Was President Andrew Jackson Overcharged? An Economic Evaluation of 19th Century Surgical Charges for Urologic Procedures and their Comparison to the Modern, RVU Era

Objectives Surgical billing is as old as the profession of surgery but there is no published data that has characterized changes in surgical fees over history. Surgical remuneration has been better studied in the Medicare era of relative value units (RVUs)-based payment but what surgeons charged in the American 18th and 19th centuries is unknown. President Andrew Jackson underwent surgery by Dr. James Hall for a hydrocele in 1832 and was billed, and then paid, $30. Our initial objective was to determine the appropriateness of Dr. Hall’s surgical billing for that era. We then wished to determine historical trends in physician billing for similar urologic procedures in the 18th-19th centuries compared to the current RVU era, correcting for inflation. Methods Published fee tables from 18th and 19th century regional medical societies, prevailing charge data from the Center for Medicare Services (CMS) from 1967-1985, and published RVU values and conversion numbers from 1992-2020 (CMS) were used for analysis. To correct for inflation, we used a published consumer price index (CPI) for 1774-2020 indexed to 2020 US dollars. Mann-Whitney U-tests were used to compare unpaired differences without parametric assumptions. Results A total of 43 fee tables from 18 states from 1818-1898 were identified. The $30 charge to President Jackson for hydrocele surgery was similar to other states’ medical society recommendations of the early 1830s. Over the 19th century, there was an insignificant increase in the low-end fee pricing for hydrocele surgery of $18.4 +/- 17.9 in 1818-1840 versus $28.70 +/- 36.83 from 1880-1890 (p > .05), adjusting for inflation. Similarly, for initial male urinary catheterization, the mean surgical fee of $4.28 +/- 1.25 in 1818-1850 was similar to the $4.75 +/- 5.62 mean surgical fee in 1851-1900 (p>.05). Adjusting to 2020 dollars, however, reimbursement for urinary catheterization in 1818-1850, 1850-1900, 1975-1984, and 1992-2020 was $113.04 +/- 38.06, $131.20 +/- 169.53, $73.87 +/- 2.38, and $23.05 +/- 4.69, respectively (p<.01). of 11%. Conclusions Dr. James Hall, physician to 10 US Presidents, appropriately billed the 7th President for what would be now described as a hydrocele drainage and scarification. Fees for that procedure remained stable or decreased throughout the 19th century. Surgical fees for male urinary catheterization, however, decreased 82% from the 1840s to the 2020s, correcting for inflation.

Ethical Issues in Physician Billing Under Fee-For-Service Plans

Medical ethics has become an important and recognized component of physician training. There is one area, however, in which medical students receive little guidance. There is practically no discussion of the financial aspects of medical practice. My objective in this paper is to initiate a discussion about the moral dimension of physician billing practices. I argue that physicians should expand their conception of professional responsibility in order to recognize that their moral obligations toward patients include a commitment to honest and forthright billing practices. I argue that physicians should aspire to a standard of clinical accuracy—not legal adequacy—in describing their activities. More generally, physicians should strive to promote an integrity-based professional culture, first and foremost by stigmatizing rather than celebrating creative billing practices, as well as condemning the misguided sense of solidarity that currently makes it taboo for physicians to criticize each other on this score.

Development of an administrative definition for celiac disease

Objective The investigation and management of celiac disease places a high burden on the health care system. Accurate methods to ascertain cases of celiac disease (CD) in population-based administrative data can facilitate epidemiologic and health services research to guide disease management. The study aim was to develop and validate administrative data case definitions for CD to facilitate further studies about the effect of CD on osteoporosis and fracture risk. Results Population-based data from the Manitoba Bone Mineral Density (BMD) Program registry, which contains medical information on all individuals in the province of Manitoba, Canada who have received BMD testing, was used to define the study cohort. Linked hospital discharge abstracts and physician billing claims were used to ascertain diagnoses of celiac disease in administrative data. A population-based CD serologic registry was used as the validation database. One diagnosis code in hospital discharge abstracts or two or more diagnosis codes in physician billing claims optimized the detection of positive celiac serology with sensitivity of 84% (95% CI 80–88%), specificity of 97% (95% CI 80–88%), PPV of 80% (95% CI 80–88%), and NPV of 97% (95% CI 80–88%). Our administrative data case definition for celiac disease demonstrates good sensitivity and specificity for detecting positive celiac serology.

