QC: Why Finding In-Network Endometriosis Specialists Is So Difficult

Dr. Jeff Arrington explains why insurance is a major barrier for endometriosis specialists and patients seeking care. The healthcare payment system fundamentally fails to recognize the difference between quick, superficial treatments and proper excision surgery that actually removes the disease.

• Insurance payment systems are based on Relative Value Units (RVUs) set by Medicare
• The RVU system has three components: work involved, malpractice risk, and geographic location
• A superficial 15-minute ablation receives the same insurance payment as a 3-hour expert excision
• The system creates no financial incentive for surgeons to perform proper, thorough excision
• Complex work around sensitive structures like ureters and bowel is not recognized by insurance
• Skilled specialists often can't afford to accept insurance due to this payment inequality

Send your questions by using the link in the description, emailing contact@indobattery.com, or visiting the Indobattery.com contact page.

Chapters

• 0:00 Podcast Introduction
• 1:40 nderstanding Insurance and RVUs
• 5:34 ow Insurance Fails Endo Patients
• 7:49 pisode Closing and Contact Info

Transcript

SPEAKER_00: 0:00

Life moves fast and so should the answers to your biggest questions. Welcome to Indo Batteries Quick Connect, your direct line to expert insights. Short, powerful, and right to the point. You send in the questions, I bring in the experts, and in just five minutes, you get the knowledge you need. No long episodes, no extra time needed. And just remember, expert opinions shared here are for general information and not for personalized medical advice. Always consult your provider for your case-specific guidance. Got a question? Send it in, and let's quickly get you the answers. I'm your host, Alana, and it's time to connect. Dr. Errington is not only an expert in advanced minimally invasive gynecologic surgery, but also a fierce advocate for endometriosis patients, both in and out of the operating room. Known for his compassionate approach and relentless dedication, Dr. Errington has made it his mission to give hope to patients who've been told their cases are hopeless. With over two decades of surgical experience and a steadfast belief in excision as the best treatment for endometriosis, Dr. Errington has helped patients worldwide reclaim their quality of life through meticulous care, cutting-edge techniques, and a deep understanding of the physical and emotional toll of this disease. Beyond the OR, he's a sought-after speaker, educator, and advocate, bringing attention to the complexities of endometriosis and the importance of individualized, informed care. Please help me in welcoming Dr. Jeff Errington. A lot of us with endometriosis are struggling to navigate the insurance piece of endometriosis. Can you give us a sense of what this is like to try to have insurance as a provider for endometriosis so that we understand why a lot of providers cannot afford to be an in-network provider for insurance?

SPEAKER_01: 2:01

Within the healthcare system, the way that it's structured, and this is all geared really toward CMS, which is the national uh Medicare system, they they really set up the underlying pay scale or fee scale or value scale of everything we do in medicine. And then all the private health insurers, they use that to set their own values to procedures. The way that works is they look at they look at everything, and it's each procedure, each office visit, everything we do is given what's called an RVU or relative value unit. And you know, the base, the ultimate base level of an RVU would be one. And let's say that's just the simplest thing, just a simple, straightforward office visit. And then everything else we do is compared to that level, you know, that one RVU scale. And they determine is that is it easier than that? Is it harder than that? If it is harder than that, how much harder? And they give a relative value compared to that one single, you know, RVU value. Uh so certainly, you know, an endometriosis surgery is far more complex than just a routine quick in and out, you know, office visit. So if the routine visit is given, say, an RVU of one, an endometriosis surgery may be given an RVU value of, say, 12. Cardiothoracic surgery and neurosurgery, it'd probably be given an RVU value of 2530. I have no idea what the number is, but it gives you an idea of how they look at things. And interestingly, within that RVU system, everything is in a single pie. So if they if they want to increase an RVU for a particular specialty or procedure, that increase has to be matched by a decrease somewhere else. And it doesn't even have to be in the same specialty. So there's there's a finite in the government, for some reason they've determined there's a finite piece of pie. And every time somebody gets a bigger piece of the pie, somebody else gets a smaller piece of the pie. So it's all configured around that part of it. Now, within the RVU, so relative value unit, they typically have three components that apply to doctors. And they look at the the amount of work that's involved in providing the care. So for surgery, they're looking at the pre-operative visit, they're looking at the surgery itself, the incisions, the entry, the procedure, the closure. And then it also takes into account an appropriate period of time of post-operative care. Usually for laparoscopy, I think that's about six weeks for most procedures, that that's all included in the work that's around the procedure. They also have a portion of the RVU that takes into account the malpractice risk. So, you know, within a medical practice, malpractice can be super expensive in the US. So the more risky a procedure is, the higher the component of the malpractice portion of the RVU. And that becomes important. And then the final piece of that RVU puzzle, the third piece, is the geography, basically the location of the procedure. So clearly throughout the country, practicing in California, practicing in New York, medical care is far more expensive in those states and those areas than it is, say in Utah. So if you take an equivalent level of care from Utah, transfer that into New York or California, big cities, wherever, the cost of that same care is going to be far higher, partly because of the geographic location and just the cost of living and cost of practice. Does that make sense? Yeah. So going back to the malpractice side of things, when we look at advanced endometriosis care, even within a, say, a laparoscopy for endometriosis, there is far more complexity to really doing good endometriosis work, doing the dissections, separating the adhesion, separating the bowel, working around the ureters, than somebody that goes in and says, oh, that endometriosis directly over the ureter. I very carefully just touched cottery to it so I didn't damage the ureter. Instead of doing the appropriate dissection and separating the disease out, or if they go in and see some bowel endometriosis to maybe just very easily, carefully, safely burn across the surface, but not really treat it, the risk of that is far less than a doctor actually going in and cutting the disease out and repairing the bowel or dissecting the ureter out. The thing where that comes into play when insurance companies look at that RVU for laparoscopy, they don't make any adjustments on the complexity risk between superficial ablation and excision of disease. To the insurance companies and to that CAMS RVU system, it's all the same. And, you know, and that that's just the malpractice side of things. Certainly the work involved, you know, taking 10, 15 minutes to quickly burn a few places rather than two or three hours to cut disease out, they have zero accounting for the extra work involved and the tedious work involved in full excision rather than just, you know, spot burning a couple places and saying that's the best I can do. Right. So when when we look at the way that insurance looks at things, they consider a superficial, you know, let's say somebody gets in and they and there's just endometriosis everywhere, but no adhesions. Right. Unless unless you say that it, you know, there is some depth to the disease, but there's no bowel involvement, no ureter dissections, but really widespread endometriosis with some depth to the to the tissues, to the side of the rectum. Going in and cutting that out, you know, can take uh hour and a half, a couple hours sometimes compared to a doc just going in and saying, oh, here's a few spots, let's burn those, and then leaving everything else untreated and untouched. We're talking a 10, 15 minute surgery versus an hour and a half surgery, and the compensation, the RVU value for those procedures is exactly the same.

SPEAKER_00: 7:47

That's a wrap for this quick connect. I hope today's insights helped you move forward with more clarity and confidence. Do you have more questions? Keep them coming. Send them in, and I'll bring you the expert answers. You can send them in by using the link in the top of the description of this podcast episode or by emailing contact at indobattery.com or visiting the Indobattery.com contact page. Until next time, keep feeling empowered through knowledge.