Service for Surgery

Financial Management

By: Demetrio Aguila III

Published: 12/6/2022

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Performing procedures in exchange for volunteer work is part of my mission to provide world-class surgical care patients can afford.


What's wrong with our healthcare system? That's the question I couldn't stop asking myself after an Air Force deployment to Afghanistan that ended in 2008. I had been thinking about the medical debt problem in this country ever since my residency days, but Afghanistan was the turning point for me. During the four months I was there, I performed more than 300 head and neck reconstructive surgeries as the only otolaryngology surgeon in the country, and nearly all of the surgeries were humanitarian. In many cases, I was able to provide better care in a more efficient manner for patients living in mud huts than I could for patients living in our nation's capital. At that point, I realized there was a real need for more affordable health care in our country, and it was a mission I was being called to fulfill. That's when I went from passively pondering the problem to actively working toward a solution.

After more than 10 years, two residencies (in plastic and reconstructive surgery and otolaryngology-head and neck surgery), two fellowships (in peripheral nerve surgery) and countless hours of planning and fine-tuning, the M25 Program was born. The program — inspired by the Gospel of Matthew 25:40 — allows patients to pay for their procedures through service hours performed at hand-picked local charities. The goal of the program is simple: To deliver world-class surgical care that doesn't require patients to incur crushing financial debt. It offers patients the opportunity to invest in themselves and their surgical outcomes, and facilitates moral and financial support from family, friends and communities.

When some people hear about the possibility of using volunteer work to pay for their surgeries, they have trouble wrapping their heads around the concept. That's understandable. As a society, we've been conditioned to believe astronomical medical debt — and the complex and often unfair billing practices that cause it — are an unavoidable part of our healthcare system. It is what it is disgruntled patients often say as they struggle to find ways to avoid going into bankruptcy to pay for needed medical care. It doesn't have to be that way. Patients shouldn't need to choose between their physical health and their financial well-being.

Patients who come to my clinic, Healing Hands of Nebraska, for sinus surgery, carpal tunnel release, nerve procedures to treat chronic pain, ear tubes placed under local anesthesia or a host of other treatments are offered three payment options:

  • Lump sum. Patients pay a discounted rate up front. Because we don't have contracts with traditional insurers, we're able to be fully transparent about the cost of our surgeries. If patients have insurance, we'll submit a claim after surgery for reimbursement. Almost a third of our patients choose this option.
  • Payment plans. We've partnered with a handful of third-party healthcare financing vendors that provide patients with the opportunity to cover the cost of care over a series of installments. About two-thirds of our patients decide to finance their procedures.
  • The M25 Program. Patients volunteer with our charitable partners and once they complete the requisite service hours, we perform the procedure at no cost to them. About 10% of our patients have taken part in the M25 Program, which has been growing steadily despite the setbacks our clinic experienced because of the pandemic.

CATCHING ON Approximately 10% of Dr. Aguila's patients pay for their surgeries by completing a predetermined amount of volunteer hours at local charity organizations — a percentage that has been increasing steadily.

There are a couple stipulations associated with the M25 Program. At least 10% of the volunteer time must be completed by the patient unless there's a legitimate reason why they can't do so. The other 90% of the hours can be completed by the patient's friends, family, neighbors or anyone else they enlist as long as the volunteers meet with the patient. That meeting allows the volunteers to look the patient in the eye to let them know they're investing their time and effort into their health and recovery.

There's a moral authority inherent in this interaction; the patient realizes they owe the volunteers their best effort in rehabbing from surgery. This is in stark contrast to conventional charitable contributions, in which faceless organizations hand out checks to help anonymous patients. Those checks are valuable and helpful, but they don't carry the weight of the investment of time and goodwill that our program's volunteers give. Their moral support often makes a huge difference in the patient's outcome. In meeting the volunteers who are investing in their care, patients have tangible proof of the gift being given. Handshakes, hugs and looks of compassion are at the core of the M25 Program's success.

PRICE TRANSPARENCY
What Are Surgeries Worth?

Here are some examples of how much surgeries cost at the Healing Hands of Nebraska clinic and the corresponding number of service hours patients can choose to donate instead of paying for their care out of pocket.

Unilateral superior cluneal nerve surgery for chronic low back pain/failed back syndrome

  • Lump-sum payment $9,271.85
  • M25 Program 490 hours

Unilateral meralgia paresthetica surgery

  • Lump-sum payment $8,176.77
  • M25 Program 430 hours

In-office septoplasty, endoscopic repair of nasal vestibular stenosis and inferior turbinoplasty

  • Lump-sum payment $4,653.39
  • M25 Program 245 hours

 

The M25 Program is not a charity — it's an alternative way for patients, and the communities they recruit, to invest in their outcomes. Time and again, patients tell me, "Doctor, thank you for respecting my dignity and allowing me to invest in my care instead of treating the arrangement like a handout."

