What is Elective Surgery? What surgery is ‘Elective’?
The term is somewhat confusing providers and patients have differing views of what is truly ‘elective’. When I had foot surgery a few years ago, the surgery enabled me to walk again. Same for my friend who had back surgery.
The term ‘elective surgery’ means surgery that is scheduled. It is not life-saving or emergent surgery.
How is this service, which requires skill and years of training by a team of professionals, provided timely, safely, and at an affordable cost?
TIMELY
From the patient’s perspective, timely might be defined as the interval:
“I am in pain”
to
“I am not in pain”.
New Zealand and most Northern European countries measure the time to see a specialist (surgeon), and then the time to treatment (surgery). The performance standard for elective surgery in New Zealand is 4 months to see a specialist, then 4 months to have surgery. The wait queue is managed by prioritizing patients based on acuity. In 2017, most (> 80%) saw a surgeon and then over 90% had their surgery within these timeframes. In the US, comparable wait metrics are difficult to obtain. In researching this blog post, the best source I could find was a study done in 1994. This study was cited by an article published by New England Journal of Medicine in 2017, who evidently did not find a more recent study, either!
Who tracks wait times in the US?
The term is somewhat confusing providers and patients have differing views of what is truly ‘elective’. When I had foot surgery a few years ago, the surgery enabled me to walk again. Same for my friend who had back surgery.
The term ‘elective surgery’ means surgery that is scheduled. It is not life-saving or emergent surgery.
How is this service, which requires skill and years of training by a team of professionals, provided timely, safely, and at an affordable cost?
TIMELY
From the patient’s perspective, timely might be defined as the interval:
“I am in pain”
to
“I am not in pain”.
New Zealand and most Northern European countries measure the time to see a specialist (surgeon), and then the time to treatment (surgery). The performance standard for elective surgery in New Zealand is 4 months to see a specialist, then 4 months to have surgery. The wait queue is managed by prioritizing patients based on acuity. In 2017, most (> 80%) saw a surgeon and then over 90% had their surgery within these timeframes. In the US, comparable wait metrics are difficult to obtain. In researching this blog post, the best source I could find was a study done in 1994. This study was cited by an article published by New England Journal of Medicine in 2017, who evidently did not find a more recent study, either!
Who tracks wait times in the US?
- Surgeons? Some track wait time to see the surgeon.
- Insurance companies? No, at least I did not find any, and concluded they probably do not track this since they do not have driving reasons to do so.
- Hospitals? No. As exemplified in a Burlington Times article (January 2017), Chris Oliver, vice president of clinical services at UVM Medical Center said, "Wait times is not an accurate measure”, so it does not track wait times for any surgeries or procedures. UVM Medical Center does monitor wait times for imaging and access to physicians, however.
SAFE AND AFFORDABLE
Both New Zealand and US track readmissions after surgery. In recent years, US hospitals have been financially penalised for readmissions, so this issue has been getting a lot of scrutiny.
A study of 346 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between January and December 2012 reported the unplanned 30 day readmission rate for 498,875 operations was 5.7 percent.
Last year (Nov 2016-Oct 2017), Health Roundtable reported the rate for 28-day post-surgery readmissions in New Zealand was 2 percent.
About half of New Zealand surgeries are performed in private hospitals, but private hospitals are not required to report their outcomes, so only outcomes for surgeries performed in public hospitals are publicly reported. If a patient is readmitted for a complication such as an infection, they are sent to the public hospital and the readmission is counted.
Private hospital services and stays in New Zealand are usually paid with insurance. Private hospitals offer wait times similar to US patients with good insurance, choice of surgeon, and a private room, such as the first story here:
NZ Patient Experience– Private Hospital
Pre-surgery
A study of 346 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between January and December 2012 reported the unplanned 30 day readmission rate for 498,875 operations was 5.7 percent.
Last year (Nov 2016-Oct 2017), Health Roundtable reported the rate for 28-day post-surgery readmissions in New Zealand was 2 percent.
About half of New Zealand surgeries are performed in private hospitals, but private hospitals are not required to report their outcomes, so only outcomes for surgeries performed in public hospitals are publicly reported. If a patient is readmitted for a complication such as an infection, they are sent to the public hospital and the readmission is counted.
