Introduction

The total spending on healthcare services in the United States (US) is the highest worldwide with an increasing pattern. Healthcare cost encompasses a progressively large share of the US economy. By the end of 2020, the healthcare expenditure is estimated to become 20% of the gross domestic product (GDP) after being 4.6% only in 1950 [1, 2]. The share of spending on healthcare is a major concern in the US. Currently, evidence on reforms that can decrease the cost of healthcare and improve its value is still lacking [3]. In Lebanon, the total healthcare spending of the GDP was 12.4% in 1998 and continued in decreasing to reach 7.1% in 2012. Currently, household share of the total healthcare expenditure is 53% [4].

As a part of the total healthcare, female spending in the US is $1231 billion, which is 56% of the total personal health care (PHC) spending, given that women account for more than 50% of the population [5]. The latest study from the Lebanese ministry of health in 2006 showed a total of 46,000 patients seeking obstetric and gynecologic care [4]. On the contrary, there is a current lack of data in Lebanon on the amount of women spending on PHC.

The abundance of female spending could be partially explained by the cost of gynecologic procedures, which is affected by the characteristics and comorbidities of the patients [6]. Additionally, patient demographics have also an impact on the gynecologic procedure cost by affecting the duration and course of stay [6].

Three of the most common performed gynecologic procedures in practice are: Cesarean section, hysterectomy, and myomectomy [7]. Approximately for every four women in the US, one will have a cesarean section. This data have a huge contribution to the healthcare bill given the relatively high cost of cesarean section, which is estimated to range between $7439 and $14,528 depending on the state compared to a range between $5017 and $10,413 depending on the state for an uncomplicated vaginal delivery [8]. These bills are mostly covered by the insurance, but the patient has still to pay a part [9]. Besides, benign tumors of the smooth muscle cells of the human uterus form leiomyomas, which are uterine fibroids. The surgical treatment of uterine fibroids costs between $10,000 and $20,000 [10]. In addition, 600,000 cases of hysterectomy are performed in the US each year summing up for a cost of $5 billion thereby forming a huge share of the healthcare spending [11]. On the other hand, Lebanon has no published data on the cost of common gynecologic procedures.

Comparative data suggest that there is a substantial difference in the cost of gynecologic procedures between the US and several middle-to-high-income countries [12]. Since there are huge variations that exist in the prices, costs, and charges of several common medical procedures across countries [13], our primary aim was to assess the variation in the cost of myomectomy, hysterectomy, and cesarean section between medical centers in the US and Lebanon. The secondary aim was to fill the gap of missing data in Lebanon and identify potential factors that can lead to high healthcare cost in the US.

Materials and methods

Study design

This is a retrospective chart review study. Our data were extracted from the billing system of one medical center in Lebanon, from 2012 to 2018 and the bill in the US was estimated by Fair Health consumer [14], an online resource estimator, due to inability to obtain the data. Our study population consisted of adult patients between the mentioned time intervals. A total of 505 patients were included in Lebanon.

The cost of vaginal, abdominal, and laparoscopic hysterectomy, open and laparoscopic myomectomy, and Cesarean section was adjusted to US dollars. Besides, the age, insurance type, comorbidities, surgery cost, medication cost, anesthesia cost, imaging cost, laboratory cost, material cost, and materials used were abstracted from the medical records.

All patients who underwent the selected gynecological procedures performed by national board and American board gynecologists during the specified period were included. Participants were excluded if they had any complications during the operation or if their operation was performed by a gynecologist who is not certified by national board or if the operation was performed via robotic technology.

The study was approved by the institutional board review (IRB) of the medical center in Lebanon.

Statistical analysis

The SPSS software version 25 was used to analyze the database. The ANOVA test was used to compare the cost taken and variables that have three or more groups. A p value < 0.05 was considered significant.

Results

Hysterectomy and myomectomy were further divided into sub-classes of surgeries depending on the approach and the structures involved. For instance, hysterectomy was divided into seven sub-classes, whereas myomectomy was divided into either laparoscopic-assisted or open. Cesarean delivery was fitted into one class. All the classifications were based on the current procedural terminology code (CPT code) (Table 1).

Table 1 The surgeries discussed in this study with their corresponding CPTs in Lebanon and the US
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The gynecologic procedure most commonly performed in Lebanon (20.4% of patients) was total abdominal hysterectomy (TAH) with removal of corpus and cervix followed by open myomectomy (19.6%). Cesarean delivery was performed on 16% of the patients (Table 2). Besides, the dominant proportion of patients in Lebanon had a second-class insurance (41.3%) followed by cash payers or first-class insurance (34.3%) (Table 2).

