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

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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

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Episode Transcript

SPEAKER_00 (00:00):
Life moves fast and so should the answers to your

(00:02):
biggest questions.
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(00:22):
general information and not forpersonalized medical advice.
Always consult your provider foryour case-specific guidance.
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I'm your host, Alana, and it'stime to connect.

(00:45):
Dr.
Errington is not only an expertin advanced minimally invasive
gynecologic surgery, but also afierce advocate for
endometriosis patients, both inand out of the operating room.
Known for his compassionateapproach and relentless
dedication, Dr.
Errington has made it hismission to give hope to patients
who've been told their cases arehopeless.

(01:06):
With over two decades ofsurgical experience and a
steadfast belief in excision asthe best treatment for
endometriosis, Dr.
Errington has helped patientsworldwide reclaim their quality
of life through meticulous care,cutting-edge techniques, and a
deep understanding of thephysical and emotional toll of
this disease.
Beyond the OR, he's asought-after speaker, educator,

(01:29):
and advocate, bringing attentionto the complexities of
endometriosis and the importanceof individualized, informed
care.
Please help me in welcoming Dr.
Jeff Errington.
A lot of us with endometriosisare struggling to navigate the
insurance piece ofendometriosis.
Can you give us a sense of whatthis is like to try to have

(01:52):
insurance as a provider forendometriosis so that we
understand why a lot ofproviders cannot afford to be an
in-network provider forinsurance?

SPEAKER_01 (02:01):
Within the healthcare system, the way that
it's structured, and this is allgeared really toward CMS, which
is the national uh Medicaresystem, they they really set up
the underlying pay scale or feescale or value scale of
everything we do in medicine.
And then all the private healthinsurers, they use that to set
their own values to procedures.

(02:23):
The way that works is they lookat they look at everything, and
it's each procedure, each officevisit, everything we do is given
what's called an RVU or relativevalue unit.
And you know, the base, theultimate base level of an RVU
would be one.
And let's say that's just thesimplest thing, just a simple,
straightforward office visit.
And then everything else we dois compared to that level, you

(02:47):
know, that one RVU scale.
And they determine is that is iteasier than that?
Is it harder than that?
If it is harder than that, howmuch harder?
And they give a relative valuecompared to that one single, you
know, RVU value.
Uh so certainly, you know, anendometriosis surgery is far
more complex than just a routinequick in and out, you know,

(03:08):
office visit.
So if the routine visit isgiven, say, an RVU of one, an
endometriosis surgery may begiven an RVU value of, say, 12.
Cardiothoracic surgery andneurosurgery, it'd probably be
given an RVU value of 2530.
I have no idea what the numberis, but it gives you an idea of
how they look at things.
And interestingly, within thatRVU system, everything is in a

(03:32):
single pie.
So if they if they want toincrease an RVU for a particular
specialty or procedure, thatincrease has to be matched by a
decrease somewhere else.
And it doesn't even have to bein the same specialty.
So there's there's a finite inthe government, for some reason

(03:52):
they've determined there's afinite piece of pie.
And every time somebody gets abigger piece of the pie,
somebody else gets a smallerpiece of the pie.
So it's all configured aroundthat part of it.
Now, within the RVU, so relativevalue unit, they typically have
three components that apply todoctors.
And they look at the the amountof work that's involved in

(04:13):
providing the care.
So for surgery, they're lookingat the pre-operative visit,
they're looking at the surgeryitself, the incisions, the
entry, the procedure, theclosure.
And then it also takes intoaccount an appropriate period of
time of post-operative care.
Usually for laparoscopy, I thinkthat's about six weeks for most

(04:34):
procedures, that that's allincluded in the work that's
around the procedure.
They also have a portion of theRVU that takes into account the
malpractice risk.
So, you know, within a medicalpractice, malpractice can be
super expensive in the US.
So the more risky a procedureis, the higher the component of

(04:54):
the malpractice portion of theRVU.
And that becomes important.
And then the final piece of thatRVU puzzle, the third piece, is
the geography, basically thelocation of the procedure.
So clearly throughout thecountry, practicing in
California, practicing in NewYork, medical care is far more
expensive in those states andthose areas than it is, say in

(05:16):
Utah.
So if you take an equivalentlevel of care from Utah,
transfer that into New York orCalifornia, big cities,
wherever, the cost of that samecare is going to be far higher,
partly because of the geographiclocation and just the cost of
living and cost of practice.
Does that make sense?
Yeah.
So going back to the malpracticeside of things, when we look at

(05:37):
advanced endometriosis care,even within a, say, a
laparoscopy for endometriosis,there is far more complexity to
really doing good endometriosiswork, doing the dissections,
separating the adhesion,separating the bowel, working
around the ureters, thansomebody that goes in and says,
oh, that endometriosis directlyover the ureter.

(05:57):
I very carefully just touchedcottery to it so I didn't damage
the ureter.
Instead of doing the appropriatedissection and separating the
disease out, or if they go inand see some bowel endometriosis
to maybe just very easily,carefully, safely burn across
the surface, but not reallytreat it, the risk of that is
far less than a doctor actuallygoing in and cutting the disease

(06:18):
out and repairing the bowel ordissecting the ureter out.
The thing where that comes intoplay when insurance companies
look at that RVU forlaparoscopy, they don't make any
adjustments on the complexityrisk between superficial
ablation and excision ofdisease.
To the insurance companies andto that CAMS RVU system, it's

(06:38):
all the same.
And, you know, and that that'sjust the malpractice side of
things.
Certainly the work involved, youknow, taking 10, 15 minutes to
quickly burn a few places ratherthan two or three hours to cut
disease out, they have zeroaccounting for the extra work
involved and the tedious workinvolved in full excision rather
than just, you know, spotburning a couple places and
saying that's the best I can do.

(07:00):
Right.
So when when we look at the waythat insurance looks at things,
they consider a superficial, youknow, let's say somebody gets in
and they and there's justendometriosis everywhere, but no
adhesions.
Right.
Unless unless you say that it,you know, there is some depth to
the disease, but there's nobowel involvement, no ureter
dissections, but reallywidespread endometriosis with

(07:22):
some depth to the to thetissues, to the side of the
rectum.
Going in and cutting that out,you know, can take uh hour and a
half, a couple hours sometimescompared to a doc just going in
and saying, oh, here's a fewspots, let's burn those, and
then leaving everything elseuntreated and untouched.
We're talking a 10, 15 minutesurgery versus an hour and a
half surgery, and thecompensation, the RVU value for

(07:44):
those procedures is exactly thesame.

SPEAKER_00 (07:47):
That's a wrap for this quick connect.
I hope today's insights helpedyou move forward with more
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(08:12):
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