I got snipped today. I was also a minor contributor to high healthcare costs due to insurance benefit design.
Vasectomies are very straightforward, generic procedures with few complications. It is a fairly low skill operation. It could be done almost anywhere. However I elected to have it done at a regional academic medical center.
This choice structure was partially influenced by my benefit design. I am insured through work, and I have a deductible with no co-insurance plan. Let’s see where the high cost choices came into play.
I had $173 of deductible left to fill for the year before everything gets covered at 100%. :
I knew this when I made an appointment with a urologist seven weeks ago. My search criteria for the urologist was simple — s/he had to be in-network, and near a major bus line between my house and my office and be able to schedule the elective procedure before my deductible reset on January 1st. This is a very broad criteria set.
I chose a urologist who has admitting and surgery privileges at both the major regional academic medical center and a community hospital that is 15 miles from my house in the other direction. The initial consultation was a specialist visit for a $40 co-pay. That visit’s reimbursement from my insurer was location independent; he would be paid the same no matter where he saw me. Pre-op screening could have been done at either the major regional medical center or a suburban ambulatory surgery center. I chose the major regional medical center as I could grab a bus from work and get it done during a very long lunch. This decision to save half a day of PTO probably cost my insurer an extra $240 because the regional medical center has a much higher reimbursement rate than a suburban ambulatory surgery center.
And then I got snipped this morning at the regional medical center because it was easier for my wife to drop off the kids at daycare and then commute against traffic to the medical center than fight the in-bound commute and then the out-bound counter commute to the community hospital. The snipping went fine and I left the hospital four hours after I arrived for check-in. However, the decision to get snipped at a flagship hospital instead of a community hospital will generate a facility fee that is double the cost of the facility fee of the community hospital.
My set of choices for this vasectomy probably will cost the insurer an extra $800 to $1,000 compared to a low cost and locally available alternative. It won’t cost me anything extra as any choice set would have burned the rest of my deductible.
How could benefit designs be changed to get me to make more cost effective choices without costing me more?
My current insurance is based on a fee for service model. Each medical widget gets paid for if it is deemed necessary. It pays out on each individual procedure without consideration for a holistic approach. There is no incentive passed the deductible and co-insurance (which I had none) for anyone to consider costs.
There are two billing approaches that could have strongly encouraged different choice sets without increasing my out of pocket costs.
The first would be a provider side payment strategy of “bundled payments.” In this system, the provider is given a fixed amount of money for a procedure. In my case, my urologist may have received a payment for $1,176.45 for a non-complicated vasectomy. The bundled payment would cover the initial consult, the surgical pre-op, the actual operation, the facility fee and the follow-up sperm testing. If the total charges came under that amount, the doc makes a profit. If charges come over that amount, the doc eats the loss. This system would have encouraged the physician practice to schedule my pre-op at the suburban ambulatory surgery center and then the actual operation at the community hospital to avoid significantly higher facility fees. Major regional academic medical centers (and their high costs) should be reserved for the strange and high care intensity cases not the ho-hum simple surgeries.
The other approach is “reference pricing” where the responsibility is on me to control my costs for generic, predictable, commonly available and non-urgent operations. Reference pricing is when the insurer looks at the cost of a procedure set within a network and determines that a set fee will be accepted by a sufficiently large number of providers to perform that procedure. The insurance company then says it is willing to pay that fee for my vasectomy. After that I’m responsible for the higher costs. The idea behind this is I’ll be motivated to trade an afternoon off of PTO to save $240 at the suburban pre-op center and my wife will be willing to drive through crap traffic to get to the community hospital this morning in order to save several hundred more dollars. Reference pricing works in providing high quality care while saving money for routine cases.
Right now, hospitals suck at providing transparent pricing to patients, even insured patients. Insurers are slightly better as they know roughly what codes will be submitted for a procedure and can be told be whom, so they can crosswalk that against the individual provider’s reimbursement contracts for a member. The initial estimate from the insurer is only an estimate as providers are idiosyncratic; one doc might like to cauterize, another may like to use clips, and the insurer can’t accurately and quickly price those differences out unless they can run instant claims histories for a given procedure to tease out provider preferences. Bundled payments avoids this information black hole and reduces search costs by placing the cost search and cost management burden on people who deal with the problem every day instead of intermittently. Reference pricing is promising but until hospitals and providers can accurately quote prices for a full set of services, it is still an interesting experiment instead of a ready for wide scale use process.
beth
Wait a minute – vasectomies are covered by insurance and the crazies are screaming about birth control pills? Why should I pay for you to have unlimited sex? Does Rush Limbaugh know about this?
a hip hop artist from Idaho (fka Bella Q)
I read the post title as “shipping costs” and was thus rather confused by a post about a vasectomy and its use as an illustration of different reimbursement models.
