Another day, Another beating up of specialists by the NY Times

[Rirruto]

wouldn't that mean that by extension, the following views are unprofessional?:
1) Not thinking healthcare is a human right
2) Putting personal interest before patient interest
3) Putting personal interest before public interest
4) Not supporting single payer systems
5) Refusing to be "unselfish"
6) Thinking that medicine isn't an art, any more than changing oil is an art.

Be prepared to get lambasted for even hinting at #1 in any of your school's mandatory doctoring sessions.

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[PL198]

Be prepared to get lambasted for even hinting at #1 in any of your school's mandatory doctoring sessions.

I'm aware, none of those are views to publicly have. That's not my point. My point is, that dude's vision literally involves mandating policy preferences or you are deemed unprofessional.

 

[AFMD]

If we Americans want cheaper health care, we have to accept a lower quality of service.

This isn't true at all. There is a huge amount of waste in the system.

 

[DermViser]

This isn't true at all. There is a huge amount of waste in the system.

Like what?

 

[jakeislove]

It'll be interesting to see how the perception of medicine, as a career, changes if primary care becomes where most people end up.

 

[DermViser]

It'll be interesting to see how the perception of medicine, as a career, changes if primary care becomes where most people end up.

Once the NY Times is done going after specialists, you don't think they'll go after primary care physicians too?

 

[jakeislove]

Once the NY Times is done going after specialists, you don't think they'll go after primary care physicians too?

I meant in the general sense. Discussion had already gotten away from the thread's topic.

I'm morbidly curious to what extent medicine will change as primary care becomes the norm for graduates.

 

[mercaptovizadeh]

Elizabeth Rosenthal is an idiot. I saw a talk of hers where she spent 10 minutes out of her 30 minute talk discussing her colonoscopy. She thinks a colonoscopy should cost like $50-100 and is outraged that it's more.

Aside from that, I haven't read the article, but I do think there are irrational disparities in physician and surgeon compensation. I am not a future surgeon and do not begrudge the fact that they are paid higher than physicians, but even there we see how things are not right. Why indeed should orthopedics and ENT be paid better than general surgery? Why should spine be paid better than transphenoidal or skull base surgery? There isn't much explanation for the situation. Same problem exists in the medical specialties. Why is adult heme-onc paid twice what pediatric heme-onc is paid? Why is GI paid so much better than ID? (and please do not tell me that ID does not do as important a job as GI in the hospital...I have seen the endocarditis, sepsis, meningitis, miliary TB patients and they are plenty sick).

 

[DermViser]

Elizabeth Rosenthal is an idiot. I saw a talk of hers where she spent 10 minutes out of her 30 minute talk discussing her colonoscopy. She thinks a colonoscopy should cost like $50-100 and is outraged that it's more.

Wow, she truly is an idiot. She's probably used to and loves communist healthcare in China.

 

[DermViser]

Aside from that, I haven't read the article, but I do think there are irrational disparities in physician and surgeon compensation. I am not a future surgeon and do not begrudge the fact that they are paid higher than physicians, but even there we see how things are not right. Why indeed should orthopedics and ENT be paid better than general surgery? Why should spine be paid better than transphenoidal or skull base surgery? There isn't much explanation for the situation. Same problem exists in the medical specialties. Why is adult heme-onc paid twice what pediatric heme-onc is paid? Why is GI paid so much better than ID? (and please do not tell me that ID does not do as important a job as GI in the hospital...I have seen the endocarditis, sepsis, meningitis, miliary TB patients and they are plenty sick).

The incidence of cancer is higher in adults, it's also more severe with more comorbidities. I don't know if Ortho and ENT pay better - but they do have better hours - which is inherent to their specialty. Don't blame them for that. GI is paid more than ID bc they undertake procedures that are much more invasive and have more malpractice risk.

 

[mercaptovizadeh]

Wow, she truly is an idiot. She's probably used to and loves communist healthcare in China.

