December 26, 2006

Selma- Home of the Discount Appendectomy

How much is your appendix worth?  Depends where you live.

Suppose you’re a 66-year-old resident of scenic San Francisco, California.  One morning, you wake up feeling vaguely queasy.

“Probably something I ate,” you conclude, continuing preparations for your trip to visit your daughter in Bakersfield this afternoon.

But around noon, the queasiness is accompanied by a dull ache, centered on your bellybutton, which worsens throughout your afternoon drive.

About six hours after the symptoms started, you know you’re in trouble.  The ache in your belly is now sharp pain that has moved down and to the right.  You have no choice but to pull over, overcome by discomfort and the urgent need to vomit.

Most surgical interns would make the diagnosis at this point—acute appendicitis.  You’re not sure, but it’s clear an Emergency Room will be the next stop on your trip.

Here’s where geography determines the worth of that inflamed worm-shaped organ that interrupted your travel and, if not addressed, may threaten your life.

Let’s say you made it an hour south of San Francisco on the 101 into “Silicon Valley” before the symptoms became severe.  The Emergency Physician at the hospital in Santa Clara examines you and immediately requests a surgical consult.  After evaluating you, the Surgeon agrees and recommends an emergency appendectomy.  You are whisked off to the Operating Room and wake up a few hours later, groggy but relieved that the severe pain has subsided.  Aside from the neatly bandaged small incision on your abdomen, no evidence of acute appendicitis remains.

Your Surgeon hopes hope to get paid for the emergency procedure he just performed.  He submits a bill to Medicare for “Code#44950—Open Appendectomy, Non-Ruptured.”  Several weeks later, he receives a check for $748.24 to cover the procedure and all follow-up care for three months afterwards.

But suppose you’re an unusually stoic type, gritting your teeth as the pain worsens on your journey from San Francisco to Bakersfield.  You drive through Gilroy and head east on 152, tempted to stop in Los Banos at your favorite restaurant, Españas.  But nausea and a strange lack of appetite compel you to forego the homemade salsa and continue, eventually reaching Highway 99 South.

Thirty minutes later, the exits for Fresno appear.

“I can make it,” you think, despite the rivulets of sweat staining the back of your shirt.  “Just ninety minutes to Bakersfield.”

Barely 30 miles further south, the limits of your high pain tolerance have been reached.  A blue “H” highway sign in the small town of Selma, California marks your exit.

Selma Community Hospital’s Emergency Department is busy, but the triage nurse is concerned by how ill you appear, and immediately ushers you to a gurney.

I am called in by my Emergency Medicine colleague to evaluate you.  I recognize the diagnosis based on information learned long ago as an Intern; urgent surgery is mandatory.  I perform an emergency appendectomy, removing the bright red, abnormally swollen source of your trouble before it bursts, spreading infection throughout your abdomen. 

In third world countries, a ruptured appendix is frequently a death sentence.  But you were in good health before this episode and received the right operation, so you’ll likely recover quickly and make a rapid return to your usual activities.

Just as my fellow Surgeon in Santa Clara did, I submit a bill to Medicare.  Identical procedure code—44950.  Identical diagnosis—Acute Appendicitis, Non-Ruptured.

Is the payment almost $750, as in Santa Clara?

No.  According to Medicare’s clever formula, your appendix just isn’t worth as much in central California as it is in the Bay area—or Napa Valley, or Newport Beach, or Carmel, for that matter.

In fact, in every county in the San Joaquin Valley and across the state’s rural communities, removing your appendix merits a 20% discount: $601.43.

“That seems fair,” some would suggest.  After all, that glass-walled medical office in San Francisco’s tony Nob Hill section doesn’t come cheap.  With higher rents should come higher payments, they reason. 

Equal pay for equal work just wouldn’t be fair.

True, rents are higher in Beverly Hills than in Selma.  But consider some other factors central California’s doctors face as we try to meet medical practice expenses and keep our office doors open 

The San Joaquin Valley’s counties have a poverty rate TWICE that of more affluent parts of our state.

We serve a population with 30% more Medi-Cal recipients, a program which reimburses California doctors at a lower level than all but eight states in the U.S.  In my practice and in those of many of my colleagues, more than 60% of my patients are uninsured or underinsured with Medi-Cal.  Medi-Cal reimbursement, based on a 1969 formula, has been increased ONCE in the past twenty years.

Our unemployment figures are THREE TIMES higher than in regions less economically depressed.

Our economy is agriculture-based, supporting a high percentage of illegal immigrants.  With little preventive healthcare and a great reluctance to seek medical attention early, they present to our Emergency Rooms with advanced disease and consequently higher complication rates.  This drives up the cost of their care, which we provide without the expectation of ever getting reimbursed.  70% of the patients I care for during emergency calls result in zero payment for care provided.

Predictably, central California has a Physician shortage.  With 25% fewer primary care doctors, 50% fewer specialists and 75% fewer mental health professionals, our offices and clinics are overwhelmed by the needs of those we serve.

Yet our region’s efforts to recruit quality doctors are frustrating and frequently unsuccessful, sometimes requiring years to attract a single qualified Physician.  The low reimbursement rate contributes to the difficulties we face in meeting our growing population’s healthcare needs.

I love our Valley’s endless rows of fruit trees, our vast acres of farmland with happily grazing dairy cows and the beautiful grape vineyards that have given my town, Selma, the title “Raisin Capital of the World.”  But even such bounty cannot compete with the appeal of California’s spectacular coastal region, the cultural attractions of Los Angeles or the sophisticated urbane chic of San Francisco.

Though 25% of this country’s population resides in rural America, fewer than 10% of its doctors practice there.  Those of us who do choose to serve in rural areas struggle to meet expenses, burdened by high medical malpractice insurance rates, skyrocketing health insurance premiums for our employees—and ourselves—and Worker’s Compensation expenses no less exorbitant than those of colleagues in affluent cities.  Yet we are guaranteed to be paid less.

Doctors are needed in rural and economically challenged parts of our state.  Our patients suffer when healthcare resources are stretched to the near breaking point.  Frustrated, we try to meet impossible demands in order to fulfill the oath we took to the patients for whom we care so deeply.

Equal pay for equal work must become a guiding principle as policymakers reform a healthcare system already creaking beneath the weight of inefficiency, bureaucracy and an ever-increasing workload.  With improved access to quality healthcare, patients in rural California will reap the benefits.