JCJ
@beth:
I agree! Richard is such a slut! I’m surprised he can walk he is having so much sex!
Another Holocene Human
@beth: I guess you’ve never been to the South–horrid billboards about how abortion is genocide (against Blacks), crisis pregnancy center scam lines, just plain strange antiabortion billboards involving late 19th century Virgin Mary iconography, even the old red lettered “Virgin–tell your kids it’s not a dirty word”, and then down the road a big old billboard for the local vasectomy provider.
Hypocrisy and double standards is where it’s at.
“GIRLS GIRLS GIRLS Cafe Exotique FREE TRUCKER SHOWERS”
Belafon
@JCJ: Right now, he can’t very well.
J R in WV
@beth:
Sweet, Beth, very funny.
Thanks for the laugh!
BGinCHI
Richard, you make it sound like anyone could do this at home with sharp scissors and boiling water.
I hope Cole doesn’t read this.
ranchandsyrup
I’m scheduled to do this but I haz a scared. :( It’s an irrational scared because I’m basing it on one anecdote but a scared nonetheless.
Richard Mayhew
@beth: yeah, but vasectomies don’t impact societal control upon female sexuality so who cares about who is shooting blanks! Guys are supposed to have control over their reproductive choices and thus have consequence free sexual autonomy not women.
And now let me leave and wash myself with that nasty pre-op anti-bacterial scrub as I feel dirty writing the above
MikeJ
Hospitals are like airlines. They don’t want a simple pricing schedule. Confusion works in their favor.
Richard Mayhew
@Belafon: Actually, I am in surprisingly good condition. I don’t want to run a 5K this evening, but stairs are easy enough to do.
beth
@Richard Mayhew: You could have saved a bunch of money if you’d just have put an aspirin between your knees!
Betty Cracker
@Another Holocene Human: Gyad, ain’t that the truth. I’ve often noted that bit of cognitive dissonance while driving on I-75. Cafe Risque — We bare all! Only whores kill snowflake babies! Godless commie atheists are stealing your Christian vote!
Belafon
@Richard Mayhew: When I got mine, I felt pretty good. I decided by the evening that I had rested enough, and tried to go about stuff as normal. Bad idea. I then had to take it easy for the next couple of days.
jl
@beth: Santa Claus is male, also too!
Richard Mayhew
@beth: If that is the case, then you’re doing it wrong or at least non-creatively :)
BillinGlendaleCA
@a hip hop artist from Idaho (fka Bella Q): I first read it as shipping costs too, too close to Christmas I guess.
GHayduke (formerly lojasmo)
Ice, ice, ice. I foolishly worked a 16 hour shift at the triage desk in the ER the day after my vasectomy. Don’t do that.
Richard Mayhew
@Belafon: Yeah, that is what I’m scared of as I’ve had a history of feeling “good enough” to create some really interesting and time consuming setbacks including walking on a broken ankle for eighteen months before I actually had an orthopedist take another look at it.
The goal today is to stay in the house and tomorrow is work remotely at a cafe for most of the day and maybe get Christmas shopping done for my wife and kids. I’ll listen to doc’s orders as I need to be able to referee on Sunday.
dpm (dread pirate mistermix)
@Richard Mayhew: It isn’t that big a deal – ice and advil for a day or two and youi’ll be fine.
It really is nothing compared to a tubal ligation, but I know guys who can’t stomach the thought of it and have made their wives get their tubes tied.
JCJ
This is exactly correct. If I am asked how much a course of radiation will cost I can honestly say I have no idea, but I can find out quickly (both professional and technical charges) since the same codes would apply to all patients. I could not begin to tell you what the reimbursement is where I practice or anyehere else.
Mike in NC
@Another Holocene Human: In rural PA one time we saw a billboard promoting teen abstinence, right next to another billboard with directions to the local adult bookstore.
beth
@Richard Mayhew: Excuse me? Non-creatively? You try having sex holding an aspirin between your knees and not be creative about it.
Belafon
Our third was delivered by Cesarian, and my wife asked for them to tie her tubes. Both of us are fixed to make sure we could have no more. (The day before I went to get my vasectomy, my wife found out she was pregnant with the third.)
Cassidy
@Richard Mayhew: When I got mine, I felt great. Two Valium and percs will do that. Once I came down, I still felt good through the weekend. Monday comes, I’m in a hurry, sat down to hard and my block and tackle exploded in pain and I had that nut punch feeling in my stomach for about two weeks after. So, don’t sit down too hard? I don’t know. Good luck.
raven
One hung low. . .
RSR
Aren’t you supposed to plan it for the Wednesday of the first week f the NCAA basketball tourney, so you can sit on the couch all day for 16 games each on Thursday and Friday?
