SMOKINCHOICES (and other musings)

January 22, 2014

Specialties bad 4 us

Health care

Specialty docs cost patients

By Elisabeth Rosenthal THE NEW YORK TIMES

CONWAY, Ark. — Kim Little had not thought much about the tiny white spot on the side of her cheek until a physician’s assistant at her dermatologist’s office warned that it might be cancerous. He took a biopsy, returning 15 minutes later to confirm the diagnosis and schedule her for an outpatient procedure at the Arkansas Skin Cancer & Dermatology Center in Little Rock, 30 miles away.

That was the prelude to a daylong medical odyssey several weeks later, through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an anesthesiologist and an ophthalmologist who practices plastic surgery. It generated bills of more than $25,000.

“I felt like I was a hostage,” said Little, a professor of history at the University of Central Arkansas, who had been told beforehand that she would need just a couple of stitches. “I didn’t have any clue how much they were going to bill. I had no idea it would be so much.”

Little’s seemingly minor medical problem — she had the least-dangerous form of skin cancer — racked up big bills because it involved three doctors from specialties that are among the highest compensated in medicine, and it was done on the grounds of a hospital.

Many specialists have become particularly adept at the business of medicine by becoming more entrepreneurial, protecting their turf through aggressive lobbying by their medical societies, and most of all, increasing revenue by offering new procedures — or doing more of lucrative ones.

  • It does not matter if the procedure is big or small, learned in a decade of training or a weeklong course. In fact, minor procedures typically offer the best return on investment: A cardiac surgeon can perform only a couple of bypass operations a day, but other specialists can perform a dozen procedures in that time span.

That math explains why the incomes of dermatologists, gastroenterologists and oncologists rose 50 percent or more between 1995 and 2012, even when adjusted for inflation, while those for primary-care physicians rose only 10 percent and lag far behind. Insurers pay far less for traditional doctoring tasks, such as listening for a heart murmur or prescribing the right antibiotic.

  • By 2012, dermatologists — whose incomes were more or less on par with internists in 1985 — had become the fourth-highest earners in American medicine in some surveys, bringing in an average of $471,555 though their workload is one of the lightest, according to the Medical Group Management Association, which tracks doctors’ income.

In addition, salary figures often understate physician earning power because they often do not include revenue from business activities: fees for blood or pathology tests at a lab that the doctor owns, or “facility” charges at an ambulatory surgery center where the physician is an investor, for example.

“The high earning in many fields relates mostly to how well they’ve managed to monetize treatment — if you freeze off 18 lesions and bill separately for surgery for each, it can be very lucrative,” said Dr. Steven Schroeder, a professor at the University of California and the chairman of the National Commission on Physician Payment Reform, an initiative funded in part by the Robert Wood Johnson Foundation.

Doctors’ charges — and the incentives they reflect — are a major factor in the nation’s $2.7 trillion medical bill. Payments to doctors in the United States, who make far more than their counterparts in other developed countries, account for 20 percent of American health-care expenses, second only to hospital costs.

  • Specialists earn an average of two and often four times as much as primary-care physicians in the United States, a differential that far surpasses that in all other developed countries, said Miriam Laugesen, a professor at Columbia University’s Mailman School of Public Health.

That earnings gap has deleterious effects: Only an estimated 25 percent of new physicians end up in primary care, at the very time that health policy experts say front-line doctors are badly needed, said Dr. Christine Sinsky, an Iowa internist who studies physician satisfaction. In fact, many pediatricians and general doctors in private practice say they are struggling to survive.

  • Studies show that more specialists mean more tests and more-expensive care.

“It may be better to wait and see, but waiting doesn’t make you money,” said Jean Mitchell, a professor of health economics at Georgetown University. “It’s, ‘Let me do a little snip of tissue,’ and then they get professional, lab and facility fees. Each patient is like an ATM machine.”

LUKE SHARRETT THE NEW YORK TIMES    Dr. Jennifer Cafardi inspects a skin sample under a microscope at the Skin Cancer Center in Cincinnati.

