Tuesday, July 07, 2009

Are we the Greedy Bastards Dr. Gawande Makes us out to be????
The criticisms of Dr. Gwande's New Yorker article have ranged from the patients in McAllen are sicker, that the cost issues are multifactoral, and that Gawande makes his point by using the outlier.

Honestly, in our own towns we see care driven by financial incentive. We see the billboard ads put up by the cardiovascular and general sugeons touting their "vein centers". The gastroenterologists and plastic surgeons that have their own in-office operating suites. The physician group that owns their own imaging center. The internist that employs 4 midlevels and also owns a "medical spa". While there is evidence that hospitalists reduce length of stay and improve quality, the main selling point for your workaday physician is that they can make more money seeing patients in their office than rounding in the hospital.

Point is also made by this paper from the Journal of the American Academy of Dermatology: Short wait times for patients seeking cosmetic botulinum toxin appointments with dermatologists :
Wait times for both routine and urgent dermatology appointments typically exceed 3 to 4 weeks. Many factors affecting physician workforce adequacy and patient access have been explored, but little is known about the impact of increasing numbers of doctors offering cosmetic services.

We sought to evaluate access to dermatologists for patients requesting cosmetic services.

Scripted patient telephone calls were made to 898 dermatologists in 12 metropolitan areas to assess wait times for an appointment to receive cosmetic botulinum toxin injections. The areas chosen were surveyed completely, and respondents represented about one tenth of practicing dermatologists in the United States. The methodology was identical to that used in a previous study of wait times for evaluation of a changing mole (a possible indicator of malignancy).

Half of dermatologist respondents (455, 50.7%) offered appointments for botulinum toxin injections, and the median wait time was 8 days. Acceptance rates and wait times varied greatly by geographic area (range of median wait times 6.0-32.5 days), with dermatologists in Miami, Fla, and Orange County, California, most likely to provide a botulinum toxin appointment with a short wait time. Many dermatologists (241, 27%) employed physician extenders, and 39% of these extenders also offered appointments for botulinum toxin injections (median wait time 6 days). In comparison with a previous study showing median wait times of 26 days for evaluation of a changing mole in these communities, wait times for cosmetic injections were significantly shorter (P < .001). Limitations The metropolitan areas surveyed contain no highly rural areas and do not represent a random sample of all US dermatology practice sites. The cosmetic and medical studies were not conducted concurrently, but were carried out in the same metropolitan areas. Conclusions Patients seeking a cosmetic botulinum toxin injection have more rapid access to dermatologists than has been previously reported for patients seeking urgent consultation for a changing mole. This study cannot differentiate between many possible explanations for the observed differences in wait times. Because physicians in many other specialties with physician shortages are also offering cosmetic services, further studies are needed to assess the broader policy implications of these findings.

I believe that a reason for this is that the reimbursement for the bread-and-butter E&M has gotten so low that physicians have to turn to these alternative revenue streams. Even the threat of decreased payments will have physicians making moves to protect their income "just in case". There is also a domino effect from this. You are sitting in the physicians' lounge and hear how your colleague has started to offer some service that has increased his revenue. You and everyone else within earshot pick this up and run with it. You may wish to avoid such financial driven practices, but if your competitors advertise, then your patients may ask why you are not offering that service. And they may then find themselves a new doctor. Curtailing these behaviors will have to be all or none. If you or only a few of your colleagues do so you further tilt the playing field to your disadvantage. So while you clear conscience allows you to sleep at night, the worry about paying your bills will make that benefit short-lived.

While the issues at hand are complex, Gawande has unfortunately provided the advocates of radical health care reform the albatross to hang around our necks. From the See First Blog: The McAllenization of Health Care Reform
When we talk about health care reform, we are really talking about dozens of different issues. Is health care reform about covering the uninsured, or about cutting costs for employers? It is about having a publicly-funded health plan, or changing reimbursements to doctors? Is it about longer life expectancies or creating insurance cooperatives? Is it about caps on medical malpractice awards, or comparative effectiveness? Is it about healthier lifestyles, or cutting the cost of prescription drugs? Is it about cutting administrative waste, or incentives for more people to go to medical school? Is it about implementing new health care IT, or preventing insurers from making excessive profits?

It’s about all of these things, and more. And that’s the problem, if you’re an ambitious reformer. There is no simple way to get all of these things under one roof.

Well, until Atul Gawande introduced us to McAllen......

......The problems of McAllen make easy talking points. But they are also a convenient way of avoiding dealing with the enormous complexity of the health care system. There are nearly 650,000 doctors in America, millions of patients, thousands of hospitals, tens of thousands of insurance and pharmaceutical companies, hundreds of thousands of employers who provide health benefits, and thousands of other charities, academics, consultants, government agencies and others who have strongly held views about our system. Too often, their voices are not being heard in all the loud talking about McAllen.

So anyone speaking out in opposition of whatever is coming out of DC under the guise of "Health Care Reform" should be prepared to be beaten with the McAllen cudgel.

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