paid $656; and $40,000 for a total hip replacement when Medicare would have paid $1,558.”
I’d like to compare this to something Wesley wrote at the beginning of this issue:
“I have no doubt private insurance companies pay more than Medicaid for amputations, perhaps thousands more. But I truly doubt it is 100 times more!”
This isn’t quite the same, since it is not about what private insurers pay in network, but what is charged out of network. But still, it may be food for thought.
August 13th, 2009 | 11:57 pm
It seems pretty apparent to me that he did mean the surgeon’s fee. This is because he is claiming that doctors have an economic incentive to give inferior preventative care so that they can reap the windfall (mixed idiom?) of lucrative amputations. This demonstrates his ignorance in another way: the primary care physician and the surgeon are probably not the same person, so the doctor providing preventative care would have no such incentive.
Or President Obama believes that the primary care physician gets some sort of kick-back!
Either way, the President’s ideas come less from facts and deliberate economic reasoning than from a marxist imagination.
August 13th, 2009 | 11:58 pm
Obama should flag himself on his own snitch-mail. The misinformation seems to largely come out of his own mouth. Someone give him his Totus and speechwriter back …
August 14th, 2009 | 9:22 am
http://content.nejm.org/cgi/content/full/358/7/661
Preventative care is smart on a micro level, but it will not be a magic red pill for saving costs in the economy. From society’s standpoint, all those extra tests can sometime add up to more than the procedure costs. I don’t have a beef with preventative care, but if the whole point of government involvement in our health decisions is to save the country money overall, then preventative care won’t do it.
I like the NEJM article above, because it makes a significant point. Preventative care is worth it, but it will only save money if used very smartly (or if we recognize it’s worth spending more money to have the colonoscopy ever year than have an overall lifetime savings by getting colon cancer).
Right now, doctors have enough trouble trying to deduce who is most at risk for the costs to make a difference. Now stick in a slew of committees, agencies and bureaucracies, all with politics and cost cutting in mind as much as good governance and smart money decisions. Do you honestly believe their broad decisions in DC based on numbers and groups will lead to more effective or better use of preventative services than doctors and patients in person?
I don’t think the President’s mistaken ideas are limited to just surgery reimbursements.
August 14th, 2009 | 9:56 am
[...] …spreading fishy information about health care reform.” [...]
August 14th, 2009 | 2:18 pm
HistoryWriter: “Wesley: Thanks, but ONE George W. Bush was quite enough.”
Thank you for again proving Wesley’s point for him so beautifully.
August 14th, 2009 | 3:26 pm
HW: Don’t worry it was just a request to imagine, not one to duplicate.
Charlie: Obama has no business opining on medical matters; he has no training in them and it’s not in his job description…yet he does. I say impeach him.
August 14th, 2009 | 3:32 pm
Charlie: Because we can’t afford to be patient and generous with a President, and we’re not supposed to have to be, and I don’t recall people being patient and generous with Bush (who was patient and generous himself) and this guy is hardly what could be described as patient and generous. Just why should we have to be anyway? Inexperience, arrogance, incompetence, being a stooge, and the affirmative-action ethos aren’t in his job description either.
August 14th, 2009 | 7:54 pm
Caleb: “It seems pretty apparent to me that he did mean the surgeon’s fee. This is because he is claiming that doctors have an economic incentive to give inferior preventative care so that they can reap the windfall (mixed idiom?) of lucrative amputations.”
Sorry, I just don’t see where he said anything about economic incentives to reap windfalls etc. That is sheer fantasy.
He may be interpreted as saying that surgeons are paid 30-50k for a foot amputation, which is false (that is the total cost, and the surgeon gets a fraction of that at best). I don’t agree with that interpretation but it is sensible, and at best what he said was ambiguous. But there is nothing in what he says to suggest that doctors don’t do preventative care so that they can get the big surgeon fee.
“the President’s ideas come less from facts and deliberate economic reasoning than from a marxist imagination”
Because there isn’t anyone anywhere near him with experience in the medical management field…
http://en.wikipedia.org/wiki/Michelle_Obama#Career
August 15th, 2009 | 2:55 pm
If Obama’s numbers are true, most surgeons would be making at a rough MINIMUM of 15 million dollars every year (one 50K surgery a day for 300 days). General surgeons make about 300,000 a year. Figure out what they make per hour and it is probably less than the guys who laid the pipe to bring natural gas to Washington, DC.
August 19th, 2009 | 1:18 pm
Eric: Excellent point about diabetes; thanks.
August 24th, 2009 | 9:34 am
I think many of the readers here are missing the point Obama was making. He was just trying to say that we need to prioritize preventive care, because there is a cost savings to society. Diabetes is an excellent example to use. A few years ago, I cared for a patient in the Bronx- 36 years old, Hispanic, had diabetes and a lower leg amputation in July. He came in briefly for another complication in November and at that time, had no prosthesis. I thought what a tragedy— here’s a young man disabled for life and how expensive for society. I wondered why it couldn’t have been prevented. Later I read an article in the New York Times about how a hospital established a special clinic in the Bronx to provide state of the art preventive care to diabetics. It turned out the kind of care it provided could not get reimbursement. So in the short run of day to day operations, it was a money loser, and the hospital ended up shutting it down. Obama is not trying to attack surgeons. He’s making the point that we can save money by rethinking a model in which a preventive care clinic can’t get paid, despite being cheaper than a scenario with the huge lifetime expenses of amputation- but the surgeon gets paid right away. I doubt the surgeons will complain if they lose some amputation business if we can improve our ability to prevent amputations.
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