For example, the procedure performed on Little, called Mohs surgery, involves slicing off a skin cancer in layers under local anesthesia, with microscopic pathology performed between each “stage” until the growth has been removed.

  • Although it offers clear advantages in certain cases, it is more expensive than simply cutting or freezing off a lesion. (Hospitals seeking to hire a staff dermatologist for Mohs surgery had to offer an average of $586,083 in 2010, even more than for a cardiac surgeon, according to Becker’s Hospital Review.)

Use of the surgery has skyrocketed in the United States — more than 400 percent in a little over a decade — to the point that last summer, Medicare put it at the top of its “potentially misvalued” list of overused or overpriced procedures.

  • Even the American Academy of Dermatology agrees that the surgery is sometimes used inappropriately.

Dr. Brett Coldiron, president-elect of the academy, defended skin doctors as “very cost-efficient” specialists who deal in thousands of diagnoses, and called Mohs “a wonderful tool.” He said that his specialty was being unfairly targeted by insurers because of general frustration with medical prices.

“Health-care reform is a subsidized buffet, and if it’s too expensive, you go to the kitchen and shoot one of the cooks,” he said. “Now they’re shooting dermatologists.”

The specialists point to an epidemic, noting there are 2 million to 4 million skin cancers diagnosed in the United States each year, with a huge increase in basal-cell carcinomas, the type Little had, which usually do not metastasize. (A small fraction of the cancers are melanomas, a far more serious condition.)

But, said Dr. Cary Gross, a cancer epidemiologist at Yale University School of Medicine, “The real question is: Is there a true epidemic, or is there an epidemic of biopsies and treatments that are not needed? I think the answer is both.”

Profitable dermatology

In America’s for-profit, fee-for-service medical system, dermatology has proved especially profitable because it offers doctors diverse revenue streams — from cosmetic treatments that are fully paid by the patient to medical treatments that are covered by insurance.

Cosmetic dermatology is a big moneymaker in high-income markets such as New York and Miami.   Botox injections take 15 minutes and cost a minimum of $500; doctors pay about $100 for the amount of medicine needed for a typical session, dermatologists say. Still, cosmetic work makes up less than 10 percent of all skin procedures, studies show, and their volume fluctuates with the economy.

For medical treatment, many dermatologists have been able to compensate for cutbacks in insurance payments by offering new services and by increasing their patient volume through hiring “physician extenders” — nurse practitioners and physicians’ assistants — to do basic tasks such as biopsies and chemical peels. Whether the physician or the nurse wields the scalpel, the charge is generally the same.

The dermatology office where Little’s initial biopsy was performed is one of six satellite offices operated by the Arkansas Skin Cancer and Dermatology Center. They are often staffed by physician assistants, who refer patients to the dermatologists in Little Rock for Mohs surgery. The dermatologists also do their own pathology, meaning that they can sometimes bill extra for that service. (That also means there is no independent confirmation of a cancer diagnosis.)

With such practices, even minor dermatology procedures can lead to big bills.

Harris Williams and Co., a consulting firm, estimates the $10.1 billion dermatology market in the United States will grow to more than $13 billion by 2017, in part because of an aging population. The Affordable Care Act requires 100 percent coverage for preventive dermatology screening sessions for seniors, which will inevitably lead to more biopsies and treatment. With more doctors being trained in Mohs surgery — generally an extra year of training, though it is not required — it has become a go-to treatment.

Outrage at charges

Little left Baptist Health Medical Center with a tiny skin flap and more than two dozen stitches. For five days she said she was “hung over” from the IV sedation that she had not wanted — a problem because she drives 60 miles on rural Arkansas roads to her university each day.

She spent months arguing down her bills, which were finally reduced: About $1,400 for the Mohs surgeon, $765 for the anesthesiologist, $1,375 for the ophthalmological plastic surgeon, plus $1,050 in operating-room charges from the hospital.

For her follow-up, she refused to return to Baptist Health and went instead to the University of Arkansas medical center, where a dermatologist told her she likely had not needed such an extensive procedure. But that was hard to judge, because the records forwarded from Baptist did not include the photo that was taken of the initial lesion.