I'm often asked how we draw the line on who's eligible for the M25 Program and how we calculate the volunteer hours needed to pay for surgery.

In terms of eligibility, it's simple: Everyone can seek care through the M25 Program. This is the only fair way to do it. I've found that patients end up self-screening for inclusion by asking themselves, "What's more important: my time or my money?" Patients who enter the program have skin in the game. They — along with their volunteers — have invested hundreds of hours of community service in the procedure.

The amount of community service a patient is required to fulfill before surgery is dictated by the cost of the procedure (see "What Are Surgeries Worth?"). For example, patients who undergo a surgery that costs $5,000 out of pocket are offered the alternative of investing 250 hours of service.

The service hours aren't arbitrarily assigned. Our team analyzed factors such as relative value units (RVUs), procedure length, the complexity of the case and the expertise required to diagnose and treat the condition to come up with a proprietary formula for assigning hours.

Healthcare providers spend a lot of time talking to patients about the clinical risks, benefits and alternatives to surgeries. It's only fair we talk to them about the financial risks, benefits and alternatives as well. For the 43 million Americans struggling with medical debt — the type of debt that's responsible for more than half of the bankruptcies in this country — you can't separate a surgery's outcome from how it will impact the patient's wallet.

Price transparency is one of the cornerstones of our clinic. I'm sometimes asked why I focus so much on revealing the true cost of care. I believe it's only fair that patients know exactly what they're paying for right from the start. One of the core debates in health care today revolves around the cost of care, but cost isn't the only factor to consider — nor is it the most important. The real discussion should be about the value of care. In order to assess value, however, you must know the cost and the quality of the care provided. That's where our approach differs from so many others.

Before I opened my clinic, I got a call from a former patient.

"Doc, I need your help," she said. "Please call my insurance company for me."

"About what?" I asked.

"I just got an exorbitant bill for the surgery you performed on me three years ago!" she said.

I was powerless to help, and it was devastating to know that I was contributing to, or even causing, the financial ruin of patients I had set out to help. Thanks to the M25 Program, I never have to worry about receiving a call like that again.

Surgical professionals, by their very nature, feel compelled to help others. They want to do everything in their power to ensure people can afford life-changing surgeries, but they don't know where to start or believe changing a broken healthcare system is an insurmountable task.

If that's how you feel, I challenge you to think outside of the box — or throw the box away altogether. I can directly impact only so many patients. My ultimate hope is that the M25 Program inspires other physicians and facilities to find more innovative ways to help patients pay for surgery. We simply must find better ways to care for those who are hurting. OSM

EXPANDED REACH
Healing Hands Set to Launch Nationwide
SPREADING THE WORD Dr. Aguila met with a group of volunteers who helped a patient donate service hours for surgery.

The M25 Program has been growing steadily as part of my Healing Hands of Nebraska for-profit clinic, but I've always had my sights set on expanding it beyond state lines. Recently, we've taken a major step toward achieving that goal by forming Healing Hands of America. Pending approval from the IRS, which we hope to receive in the next six months, Healing Hands of America will become a national non-profit. The implications of that are huge. We'll be able to accept donations and expand the program in ways that simply aren't possible right now.

The M25 Program, in its current state, addresses the financial impact of the professional fees/surgeon fees for a particular procedure. It does not, however, address the facility fees or anesthesia fees that can account for more than 90% of a procedure's cost. Obtaining 501(c)(3) status from the IRS will allow us to accept monetary donations to help cover the costs of implants, supplies, equipment and personnel needed to provide safe, effective, world-class surgical care.

We elected to pursue non-profit status for the M25 Program because, since it was featured on CNN's Champions for Change, we've been approached by people all over the world who want to know how they can help scale our efforts. It's humbling for me to see the generosity fellow human beings are so eager to share, and the M25 Program provides an additional mechanism for people to do that.

With non-profit status, our hope is that Healing Hands of America will set up a network of M25 Program charity partners across the country. We already have partners in Fort Collins, Colo., and Chicago, in addition to our original partners in Nebraska.

Hopefully, we'll soon have Healing Hands of Texas and Healing Hands of California and, maybe someday, programs established in Canada and other countries throughout the world.

While Healing Hands of America will allow global reach, it's the actions of each charitable partner that make the difference. In the end, it's a local mission that's all about neighbors helping neighbors.

— Demetrio J. Aguila III, MD, FACS

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