See article I copied in this post below.  It is a good article and I understand his point.  However I am bothered by the short coming of this article missing some key points such as a lot of the test ordered for the heart murmur are driven by defensive medicine.  I believe Dr. Fisher is being ignorant about the fact that if certain tests are not done and then a problem develops that these test could have caught..... you can imagine the ensuing issues.  There is also no mention of standard of care for these test or any reference to what should or not should be done.

I feel most, if not almost all physicians are looking to what the patient needs rather than what they or the hospital will get reimbursed for what is being done or ordered.  These physician are the absolute minority and do not represent the majority, thus these type of articles are alarmist and to me serve to feed a different purpose or agenda.  These minority doctors just need to be addressed on a doctor by doctor basis by thier peers in a peer review environment.

My two cents, any other thoughts?

Karr



Perverse incentive' in current health care system, says expert

The emphasis above is mine. I live in Texas and I have seen this happen and I have seen what was behind it.
Jeff, you are right - DPMs, MDs, DOs, DDSs - most all of us enter our professions to help our patients initially and then some seem the incredible money that arrives in bank accounts, where before there was such a paucity and it is an incredible lure. That is one thing that happens.

In Texas, there was an added thing that happened. We started losing doctors, primarily MDs and DOs, by the train load. It got to the point where emergency departments in the Rio Grande Valley were simply shutting down and patients were being airlifted to San Antonio.

Stroke? Sorry, you have a 45-minute flight into San Antonio because the local ER closed last month when the neurologist moved to Chicago because his malpractice premium in the Valley shot up 3X its original price and she couldn't afford to keep her doors open. Same for the OB/Gyn, he left for Phoenix and for the cardiothoracic surgeon. He left too.

The state legislature implemented Tort Reform, basically allowing the physicians of the state free reign when it came to getting away with just about anything and leaving patients' without any protection. Now, don't get me wrong...I think we SHOULD be protected against every frivolous lawsuit out there but if some rank amateur or even some seasoned person makes a bum-headed outright mistake or even worse a criminal error, they should have to pay the patient a fair amount. With the new rules, they pay only $250,000 for pain and suffering and frankiy that's not enough for a young person who is truly in person or whose career has been crushed.

But that will perhaps bring some clarity to the issue in Texas. I just wish the pendulum would swing to the middle a little more often rather to the extreme right and left. Someone always gets hurt when that happens.

Great topic, Jeff. Thanks for posting it. I'm sure it is bound to raise some comments here.

Thanks Jeff for posting this article! 

Disclaimer: Please forgive me if this thread lacks a degree of political correctness.

 I see "stuff" like this and it makes my Italian blood "boil." I resent these non-medically trained statisticians that influence medical care/testing. I think of this as "penny-wise...dollar-foolish medicine." Dr. Fisher's contention that the region of Texas studied is "one of the poorest counties in the country" and yet has no proportional increase in health problems in such a population makes me highly suspect of his "study." Unfortunately, the portrayal by those that tests are being ordered by most physicians for financial benefit is insulting. It unfortunately makes caring for chronically ill patients due to socio-economic factors and non-compliant patients more difficult since the perception through the media is that these tests are not being ordered  for the patient's benefit but for the financial gain of the physician. These governmental/academic bureaucrats (many who haven't ever treated any patient) in my humble opinion may be well-intentioned idiots but ARE idiots nevertheless. They are such idiots since many of them formulate a complete overhaul of a healthcare system that requires targeted "fixes" and not "scraping the entire system" without the benefit of many "frontline" physician groups' input.

I just love when government officials state that mammographies should be performed after 50 years of age since statistically they are not cost-effective to breast cancer prevention. I just love when a government official states that it is more financially lucrative to "cut out tonsils" rather than treat tonsillitis with an "antibiotic." By the way, the average tonsillectomy reimburses at the $350.00 level according to an ENT physician friend. I also love when that same government official states that it is financially lucrative to cut off someone's foot for $50,000.00. I didn't go into practice to "cut off feet" but to "save them" through preventative measures. Unfortunately, when amputation does occur it's not done for the money (typically $250.00-$1,100.00 dependent on the insurance plan.) No doctors I know perform those procedures without empathy of its effect on patients and their families.

The use of screening tests when there is a clinical suspicion by the physician is NOT overutilization. Is the criteria of perhaps running a glycohemoglobin A1c on a obese, sedentary patient with lack of Semmes-Weinstein filament sensation indicated? I THINK SO! How many of us have picked up non-diagnosed diabetics in that manner? How many of us have picked up paresthesias in the foot being influenced by a lower back radiculopathy/herniation at a L4-5 spinal segment via MRI? How many of us have picked up peripheral arterial disease and plaque formation by ordering and/or performing arterial doppler studies and duplex ultrasonography when patients have complained of generalized foot/leg fatique, only to find the etiology as PAD that may have been overlooked by other specialties or the patient him/herself? These individuals make the argument, though faulted and lacking, that it was NOT cost effective. In other words, treat the symptomatology rather than etiology since treating symptoms short-term would cost less. What these "policy influencing miscreants" do not factor into their neat little statistical formulas is the financial and emotional costs outside of the healthcare delivery systems. They do not figure loss of productivity, costs to society not only for conditions that could have been prevented but also to the dependents of that individual. What they don't realize is that these costs extend beyond the patient. Indeed they impact not only to patients and their families, but to society overall. But what do I know?.....I didn't go to Harvard or Dartmouth for that matter!!