She was outraged as she wrote checks for the nearly $3,000 she owed to the doctors under the terms of her insurance.

“It was like, ‘Take out your purse, we’re robbing you,’” she said.

(My Comment:

Primarily because of the plight of our beleaguered medical-care system; it’s global ranking with regard to outcomes being near the cellar;  and the mere accessibility of it financially to the average American,  coupled with what it is doing to the budgetary limits of our government to manage, . . . it strikes me as near the point of being scurrilous.   Yes, scurrilous for it far surpasses mere greed, it borders on buffoonery!  

My own experience of dis-satisfaction began rather decisively in the ’70’s when my teenager was being deeply traumatized by acne.  I felt it was diet somehow and suspected his over-emphasis on protein and and dairy in general, but had no proof – only instinct.  Even as a kid, his interests were anchored in physicality and sports and body building.  Tho a novice, he seemed well directed and I admired his sense of purpose.  But I also suffered with ongoing adult acne, so what did I know?  Ergo, the dermatologist.   

That office wouldn’t accept the new patient without the patient  and parent sitting in on their “brain-washing” video where one was schooled on current thinking. . .DIET HAD NOTHING WHATEVER TO DO WITH ACNE.   That was so stunning to me that I barely remember anything else contained in the instructions.  Emotionally and intellectually, I bolted and was outta there,  but he believed this to be his last hope.  Others he knew had been successful and he pleaded to be allowed to try it.  I was opposed to the endless anti-botics – it was just wrong-headed, but I couldn’t ignore his genuine need, and thus relented.   Later as he engaged in the program and had to endure the weekly puncturing,  probing and squeezing of each pustule, he found much to dislike as well. 

It doesn’t seem fair to leave it at that; of course, the body’s systems can be over-ridden – can be made to do almost anything.  Anti-biotics can indeed shut down the body’s natural reaction to something to which it is strongly defending with a so-called allergic reaction.   So his symptoms were shelved, but nothing was fixed.  His acne returned and again was treated, endlessly.  .  eventually, I learned from a Dr John McDougall whose books I bought and learned from that drinking the milk of cows was not a normal thing to do.  No other species in the world does that, nor should we if we want to be healthy.  It was in fact why and what primarily triggers acne for either sex and all the monthly problems young girls go through with the advent of menses.    Then eventually learned from Dr Loren Cordain with his Paleo Diet, the easy to understand logic and sequential events behind acne (one of his books), arthritis, the balancing of the ins and outs of Calcium and how to handle all that. Both of these men are highlighted in their own categories up in FIND IT and in section 4 (docs).

Gimme a Doc who treats the whole Me

But this article is about the fleecing of America via (pick your poison) – any Specialty one can imagine, medically.  

Who could question anyone’s desire to be the best, have the best — or for sure, when sick, be able to be treated by the best?  When one is heavily credentialed, it is assumed that it connotes a superior status or greater knowledge. . . but assumptions don’t always pan out.  And this story details the very things about which we should all be cautious.  When dermatologists are commanding greater incomes than cardiac surgeons, one wants to go off somewhere and be sick.  How ridiculous can anything be? 

The story above starts off with a simple query from an assistant to biopsy an innocuous white spot which was not even in the running for anything serious — but the word biopsy strikes fear into anyone’s mind, can rattle you. So part of the trickery here is not only the excessive “monetization” of their craft (trade, talent), but also the vulnerability of most of us — the uninformed and trusting public. . . read that as F-E-A-R. This is a frightful state of our current medical community.  And so prevalent.  Our nation is in desperate need of competent physicians who are trained to understand the the entire body and how all the pieces and parts relate to one another.  That is what I prefer,  moreover;  it is about all I can trust.  I don’t like being referred out to anyone. I still believe our country should be footing the bills educationally for new doctors in exchange for some agreed upon period of time in service to the general population (5 years?), especially, under-served areas.  We’ve done it before, we could and should do it again. 

Do your due diligence folks,    Jan)

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