Saturday 26 May 2012

Are you getting your money’s worth from surgery?

There is a common belief that if something costs more, it must be better; that you get what you pay for. Recently, a friend of a friend (this is not sounding very scientific, but hear me out) went to see two spine surgeons about his neck pain. One surgeon advised against surgery. The other recommended a neck fusion, to be done in the private hospital with an out-of-pocket “gap” (the fee, above and beyond the health fund rebate) of $10,000. He is now considering drawing on his retirement fund to pay for the surgery. Considering that there are surgeons who will perform this operation for no “gap”, is this worth it? Is the price a reflection of quality?

Firstly, in this case it sounds as if the surgery may not be necessary at all, but let’s run with the assumption that the surgery is going to be helpful for the patient.

There are always going to be examples in life where you actually get what you pay for, but surgery is different. Many surgeons are playing off the fact that people will think more of you if you charge more. But what is the evidence that paying more for healthcare (and surgery in particular) gives you better health?

When comparing countries, the commonly used example is Canada vs the USA. Canada spends about half of the amount the USA spends on healthcare per capita, yet Canada outperforms the USA on most healthcare outcomes. Part of this is probably due to ethnic differences and facts like the obesity rate in the USA being twice that of Canada. But if that is the case, shouldn’t the USA be spending money on preventing obesity through public health programs, rather than spending money on high-end procedures to treat obesity related complications?

In a recent study on one of the most basic operations of all, appendicectomy (“appendectomy” for the Americans), costs between hospitals in California varied from $1,529 to $182,955. I can’t see how there could be any real between-hospital differences in the outcomes for this simple operation.

Fees for another common operation, cataract surgery, were shown to vary from $358 to $2,790 within one province in Canada. Similar variations in cataract costs have been reported in China, and for surgical costs in general in the USA.  Unsurprisingly, surgeons’ fees are related to surgeon density, such that if you increase the number of plastic surgeons in one area by 30%, the operation fees will fall by 30% (here). It appears that surgeons are charging what they can, not what they are worth.

There is a lack of evidence to support an association between cost and quality in surgery, so my advice is that doctor shopping may save you some money if you receive a quote for surgery that seems excessive. Or better still, ask surgeons for their published outcomes. The surgeon who does not routinely and objectively measure his patients’ outcomes is probably overestimating those outcomes, and therefore overestimating his worth.


  1. Your clarity of expression is so necessary to a topic that needs to be further discussed.

    I'm currently doing a neurosurgical rotation in Buenos Aires, Argentina, as a travelling registrar from Australia and the system here sounds very comparable to the one in the U.S. However, the problem here is compounded by a weak economy and restrictive importation rules that make it even more expensive to pay for surgical implants.

  2. Thanks Seb,
    You raise the problem of the cost of implants, a complex but interesting topic. Just like drug costs, they can vary considerably between countries, and the costs are influenced by patents, industry competition and, unfortunately, ability to pay.
    Drug companies have been criticised in books by such authors as Ray Moynihan (Selling Sickness) and former New England Journal of Medicine Editor Marcia Angel (The Truth About Drug Companies: how they deceive us and what to do about it), but the implant companies seem to fly under the radar.


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