Table 2 The percentage of the total patients belonging to each surgery type and insurance class in Lebanon
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Insurance companies in Lebanon offer plans that differ in co-insurance. First-class insurance has the lowest co-insurance and highest premium. While third-class insurance would have relatively the highest co-insurance percentage and lowest premium; second-class insurance would be in between these two.

The mean total bill was the largest for first-class patients or cash payers among patients stratified into their insurance class status. The difference in the mean total bill was significant when comparing first-class to third-class insured patients (Table 3).

Table 3 The mean total bill corresponding to each insurance class in Lebanon
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The average out-of-pocket amount for every surgery was calculated and classified according to the insurance class in Lebanon (Table 4). Class 3 insured gynecologic patients paid the highest out-of-pocket amount for surgeries 1, 3, 9, and 10 whenever compared to other insurance classes. On the contrary, class 1 insurance patients paid the highest out-of-pocket amount for surgeries 4 and 6. Class 2 insurance patients paid the most for surgeries 2 and 8.

Table 4 Difference in the out-of-pocket paid according to the type of surgery and the insurance class
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The averaged total bill for every type of gynecologic surgery in Lebanon was compared to the corresponding surgery averaged total bill of insured and non-insured patients in the US (Table 5).

Table 5 Mean total bill for each surgery among patients in Lebanon, insured patients in the US, and non-insured patients in the US along with the statistical difference between patients in Lebanon and insured and non-insured, respectively
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The averaged total bill for surgery 1 was significantly lower in Lebanon than the “in Network” and “out of Network” US patients for surgeries 1, 2, 3, and 8. For surgery 9, the mean total bill was significantly lower in Lebanon than the US “out of Network”. However, it was similar to the “in Network” US patients. Interestingly, the mean total bill of insured patients was lower for insured patients than non-insured for all types of surgeries.

Discussion

Our results showed that the majority of gynecologic patients in Lebanon belong to the second-class insurance. These results are logical and reasonable for two main reasons. First, patients have a preference to pay for the average insurance type and receive a relatively good medical coverage. Second, the public sector and private companies tend to provide mostly a second-class type of insurance to their employees.

The mean total bill in Lebanon was lowest for second-class insurance patients and highest for first-class patients. While the highest mean total bill is expected to result from the accumulation of high cost rate of hospitalization, the mean total bill of third-class insurance was higher than that of second-class insurance that might be explained by the higher prevalence of patients covered by third-class insurance undergoing expensive surgeries.

The lower bill paid by insured US patients than non-insured US patients might be explained by the power of negotiation and transparency’s effect on reducing prices. The insurers or payers have a huge power of negotiation and can bargain to reach a much cheaper contract.

Comparing total bills between Lebanon and the US, bill components were taken into consideration. Two potential variables that definitely could potentially have an impact on billing are instrument sets and operating room staffing. The set of instruments used in each of the surgeries described in the study is identical in the US and Lebanon and this even includes suture types and laparoscopic devices. The Lebanese American University Medical Center being American affiliated and having American and international accreditation follows the universal standards followed in the US. In regard to staffing, operating room staffing in LAU Medical center is almost the same as in the US. The staff present in operating rooms in the US and Lebanon are the surgeon, resident physician, assistant surgeon if any intervention needed like a urologist for a bladder or ureter injury, surgical tech or scrub nurse, student, anesthesiologist, nurse anesthesiologist and a pediatric resident in case of a cesarean section.

Another variable that could impact the total cost is the length of stay for which hospitals usually add proportional charges. In our study, the length of stay for the surgeries studied in Lebanon and the US was similar. The overall trend in both was to discharge home in the same or next day postoperatively.

After accounting for these variables, the difference in cost is mainly attributed to the relatively elevated workforce and services’ costs. These comprise workforce compensation for surgeons, anesthesiologists, nurses, assistants, techs, pharmacists and the costs of medical services as operating room time, laboratory work, imaging studies, prosthesis, medications and equipment. Also worth mentioning, is the standard monetary compensation of healthcare workers in the US that is relatively higher than their Lebanese counterparts in occupation stratification, respectively.

Given the huge gap in the total bill between both the “out of network” bill and the “in network” bill and total bill in Lebanon, and given that a decent percentage of the surgeries performed in the university medical center in Lebanon is operated by gynecologists trained in the US, it is necessary to shed the light and manage the cost components in the US to set strategies to cut costs and reduce bills.

There are certain limitations regarding our manuscript. We only could get the total bill from the US. No bill stratifications or components were allowed for privacy issues.

Conclusions

There is a significant difference in the cost of gynecologic surgical services between Lebanon and the US, especially when the bill is computed as out of Network. Studied gynecologic procedures in the US have a much higher bill total when they are out of coverage than in coverage. The presence of an insurance program reduces the billing gap. There is a real and solid potential to cut the surgical bill in the US by expanding the population covered by insurance and improving negotiations between insurers and hospital centers.