One thing I forgot to add on this, and no I don't have hard cold facts, but I do know of several individuals in South Texas who are involved in healthcare and they are partners in hospitals, surgical centers, diagnostic labs and imaging labs.

One who I know personally has absolutely no bad motives and he doesn't care if people refer to his place or to the one down the street - really. But the other guys? I can't say.

What I can tell you though, is that each person gets a check in the mail in the five figure range every single month.

For the unscrupulous person, that would be like waving a red flag in front of a herd of bulls. Can you say "Stampede" ?

This was an okay article, but short on the facts. For a more comprehensive picture of the situation in McAllen, read Atul Gawande's article in The New Yorker magazine from June 2009. It is very well written. I've attached the link to the article:
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

Financial incentives are powerful. While I think nearly 99% of physicians believe they are doing what is best for the patient, it does not mean that financial incentives do not influence their (our) decision-making process. If other local physicians are ordering extra tests to diagnose the zebra, and/or are practicing defensive medicine, it is easier to justify these practices ourselves. Physicians practice to the community standard. The community standard is not always the highest standard and may be anecdotal at best. 

We are professionals and expect to be treated professionally. Lawyers, economists, academics, journalists, etc are professionals too. They deserve our respect and their views should be examined, not discounted because they may be inconvenient. To discount others (non-physicians) assessment of healthcare as irrelevant (or arrogant) is arrogant and simply a defensive act. It does nothing to improve patient care nor the system. 

I do not see any hidden agenda in these articles. This is not an affront to doctors nor the quality of care provided by US physicians, just an examination of some facts. Our health care system is broken in many ways. These articles discuss one aspect of the problem, reimbursement. To pretend that our health care system is not affected by physician reimbursement is naive at best.

I appreciate Jamie Kinchsular directly linking the New Yorker article for all of our benefit. I do have a contention in that individuals as well intentioned as they may be are due "respect" especially when portrayal of facts are "slated" in a certain manner and may influence healthcare for our patients. I am always of the opinion that if your are to make recommendations/analyses regarding healthcare policies that a comparison of "apples to apples" should be made with all facts FULLY disclosed.  If one reads Jeff's accounting, Dr. Fisher contends that despite McAllen, Texas being in one of the "poorest counties" of the country, there was no discernable increase in health conditions which may lead to increased healthcare costs. This made me initially highly suspect of this "study." This is counter-intuitive to the conclusions most people would come to I  think. Within the New Yorker article (hardly a hard source for medical information) ,by Atul Gawande, the basis of the article is not written in an objective manner. I come to this conclusion, when an individual dressed up like an ATM machine has the caption, "costlier care is often worse care" graces this "well written article." In fact, my impression is exactly what I thought and what Jeff questions in his initial post of this topic. Within the article, it states in regard to McAllen, Texas "yet public-health statistics show that cardio-vascular rates in the country are actually lower than the average, probably because its smoking rates are quite low. Rates of asthma, HIV, infant mortality, cancer and injury are lower too." Yet the exact same article sites "McAllen, with its high poverty rate, has an incidence of heavy drinking sixty percent higher than the national average." This article states that in 2006, Medicare spent twice the national average in this region as compared to other regions of the country. The article makes note of the substantial investment of technology in Doctors Hospital at Renaissance. Why???? Is there a demographic need for it? It does not however, take into account the consumer utilization aspect of hospitals/medical centers. What do I mean by this? Is it not probable that individuals may opt to use one hospital over another? Damn right it does! I practice in a region of the country where individuals DO travel for the best cardiac hospital or cancer hospital from regions afar regardless of their socio-economic standing. Lets face it...patients are consumer driven. Would that reveal a statistical increase in procedures/tests performed for a particular disease condition for that hospital/medical center and its locality? Damn right it does!
The article contends that the average income is $12,000.00 per year and yet somehow magically DOES NOT reveal an increase in disease states in these patient populations. I note however, the article does not make a comparison on the proportion of these patients getting medical care as compared to those not in those limited income levels. Bottom line, if you are worried about the cost of medication (to your Medicare Part D Plan) relative to food, housing, etc., I would think food, housing, etc would probably be more of an immediate concern. This would lead to an eventual crisis in healthcare and increased associated costs due to non-treatment of preventative measures and disease states. Do these patients even seek care for their chronic conditions? The article itself points out that "we may be more obese than any other industrial nation, but we have the lowest rates of smoking and alcoholism, and we are in the middle range for cardiovascular disease and diabetes." Yet this provides no correlation to utilization of medical services relative to these "clinical" findings. 
The article points however, that the cardiac surgeon who operated in over 8000 cases, "nearly all were obese or diabetic or both."  I wondered if a cardiac surgeon in "20 years of practice" could amass 8000 cases? I wonder what is McAllen, Texas like? What demographic factors may account for this doubling of Medicare costs relative to the rest of the country? I mean do like people in Texas look forward to getting surgery or going to the hospital to persons in other parts of the country? Are they averse to seeking out second opinions in regard to getting information regarding the necessity of these procedures or recommended courses of treatment? So what did I do?....when in doubt ....Google! Amazing!, McAllen, Texas is the fastest growing city in Texas. According to the the US 2000 Census it had a population of 106,000 persons. By 2007, rapid growth had pushed it to over 710,514 persons within the town and surrounding areas. Is it conceivable that a population increase by seven times within a ten year period with a population revealing a lower income level to most Americans and a population that suffers from over 60% chronic usage of alcohol relative to the national average would incur twice the normal Medicare costs?....quite honestly, I'm surprised it is not more!
No one doubts spiraling healthcare costs impact on us all. No one doubts there are a few bad apples that overutilize due to financial benefits over the needs of their patients. I however, take the position that many on the other side that "ration" or "deprive" necessary healthcare (many who have never practiced frontline medicine) are indeed "policy influencing miscreants" unworthy of any "respect" when they portray "studies" as objective when in fact, they are NOT. Therefore, Jamie, I do appreciate you posting the link to this article, however, my opinion has NOT changed. Studies that deserve "respect" should be based on objective research and FULL disclosure. Something that any first year journalism student could easily have done....if they only had a computer access to Google!  I agree that we should not be averse to evaluating viewpoints if they are inconvenient....but they are NOT inconvenient truths!

