Economic Aspects of the Management of Choledocholithiasis

Abstract

The management of common bile duct stones in the laparoscopic era has become primarily a staged procedure: cholecystectomy with endoscopic retrograde cholangiopancreatography (ERCP) and stone extraction on two separate occasions. Traditional fee-for-service and referral patterns support this—two physicians each get a professional fee, the facility is reimbursed for each procedure, and overall margins are sustained. Even with improved technology making laparoscopic common bile duct exploration (LCBDE) feasible, surgeons did not want to spend the extra time for an incrementally small increase in reimbursement, and there were fears of loss of referral from gastroenterologists. A catch-22 has developed as attending surgeons do not have the volume themselves to teach the next generation of surgical residents. With increasing scrutiny of medical costs, a focus on patient satisfaction, and new payment models, there is significant interest in single-stage management of choledocholithiasis, as was done in the “open” surgical era. A review of the cost for the management with each scenario showed that the median professional fee for LCBDE was $1150—slightly more than the sum of a laparoscopic cholecystectomy with cholangiogram and ERCP with stone extraction, $1127. However, the direct costs to the facility were much greater for the staged procedure: $13,865 versus $7905. Median length of stay was 2 days longer in the staged situation. As more institutions assume risk for patient populations, and new payment mechanisms will support gain sharing with physicians, single-stage management of choledocholithiasis with LCBDE will become the procedure of choice.