Private hospital services and stays in New Zealand are usually paid with insurance. Private hospitals offer wait times similar to US patients with good insurance, choice of surgeon, and a private room, such as the first story here:
NZ Patient Experience– Private Hospital
Pre-surgery
“I had two surgeries in a private hospital. The first surgery was for prostate cancer and the second fixed a complication from the first surgery (classed as a treatment injury by ACC). I was originally diagnosed in June through the public system. In reviewing the biopsy and results with the physician, we discussed options for surgery or active surveillance. I initially opted for surveillance but decided to seek a second opinion on the advice of my GP. I saw a surgeon at a private hospital, who advised me get a different type of biopsy, which identified significantly more tumour than the first biopsy. After discussion with this surgeon, and researching the different surgery options, I decided to have the surgery in the private hospital, mainly because it would be robotic assisted and gave me the greatest chance of a quick recovery back to full fitness. I elected to wait until after the Xmas holidays so had the surgery at the end of January.
Surgery
Surgery
The surgery should have been a 1-night stay, but I ended up staying 4 days because of an infection and I needed readmitting to the public hospital a week later. I had a private room at the private hospital but shared a ward with three others in the public hospital. The care I received in both hospitals was fantastic. The source of the infection and reason for it is still a mystery to this day. I would rate the care I received a ‘5’ out of ‘5’ in both hospitals. The surgeon was outstanding – I had many complications yet he was accessible by mobile all hours to help.
Costs
Costs
I have private insurance, which is paid for by my employer who pays around $170/month for myself and my wife. My company has about 40 salaried employees who are provided with this insurance. The operation in the private hospital was robotic assisted and cost approximately $25,000 NZ ($18,000 US) and my insurance covered about 80% of the cost, so I paid approximately $5,000 NZ ($3,600 US) out of my own pocket. The cost of the second operation was covered 100% by NZ ACC since it was considered treatment of an injury that resulted from the first surgery.”
Blogger’s note: To validate this cost of insurance, I researched New Zealand’s largest insurer, Southern Cross, which insures about 25% of the population in NZ. I obtained a quote for the premium plan which included coverage for some cancer care, unlimited surgical treatment, consultations, diagnostic imaging and tests, and other benefits, with additional coverage options for cancer treatment, vision, and dental. Without these add-ons and unsubsidized by an
employer, a 50-year-old female non-smoker would pay $53/week for one person, or $38US. https://join.southerncross.co.nz/quote.
What is the surgical experience of the public hospital in New Zealand?
NZ Patient Experience – Public Hospital
Blogger’s note: To validate this cost of insurance, I researched New Zealand’s largest insurer, Southern Cross, which insures about 25% of the population in NZ. I obtained a quote for the premium plan which included coverage for some cancer care, unlimited surgical treatment, consultations, diagnostic imaging and tests, and other benefits, with additional coverage options for cancer treatment, vision, and dental. Without these add-ons and unsubsidized by an
employer, a 50-year-old female non-smoker would pay $53/week for one person, or $38US. https://join.southerncross.co.nz/quote.
What is the surgical experience of the public hospital in New Zealand?
NZ Patient Experience – Public Hospital
Pre-surgery
“I had knee surgery about 8 months after first discussing with my primary care physician. Half that time, about 4 months, was spent waiting to see a specialist. My doctor gave me pain medication while I was waiting. I did not get to choose my surgeon, but felt I got the right one.
Surgery
Surgery
The surgery was exactly as described to me. I rate the care I received a ‘5’ out of ‘5’, even though I did not have a private room. I did not have any complications and my total stay was 5 days.
Post-surgery
Post-surgery
I received physio therapy once a day while in the hospital, then once / week, where the therapist visited me at home. They also dropped off and picked up physio equipment and various items. Post-op pain was managed with Tramadol, Paracetamol, and Celebrex. I phased out Tramadol after about 3 weeks, and the rest after six. I would rate the whole experience a successful ‘5’ out of ‘5’.
Costs
Costs
My total cost was for the initial x-rays, about $350. ($252 US).”
How do these experiences compare with the US?
US PATIENT EXPERIENCE
Pre-surgery
How do these experiences compare with the US?