I apologize if the above response is somewhat confusing. I felt I could best address Dr. Scartozzi by inserting my comments within the quotation. Below is my initial response.

I am simply addressing the information noted in the article by Atul Gawande (general and endocrine surgeon) since I believe it is more complete and illustrates the point better that physician reimbursement, and/or investment in medical care, does seem to have an impact on health care costs. Despite the fact The New Yorker is not a scientific or medical journal, the state of health care was examined by a physician and his opinion was stated in a clear manner. The views and opinions could have been addressed as an editorial in JAMA, NEJM, or other venue for expressing these ideas. The message does not change because it was published in the New Yorker. Furthermore, the image of the patient in an ATM machine does bias the reader, but was this Gawande's intention, or the editors? I don't think that can be answered, nor does it change the message of the article.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

I respect your positions Jamie but disagree with your conclusions. However, the issue of analyzing reimbursement rates for Mayo in El Paso will be difficult in that their doors for eg in Arizona are no longer open to Medicare patients due to a recent decision they have taken due to staggering financial losses. Does this indicate that perhaps Mayo in El Paso or Arizona may have a larger portion of uninsured and subset of "sicker" patients? Are these "teaching" institutions, which are very necessary and provide world-class care not adequately reimbursed for procedures deemed "experimental" and not yet established as a new standard in care and not available for reimbursement for costs they incur? Are we now comparing "apples to apples" with not for profit to for profit hospitals? The basis of my argument although I admit it is a bit long is that the increased utilization of services is due in large part probably to a large increase of nearly seven-fold population in less than ten years. A point not even contemplated by the author which was easy enough to research if he even bothered. An increase in the utilization of services is also most likely due to a large portion of the population with higher healthcare problems due to a lower socio-economic  levels of income.  My point is that this "editorial" or "study" did not bring out demographic studies as a cause or potential source of explanation for their position. Indeed, the PRIMARY position taken is that it was doctors who drive up these healthcare costs. In my opinion, this comes across as "simplistic" and feeds a "populist" sentiment devoid of exploration of all facts. As such, the position of this "investigative piece" in my opinion is lacking and without objective evaluation.  I don't view this as being an affront to physicians since  I just view this for what it is .... an "opinion," .....no more, no less. Best regards.

Dear Jeffery Karr, I have been a physician here in McAllen since 1991 plus my family has been in this area for over 5 generations so I am fully aware of what Dr. Ramirez was addressing.  It is embarrassing the behavior of my "friends" since they and a very greedy banker built the hospital referenced in the article.  I have always been very critical of the Stark laws against doctors, but the way these doctors are now conducting business has actually make me doubt that criticism.  Actually, that is mainly what they are now doing, conducting business, not practicing medicine. 
Sadly, you were incorrect to say that doctor in the article was ignorant.
Sincerely, a Doc in the know.

Thank you Daryl for talking time to share your opinion.  

Certainly, not knowing me it would be unfair to jump to any conclusions.  As well I did not intentionally mean to direct any disrespect.  However, to focus on one word and not the global idea/concept of the this discussion seems to be an attempt at deflection from the issues(s) at hand.  But, again, no disrespect intended.

Karr 

Jeffrey, I did not mean to comment on the manner of how you used a single word, I was just saying that the article had merit.  I wish you were completely right, but there are some in the healthcare field that are gaming the system and it makes it easy for our critics and those who think socilized medicine is good to have "an arguement".  Unless you are an Obama liberal, you and I are on the same side of the debate.  And we must call out the bad behavior amongst us to hold together stronger.
Sincerely, Darryl

Darryl,

Well said and thank you.

Karr