Richard Mayhew
@dpm (dread pirate mistermix): That was the agreement between my wife and I. She would pass two watermelons and I would get a quick same day surgery to make sure she did not have to squeeze out a third.
I still think I am coming out ahead on the deal.
Flukebucket
@Richard Mayhew: don’t push your luck my friend or else you will be back to see the doctor holding a basketball sized scrotum.
Crusty Dem
@Belafon:
Haha! My wife’s ob suggested it when she had he C-section “already open, no problem” – she said “no, he’s getting snipped!!”
Very small deal. Sore for a day. Got to see my vas deferens.
dpm (dread pirate mistermix)
@Richard Mayhew: My wife cut a tougher deal – one watermelon only.
One of my friends who made his wife get her tubes tied had a child after that because her tubes spontaneously reunited. The gyn swore that was the only time that had ever happened in his practice. My friend got a vasectomy after that.
RSR
Also, a warning from past experience. Even though it’s winter…do not go sledding for a long, long time.
NonyNony
So basically “bundled payments” puts the onus on the doctors (or at least the folks managing the doctors) to understand how much things cost, where the profit is going to be, and how to direct things to maximum profit. While the “reference pricing” model puts the onus on the patient to try to force their doctors into reasonable practices.
Yeah – somehow I think the “bundled payments” model might actually do quite a bit more to control costs than the “reference pricing” model could ever hope to. Hospitals these days are businesses, and businesses have bean counters to figure out the small stuff. My wife and I are the bean counters and, frankly, when I decided to get myself snipped I thought I was going to have to pay it entirely out of pocket and I was STILL not going to be doing anything my doctor didn’t say. Because holy crap we’re talking about a guy with scissors getting near your junk – I’m not going to go to Crazy Al’s Doc In A Box And Car Wash to get that kind of thing done…
Yatsuno
@Richard Mayhew: I will never have said procedure since in order for me to reproduce the methods have to be more…creative. I still winced at this post.
(Neither the NYD nor I want kids. That helps too.)
Lee
@ranchandsyrup:
As others have pointed out it is really not that big of a deal. Ice immediately after then advil & tighty whities for a couple of days.
Had mine done on a Thursday and by Sunday no more advil but I wore tighty whities for a couple more days just to make sure.
300baud
Would you switching actually save anything? Not in the sense of lower bills, but in terms of actual effort or material consumed?
It seems to me that this is more an accounting issue than a costs issue. If everybody shifted consumption of these services to the nominally cheaper alternative, wouldn’t the more expensive alternatives just find a different place to stick their overhead costs?
ranchandsyrup
@Lee: Thanks. I know it will be fine. Have a buddy that had some complications and is now in the midst of litigating. Going in on Friday.
Belafon
@Crusty Dem: My kids are almost five years apart, so, even though we both took steps to prevent another pregnancy, we sweated the time when our youngest was four years old.
catclub
@Another Holocene Human: And also Vasectomy Reversal billboards. Odd.
Mnemosyne
@ranchandsyrup:
I think that’s the kind of thing you have to chalk up to “freak accident” or “really incompetent doctor.”
Arthur
@Lee:
NCAA March Madness season is the most popular time to get a vasectomy. That’s when I got mine.
ranchandsyrup
@Mnemosyne: Yeah, looking like it is the latter.
My (male) cousin is a nurse. Back in his 20’s he had a vasectomy done because he didn’t want kids. In his mid 30’s he had it reversed because he met and married the love of his life. They were having problems conceiving and they told him that due to his love of cycling, he had crushed his “tubing” enough that he didn’t need the vasectomy and sure as heck didn’t need the reversal. They had twins with donor sperm so it all ended well.
John M. Burt
@BGinCHI: http://www.wsufootballblog.com/2012-articles/october/wsu-cal-the-post-op-prediction-edition.html
TaMara (BHF)
May I just say to all you brave men who have been snipped, ‘Thank you”. Real men take control of their reproduction.
Richard Mayhew
@300baud: Any one person switching — you’re right, there would be minimal change. Several percent of the population switching, the overhead could be reduced or high cost capacity could be shut down (remember, hospitals are like Vegas hotels, extremely expensive to open the doors, fairly cheap to shut down and very low marginal costs for non-surge/noncrisis capacity).
Dupe70
@Richard Mayhew: Avoid too much ice. I had a friend of friend think ice good, more ice better and needless to say he suffered from overicing. Yes near frost bite on his family jewels. Took him out for almost a week.
Gin & Tonic
@TaMara (BHF): Like the others have said, it was really no big deal from my end, and it did wonders for our sex life.
300baud
@Richard Mayhew: Thanks. What I’m wondering is more about the nature of the increased costs at the more expensive facilities.
Is it pure waste? If so, I’d rather focus on eliminating the waste there. Or is it related to an an accounting trick, where they are shifting costs? In which case I’d expect the shifted costs to just get shifted somewhere else, resulting in no overall savings.
