From Labor and Delivery to LDL Gender Issues in Cost and Quality of Care Eric Bricker, MD

1. From Labor and Delivery to LDL Gender Issues in Cost and Quality of Care Eric Bricker, MD Dallas Association of Health Underwriters November 16, 2011

2. Background Compass Professional Health Services -Tools and Support for Healthcare Consumers General Internal Medicine Physician -“Internist”, “PCP” Johns Hopkins trained Hospital finance consultant with Stockamp & Associates

3. Labor and Delivery Cost Variance Ob/Gyn fee – global billing Hospital fee – local variation Anesthesia fee – INN vs OON challenges

4. Compare prices for Labor and Delivery: In Network Facility 1 $6,450 $3,350 wasted In Network Facility 2 $3,100

5. Compare prices for C-section: In Network Facility 1 $12,400 $4,600 wasted In Network Facility 2 $7,800

6. Compare prices for MRIs: In Network Facility 1 $2,300 $1,350 wasted In Network Facility 2 $950

7. Why? How can this be? Hospital B “I am willing to take lower reimbursement for imaging” Contracted Rate of $950 “I want good reimbursement for deliveries” Contracted Rate of $6,450 Hospital A “I want good reimbursement for imaging” Contracted Rate of $2,300 “I am willing to take lower reimbursement for deliveries” Contracted Rate of $3,100

8. Repeat that dynamic for: • Labor and Delivery • Endoscopy • Outpatient Surgery • Implantables—pacemakers, stents • MRIs • Med/Surg Day Rate Final Average Discount Rate Hospital A 50% Hospital B 50%

9. Labor and Delivery--Quality Variance “Despite the more than 4 million deliveries in the United States each year,1 there are currently no uniformly accepted measures of obstetric quality” --Obstetrics and Gynecology May 2010 Delivery Volume—does NOT appear to correlate with better outcomes (unlike some other medical procedures) CMJ May 2002, J of Womens Health Oct 2010 Highly Variable—Personal Diligence Communication breakdowns w/ handoffs Rushing

10. Hysterectomies Cost Variance Ob/Gyn fee—not much variation Facility fee Hospital Outpatient - Most ASC Outpatient - Middle Hospital Inpatient - Least

11. Hysterectomies—Quality Variance Frequency of Hysterectomies is highly variable—should it be done? 50% more hysterectomies performed in the South than in North East or West CDC 1994-1999 Five-fold difference within one state Am J of Obstetrics and Gynecology Alternatives to Hysterectomy—second opinion Medication, uterine artery embolization, myomectomy, ablation

12. Cardiovascular Disease #1 Cause of mortality for women Prevention is the best medicine—ABCs Mayo Clinical Proceedings Aug 2008 A – Anti-platelet therapy (aka Aspirin) Platelets form blood clots Body is constantly producing and dissolving clots in the blood stream Must be weighed against risk of stomach and intestinal bleeding

13. Cardiovascular Disease B – Blood pressure control 30% have high blood pressure 30% of those with high blood pressure are unaware of it 50% of those treated for high blood pressure are NOT adequately treated --usually requires 2 or more medications CDC Jan 2011

14. Cardiovascular Disease C – Cholesterol and Cigarettes Cholesterol LDL and HDL numbers are important ATP III Guidelines Cigarettes Tear up the blood vessels Must address cravings

15. Cardiovascular Disease D – Diabetes 1 in 12 adults have diabetes 30% of those with diabetes are unaware of it 40% of those treated for diabetes are not adequately treated CDC, American Diabetes Association E – Exercise Goal of 10,000 steps per day (30 min of exercise) Buy a pedometer (F) - Fun

16. Cardiovascular Disease (F) – Fun Attitude, Stress and Coping Mechanisms count Cortisol, Epinephrine stress hormones Northridge Earthquake Tako-Tsubo – Stress Cardiomyopathy aka “Broken Heart Syndrome” Type A personalities at increased risk Psychosomatic medicine Nov 2006

17. Comments and Questions Eric Bricker, MD Compass Professional Health Services Tools and Support for Healthcare Consumers --Price Transparency --Quality Transparency --Consumer Advocacy ericb@compassphs.com