Richard Gimpelson, MD

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 Hi, I am  Paul Indman. We are at the AAGL meeting in Las Vegas, Nevada, and I have with me  Dr. Richard Gimpelson, from Chesterfield, Missouri. That’s somewhere near St  Louis?
 
 

 Now, when I was starting  out my interest in hysteroscopy in the dark ages, in 1984 I read an article that  was very influential and is still quoted about the accuracy of D&C as compared  to office hysteroscopy. At this point, I consider hysteroscopy in an office  setting as basic to gynecology as looking into an ear is for an ear, nose and  throat doctor. Now given that, what percentage of gynecologists do you think in  this country are doing office hysteroscopy?
 
 

 I think today, Dr.  Indman, probably less than 10% of gynecologists in offices throughout the US,  and even overall, probably not more than about 30% are doing any kind of  significant numbers of hysteroscopy in general.
 
 

 Why is that? Your studies  clearly show the accuracy rate of hysteroscopy with suction curettage exceeds  that of D&C. Help me understand why that is.
 
 

 I think part of it is  a little element of a learning curve and part of that, especially in an office  setting, are the problems with insurance company reimbursements. Insurance  companies somehow have a reluctance to pay for supplies that physicians will  utilize in an office setting yet seem to have no problem paying ten times that  amount for similar supplies or even fewer supplies used in a hospital setting.  So some of this becomes economics, that insurance will pay for a D&C done in a  hospital setting and not pay for a better procedure, a hysteroscopic exam, which  is anywhere from 15% to 35% more accurate than a D&C, done in an office setting.
 
 

 How much more do you think  the insurance company is paying for the hospital or surgicenter D&C as compared  to an office hysteroscopy?
 
 

 I would say it is  probably five to ten times more in the hospital and probably at least three to  four times more in an outpatient surgical facility.
 
 

 Certainly you have an  anesthesiologist there and instead of being a diagnostic exam, now it is an  operation. To me, hysteroscopy is little more than a PAP smear. It is a very  simple exam. How would you suggest someone get started in office hysteroscopy?
 
 

 I think to get  started, first of all, they have to be able to do the hysteroscopic surgery in a  hospital setting and be very comfortable with the instrumentation, with the  manipulation, and then once they are comfortable doing the procedure itself,  start doing the patients under local anesthetic with sedation in the hospital  setting. When they feel they can make sure those patients are comfortable, then  move to the office setting. There are a lot of physicians who insert IUDs in the  office, often do endometrial biopsies in the office. Those are about the same  discomfort as a hysteroscopic exam; there is not this reluctance to do an IUD or  just a biopsy, but to put an instrument in, which is really the same size, all  of a sudden, there seems to be an element of hesitation.
 
 

 You know, I would wonder  because to me, if you can put in an endometrial biopsy curette or an IUD, why  even bring this to the hospital? I see no reason why a physician who can put an  IUD in the uterus, can’t put in a hysteroscope sheath of the same diameter.  Perhaps it’s the thought, oh, I have to bring it to the hospital and do it  there, and often equipment is so complex in the hospital because they have all  the urology instruments and the resectoscope all thrown in to one tray and it is  overwhelming, whereas simplified office hysteroscopy systems are just one or two  pieces. Before every endometrial biopsy, take a quick peek.
 
 

 You are absolutely  right. In the office setting, where I have my own equipment, we know the  equipment is working, we have very little breakage and if some instrument does  need repair, we know right away, so we don’t wind up like sometimes in a  hospital setting where you ask for an instrument and you get the instrument and  it is broken. You explain it is broken and a week later, you are doing another  surgery and you ask for the instrument again and you receive the same broken  instrument back. So I find it is much, much better for the patient, it is much  easier on the patient. My instrumentation is actually in better shape than a  hospital’s, and there are several companies around the country where, if you  don’t have your own equipment, will bring excellent hysteroscopic equipment,  video equipment, digital imaging equipment into an office setting so that you  can do these procedures. If you know how to make your patients comfortable,  which is really not very hard, the procedure is better than in the hospital, the  patients do better, they are not as sedated, they go home much quicker and they  are much happier and it is less interruption on your own schedule.
 
 

 I think there is no  question it is better. So let’s look into the economics because this is a real  issue. I can just imagine an auto mechanic fixing a car and then they say we are  going to deduct the parts from your salary. Obviously, that auto mechanic could  not afford to fix very many cars before going bankrupt if he is going to have to  buy all the parts and all the equipment himself. I know you have been involved  in trying to make some changes in this. Could you say a little bit about that?
 
 

 Yes, again, I am  working with the insurance companies, as I said a little bit earlier, to use  supplies in your office setting and then file a charge for those supplies which  reflects the cost of supplies and not much more and then having the  reimbursement rejected with the statement, “insurance does not pay for equipment  supplied by the operating surgeon”. It is very puzzling that they pay for  equipment supplied by the hospital and the identical equipment supplied by the  operating surgeon for some reason in an office setting has no value to an  insurance company. But, as I said, with companies now that will bring equipment  into the office, you now do not have to buy some of the large capital equipment.  You still have to supply the medication, but even that is a problem. Some of the  medication is not negligible in cost or not overwhelming but, again, it is like  the insurance company still refuses to pay you for your medication, for your  local anesthetic, they refuse to pay for your syringe needles. Some will, but  many will not. I cannot blame a physician for being reluctant to eat the cost of  that equipment to save money for the insurance companies.
 
 

 So what do you think we can  do as physicians to change that?
 
 

 Part of it is for  physicians to continue to pressure the insurance companies but I think, this  also has to come from industry. The manufacturers of equipment and the  developers of procedures and devices also need to lean on the insurance  companies to make the public aware. It was a lot easier in the past when  insurance companies could just cut the payments to physicians, but now we are  seeing double digit inflation, so people are paying more for their premiums and  I think the public is now probably more willing to become pro-active and also  aggressive against the companies, saying we do not want to continue to pay 10%  to 15% increases in our insurance premiums if there is a way for this surgery to  be done in an office setting at one-tenth of the cost.
 
 

 I think it needs to come  from the consumers and industry, as you say. Well, thank you very much, Dr.  Richard Gimpelson, Chesterfield, Missouri.
 
 

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OBGYN.net Conference CoverageFrom the 32nd Annual Meeting of the American Association of Gynecological Laparoscopists (AAGL)

Hysteroscopy in the office setting

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Author | Richard Gimpelson, MD

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