Dermatitis among workers in Ontario: results from the Occupational Disease Surveillance System

ObjectivesDermatitis is the most common occupational skin disease, and further evidence is needed regarding preventable risk factors. The Occupational Disease Surveillance System (ODSS) derived from administrative data was used to investigate dermatitis risk among industry and occupation groups in Ontario.MethodsODSS cohort members were identified from Workplace Safety and Insurance Board (WSIB) accepted lost time claims. A case was defined as having ≥2 dermatitis physician billing claims during a 12-month period within 3 years of cohort entry. A 3-year look-back period prior to cohort entry was used to exclude prevalent cases without a WSIB claim. Workers were followed for 3 years or until dermatitis diagnosis, age 65 years, emigration, death or end of follow-up (31 December 2016), whichever occurred first. Age-adjusted and sex-adjusted Cox proportional hazard models estimated HRs and 95% CIs. The risk of dermatitis was explored using a job exposure matrix that identifies exposure to asthmagens, many of which also cause contact dermatitis.ResultsAmong 597 401 workers, 23 843 cases of new-onset dermatitis were identified. Expected elevated risks were observed among several groups including furniture and fixture industries, food and beverage preparation and chemicals, petroleum, rubber, plastic and related materials processing occupations and workers exposed to metal working fluids and organic solvents. Decreased risk was observed among farmers, nurses and construction industries, and occupations exposed to latex and indoor cleaning products.ConclusionsODSS can contribute to occupational dermatitis surveillance in Ontario by identifying occupational groups at risk of dermatitis that can then be prioritised for prevention activities.

Estimating Health Care Costs of Non-Melanoma Skin Cancer in Saskatchewan using Physician Billing Data

Introduction Given the high occurrence and morbidity of non-melanoma skin cancer (nmsc), its economic burden on the Canadian health care system is a cause for concern. Despite that relevance, few studies have used patient-level data to calculate the cost of nmsc. The objective of the present study was to use physician billing data to describe the health care costs and service utilization associated with nmsc in Saskatchewan.Methods The Saskatchewan Cancer Agency’s cancer registry was used to identify patients diagnosed with nmsc between 2004 and 2008. Treatment services and costs were based on physician billing claims, which detail physician services performed in an outpatient setting. Total and annual outpatient costs for nmsc and mean outpatient cost per person were calculated by skin cell type, lesion site, and geographic location. Service utilization and costs by physician specialty were also explored.Results Total outpatient costs grew 12.08% annually, to $845,954.98 in 2008 from $527,458.76 in 2004. The mean outpatient cost per person was estimated at $397.86. Differences in the cost-per-person estimates were observed when results were stratified by skin cell type ($403.41 for basal cell carcinoma vs. $377.85 for squamous cell carcinoma), lesion site ($425.27 for the face vs. $317.80 for an upper limb), and geographic location ($415.07 urban vs. $363.48 rural). Investigation of service utilization found that 92.14% of treatment was delivered by general practice and plastic surgery/otolaryngology physicians; dermatology delivered only 6.33% of services.Conclusions Our results underestimate the direct costs of nmsc because inpatient services and non-physician costs were not included in the calculations. The present research represents a first step in understanding the cost burden of nmsc in Saskatchewan.

Identifying Rheumatoid Arthritis Cases within the Quebec Health Administrative Database

Objective.Our objective was to calculate rheumatoid arthritis (RA) point prevalence estimates in the CARTaGENE cohort, as well as to estimate the sensitivity and specificity of our ascertainment approach, using physician billing data. We investigated the effects of using varying observation windows in the Régie de l’assurance maladie du Québec (RAMQ) health services administrative databases, alone or in combination with self-reported diagnoses and drugs.Methods.We studied subjects enrolled in the CARTaGENE cohort, which recruited 19,995 participants from 4 metropolitan regions in Québec from August 2009 to October 2010. A series of Bayesian latent class models were developed to assess the effects of 3 factors: the number of years of billing data, the addition of self-reported information on RA diagnoses and drugs, and the adjustment for misclassification error.Results.The 3-year 2010 point prevalence estimate among cohort members aged 40–69 years, using physician billing plus self-report, adjusting for misclassification error in each source, was 0.9% [95% credible interval (CrI) 0.7–1.2] with RAMQ sensitivity of 84.0% (95% CrI 74.0–93.7) and a specificity of 99.8% (95% CrI 99.6–100.0). Our results show variations in the prevalence point estimates related to all 3 factors investigated.Conclusion.Our study illustrates that multiple data sources identify more RA cases and thus a higher prevalence estimate. RA point prevalence estimates using billing data are lower if fewer years of data are used.

Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial

BackgroundIn 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level.MethodsThis retrospective observational cohort study identified patients undergoing pde for malignancy, 2005–2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd.ResultsOf 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412).ConclusionsRates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.