Heart-stopping surgery for a heart-stopping cost

Posted: Sunday, December 27, 2009

I had a quadruple by-pass at Anchorage's Providence Hospital in October.

I'd gone to the hospital the day before for an angiogram, a test where they squirt a dye into your heart to disclose any blockages. Best outcome would be a clean bill of health, but even if they found a blockage chances were they could fix it with a stent or angioplasty. I'd be out of the hospital in about 24 hours. That's what happened in 2006, when doctors first diagnosed my coronary artery disease.

You are awake as they do the angiography. My cardiologist is peering into a screen showing the flow in my coronary arteries. I can't see him, but he asks me questions, and sometimes talks to himself. "Oh, boy, oh boy," he says. That's not what you want to hear your cardiologist say.

My surgeon kicked me out of the hospital six days later. "I've had a few patients that met the (discharge) milestones as fast as you, but not many," he remarked.

The truth is I'm extraordinarily lucky they discovered the 95 percent blockage in my right main coronary artery before it shut down completely. The right main feeds half the heart. Enough said.

Fifty years ago, surgeons started using veins and arteries extracted from less crucial parts of the body to bypass these blockages. The basic surgical scheme is little changed in 35 years. The surgeon and assistant use a high-tech jigsaw to cut through the sternum, then crank the chest open with a device that would be right at home in a shop repairing truck tires. Next they hook you up to the heart-lung machine with a spaghetti of tubes, wires and catheters. The team - 11 people in my case - then stops your heart by clamping off the aorta and flushing its chambers with a cocktail of your own blood chilled to 39 degrees Fahrenheit.

For the next 66 minutes my surgeons sewed away, replumbing my heart with pieces of my left mammary artery and a long vein from my right leg. My heart, having thumped unceasingly for 68 years, rested.

Mortality rates for this procedure used to be above 10 percent, but survival improved as doctors and nurses learned better ways to manage the trauma of surgery and prevent complications during recovery. Total one-year mortality is now about 2 percent, compared to about 1 percent for people of similar age in the general population.

Whether the procedure improves survival of those with coronary artery disease is controversial. Doctors in some advanced countries like Sweden do only about one-fourth as many of these procedures, preferring to treat patients with pills and exhortations for life-style changes alone.

The bills for my procedure are now all in. The cost was $138,265. Medicare, the government-run universal coverage program for old folks, paid $41,353 (30 percent). My state retiree coverage paid $2,229 (2 percent). I paid nothing.

What happened to the remaining $94,683 (68 percent)? Providers wrote it off. Why would they do that? Because the federal government uses its market power to force on them a "deal they can't refuse." Take the deal, or we won't certify you as a Medicare provider.

This is justified as a way of offsetting the market power of providers who can charge what the market will bear, often way more than could be justified by costs. Big insurance companies can sometimes negotiate smaller reductions with "preferred providers" using their lesser market power.

If you're a self-pay patient, you pay what the market will bear. So do most insurance plans providing coverage to all but the largest Alaska businesses. That's why costs, co-pays and deductibles for such plans have grown so dramatically; what providers write off on patients who don't pay the full freight, they make up on their charges to those without market power. Want to start your own business? Unless you have health coverage through your spouse or as a retiree, don't try. You can't afford it.

Where they sawed through my breastbone won't completely heal for another couple of months. "Sorry honey, no snow shoveling, doctor's orders." But all in all, my New Year's prognosis is outstanding.

I wish I could say the same for America's health care system. Those of us who have done well under the current system need to think about young folks trying to start their own businesses, and about coverage for our children who have chosen careers outside of government or big business. Let's ask our senators and representative in Congress what they've put in their new plan to take care of those younger citizens.

• Juneau economic consultant Gregg Erickson is editor-at-large of the Alaska Budget Report, a newsletter covering the state's economy and government. A spreadsheet containing Erickson's analysis of his hospital and doctor bills is available. E-mail him at gerickso@alaska.com.

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