Janet Strange
The thing I don’t understand about the “bundled payments” system is – what is to prevent doctors and other providers from not giving you care that you actually *need* in order to increase their profits?
We’d like to think that they wouldn’t do that but giving you care that you don’t need to increase their income is common now, even though complications etc occasionally kill someone. Wouldn’t it be even easier for a similarly ethically challenged provider to not do something if that gives them more money?
Douglas Wayne Wieboldt
The other point that you don’t mention is that insurers look at price points and deductible benefits very carefully. If I note this correctly, at the end of the plan year you just about used up your deductible obligations, and they get off mostly scot free. That isn’t of course an accident…
retr2327
@BGinCHI: The thing is, with Cole, he would not have been trying to give himself a vasectomy with sharp scissors and boiling water. Most likely, he would have been trying to clean up tangled cat fur on a Maine coon cat, and ended up giving himself a vasectomy by accident . . . .
Tell me it’s not true.
E
One more data point in the “be careful” narrative. I felt great 12 hours after I got mine. But twelve hours after that my nutsack was stretched tight as a drum, the size and color of a largish eggplant. The stitches were tearing and it felt like I was being kicked in the balls repeatedly, without stop. It was a bad coupla days. That was 1980’s technology so maybe things are better now.
One problem may have been that I lived way out in the sticks and had a four-hour drive home from the clinic, over washboard dirt roads.
Ruckus
@E:
Mine was mid 80’s and it was real easy. Two small cuts, ten minutes, done, Sore for 2-3 days then OK. Don’t know how much the technology for something like that can change. Only difference now would be, mine was done in the Dr office and they don’t do that any more.
gogol's wife
This thread is gruesome but hilarious.
Bill
We were having a bull-session on this subject one day. I told everyone, “Afterwards, for a guy, there’s no vas deferens. For a woman to do this, now that really takes guts.” One of my female co-workers was doubled over, laughing for ten minutes.
My only issue is one of the incision scars ITCH horribly.
Mnemosyne
@Dupe70:
20 minutes on, 20 minutes off.
Ukko
I went to the local research hospital to get mine done. Thinking that an MD is good but an MD PhD is better!
That held true until I was up in the stirrups and he walks in with his “grad student”. It would have been bad form to run from the room screaming. So I really tried to encourage him.
The was a strong wiff of first time in the room as he had some issues “manipulating” me. The professor walked him through each step very and i am sure nothing was done incorrectly. But gently is another story. I was fine until the meds wore off. The bruising was terrible and it took me weeks to recover.
negative 1
@JCJ: right now he probably can’t do either.
negative 1
@ranchandsyrup: Me too, brother. Consult today, good-bye nuts next month. Why do they brag about minimal anasthetic? I had the twilight stuff for my wisdom teeth and that’s just my mouth…
Gin & Tonic
@negative 1: Uh, pro-tip. They don’t actually cut your nuts off. Unless you signed up for something completely different.
JoyfulA
Remember, this can’t be done at a Catholic hospital, which cuts your choices in many areas.
pseudonymous in nc
And the logical extension of that is a standard tariff. Telling a potential patient that you charge “tariff” or “tariff plus X” makes more sense than stating a dollar figure.
With that, you can do a different kind of bundling, where if you charge the tariff, you get fast-track reimbursement.
Central Planning
@Crusty Dem:
Did you get to smell cauterized vas deferens? It’s weird smelling a burned part of your body and not feel any pain.
@Gin & Tonic:
Yup, I think so too (mine, can’t comment on yours)
If our last child was cesarean, we talked about getting her tubes tied. That just wasn’t in the cards, and the odds weren’t with me – 75% natural rate going in.
Anyone who is considering it: just do it. It’s fast and relatively painless if you take it easy for 24-48 hours.
Crusty Dem
@Central Planning:
Yeah, it didnt make me queasy or anything, but probably because my doc wasn’t a cautery maniac…
That said, looking down and seeing internal parts lying external was not a high point. It did result in me being gentle to my bits for the next few days, which was good because i felt fine for 24+ hrs until a little soreness stepped in. Otherwise i might have gone for a jog the next day and that wouldve cost me, big time (I think).
JGabriel
dpm (dread pirate mistermix):
Reunited: and it feels so good.
wkwillis
I had my vasectomy at Kaiser. They lost my application for a vasectomy twice, then tried to tell me I wouldn’t get anesthetics or antibiotics. I asked them if they had religious issues and they decided to go ahead, probably because they were afraid of consequences.
I was 50 plus, we have defective DNA at increasing rates as we go older.
Jake
@TaMara (BHF): @TaMara (BHF): Real Women get tubectomys and take control of their reproduction