US PATIENT EXPERIENCE
Pre-surgery
“I developed sciatica from a herniated disc. Initially, the pain was intermittent, however it quickly became acute and ultimately debilitating. Prior to the surgery, a pain management specialist injected cortisone into the L3-L4 and L4-L5 zone of the lower back. After 3 such treatments, relief of pain was only partial and transitory and it was determined that surgery would be required. Further injections of cortisone were utilized for diagnostic purposes, to better identify the exact location of spinal stenosis. It was an 8 month process leading to surgery in October.”
Blogger’s note: The 8-month wait time of this patient’s experience is not uncommon, but not representative of the norm. Wait times vary widely depending on the type of surgery, geographic location, and type of insurance. A very unscientific poll of a small group of US friends and family with good insurance reported their time to see a specialist was about 3-4 weeks, then surgery was scheduled for 3-4 weeks later, for a total average of 6-8 weeks.
Surgery
Blogger’s note: The 8-month wait time of this patient’s experience is not uncommon, but not representative of the norm. Wait times vary widely depending on the type of surgery, geographic location, and type of insurance. A very unscientific poll of a small group of US friends and family with good insurance reported their time to see a specialist was about 3-4 weeks, then surgery was scheduled for 3-4 weeks later, for a total average of 6-8 weeks.
Surgery
“Laminectomy procedures are performed by either of two different medical specialties – surgeons trained in orthopaedics or surgeons trained in neurology. The task is the same, which is to relieve pressure on nerves. I started with an orthopaedic surgeon, however, I elected to switch to a neurological surgeon.
I stayed one day, in a post op recovery area. I rate pre-surgery and surgery as a ‘5’. I did not have any rehab or physio services in the hospital.
Post-surgery
No physical therapy program was followed. No one came to the house. Pain was managed by prescription to relieve inflammation at lower back (steroids?), a muscle relaxant, acetaminophen and ibuprofen. Household assistance, such as getting up from a seated position, was provided by my spouse. My recovery has been much slower than anticipated, and the doctors speculate upon possible need for additional surgery.
The surgery was as described to me with both plastic spine models and MRI imagery. I am delighted and rate the final result a ‘5’ out of ‘5’.
The surgery was as described to me with both plastic spine models and MRI imagery. I am delighted and rate the final result a ‘5’ out of ‘5’.
Costs
My out of pocket costs were $6,000 and insurance paid for the rest.”
Like wait times, costs of procedures in US healthcare are also elusive, as experienced by my friend who tried to shop around for the best price for the surgery on his finger. He was told to have to the surgery and then he will know how much it cost. He said, “I picked a doctor, supposedly the best in (large academic medical center in large US city), and had the surgery and then random bills showed up in the mail.” He is still experiencing pain.
Cost of healthcare services and treatments in the US are dependent upon who is paying, as providers negotiate unique service contracts with each payer, and payers negotiate unique agreements with each provider. Payers and providers guard this information and without transparency, there is no way to compare prices of surgeries. The person without insurance usually pays more than any insurer. As I write this, I imagine the salaries of those negotiating and managing these contracts would be equivalent to quite a few physicians, nurses, pharmacists and other care providers at the patient bedside.
Public versus private healthcare debate continues everywhere, but the combination works in New Zealand at a more affordable cost. Health insurance and New Zealand’s private hospitals will be discussed in more depth with a future blog post about Cancer and Palliative Care.
Like wait times, costs of procedures in US healthcare are also elusive, as experienced by my friend who tried to shop around for the best price for the surgery on his finger. He was told to have to the surgery and then he will know how much it cost. He said, “I picked a doctor, supposedly the best in (large academic medical center in large US city), and had the surgery and then random bills showed up in the mail.” He is still experiencing pain.
Cost of healthcare services and treatments in the US are dependent upon who is paying, as providers negotiate unique service contracts with each payer, and payers negotiate unique agreements with each provider. Payers and providers guard this information and without transparency, there is no way to compare prices of surgeries. The person without insurance usually pays more than any insurer. As I write this, I imagine the salaries of those negotiating and managing these contracts would be equivalent to quite a few physicians, nurses, pharmacists and other care providers at the patient bedside.
Public versus private healthcare debate continues everywhere, but the combination works in New Zealand at a more affordable cost. Health insurance and New Zealand’s private hospitals will be discussed in more depth with a future blog post about Cancer and Palliative Care.
