Who Pays For It?

Here is a hypothetical scenario. An older gentleman is scheduled for a total knee replacement. On the pre-operative anesthesia exam, his airway looks reasonable. He's brought into the operating room and anesthesia is induced. However, the anesthesiologist cannot intubate the patient; he has an unanticipated difficult airway. He calls for the difficult airway cart, puts in a laryngeal mask airway as a rescue, uses a fiberoptic bronchoscope, and safely intubates the patient. The surgery gets underway. The surgeon, examining the patient and the X-rays, asks for one prosthesis. However, as he starts putting this prosthesis into place, he realizes it doesn't fit perfectly. He then asks for a different prosthesis. The rest of the surgery finishes uneventfully.

This could be a fairly common situation happening throughout the United States. Despite our best efforts from an anesthesia and surgical side, we run into unanticipated problems requiring new and different equipment. But who should be charged for this equipment? Should the patient be billed for the resources going into the initial intubation attempt as well as the rescue? Should he be billed for one or two prostheses? In both cases, it's not his fault that additional resources were required; in fact, given that the surgeon and anesthesiologist did due diligence, it's no one's fault. So then does the hospital absorb these costs?

Or consider a teaching facility. A patient could be intubated simply and easily with direct laryngoscopy. But the attending wants to teach the resident to use a video laryngoscope, and he is intubated with that. Should he be billed for the higher-cost more-complex procedure even though this was done only for educational purposes? A surgery resident is closing up an incision, but because he is less efficient than the attending, he uses an additional pack of sutures. Who accounts for that?

I don't know the answer to these questions, though I have a suspicion that the hospital picks up the excess. However, I also don't know what the right answer is and although I don't think this is a large contributor to the cost of healthcare in America, it certainly has some effect.