It was a medical school graduation speech, too, so we got a lot to hear about a colonoscopy and very little about what lay in store for us in residency and beyond.

 

[Roxas]

It was a medical school graduation speech, too, so we got a lot to hear about a colonoscopy and very little about what lay in store for us in residency and beyond.

 

[DermViser]

It was a medical school graduation speech, too, so we got a lot to hear about a colonoscopy and very little about what lay in store for us in residency and beyond.

Depending on specialty, the two can feel similar, figuratively speaking.

 

[jakeislove]

Depending on specialty, the two can feel similar, figuratively speaking.

Colonoscopies use steri-lube, DV.

 

[DermViser]

Colonoscopies use steri-lube, DV.

True. The latter is all at once with no lube or anesthesia.

 

[jakeislove]

True. The latter is all at once with no lube or anesthesia.

Sallie-Mae likes it rough, LOL!

 

[jakeislove]

Elizabeth Rosenthal is an idiot. I saw a talk of hers where she spent 10 minutes out of her 30 minute talk discussing her colonoscopy. She thinks a colonoscopy should cost like $50-100 and is outraged that it's more.

Aside from that, I haven't read the article, but I do think there are irrational disparities in physician and surgeon compensation. I am not a future surgeon and do not begrudge the fact that they are paid higher than physicians, but even there we see how things are not right. Why indeed should orthopedics and ENT be paid better than general surgery? Why should spine be paid better than transphenoidal or skull base surgery? There isn't much explanation for the situation. Same problem exists in the medical specialties. Why is adult heme-onc paid twice what pediatric heme-onc is paid? Why is GI paid so much better than ID? (and please do not tell me that ID does not do as important a job as GI in the hospital...I have seen the endocarditis, sepsis, meningitis, miliary TB patients and they are plenty sick).

She should go into GI and try running a practice.

 

[AFMD]

This isn't true at all. There is a huge amount of waste in the system.

Like what?

The healthcare system in the US is quite unique. I don't want to talk about politics at all, so I'll just stick to facts. The system we in the US have is very expensive in comparison to other healthcare systems in developed nations. US healthcare spending, as expressed as percent of GDP, is by far the highest. Period. (This is according to data reporting by WHO).

Combined with the fact that health outcomes in the US are pretty mediocre, but at least comparable to other developed nations. This can be somewhat subjective, and will depend on what metrics you use. So, use you're own judgement. I feel most would agree with the evaluation: We pay much more, and receive reasonably comparable care in the US. This premise would suggest we spend money, that other countries do not, that does not effect patient out comes.

But what do we spend this money on? If the answer was easy, we'd just fix it. But, I feel there are several areas that are worth discussing, and the over-arching theme is simply: The cost of system complexity.

First of all, some may disagree that this is "waste" spending. It may just be the necessary spending for the type of healthcare system that a large portion of the the US population desires (because of desire for free market, personal freedom/responsibility, etc.). Whether this is "waste" or "necessary" spending is subjective, and I will reserve judgement. The fact remains: It is extra spending that has little effect on patient care, and it can be defined and debated.

The Easy Stuff
Information Systems and Health Records: We have many different healthcare entities, and many different systems to store their information. Different offices, hospitals, insurance companies, etc. Sometimes records don't get places on time, or ever. This can cause duplication in tests, unnecessary procedures, etc. etc. This is not necessarily a problem exclusive to the US.

Preventative Medicine: Either because they cannot afford it, don't have access, don't have time, etc. easy problems become expensive problems.

Lack of Price Transparency: Another problem of complexity. Contracts between healthcare providers and insurance companies decide a lot of the prices in health care, and so do arbitrary price schemes made by some providers. These prices are not commonly communicated to a patient before the service is given, not even in non-emergent care. This seems rather silly when you really think about it. As a result there is a lot of non-payment, imagine that. This is easy to fix: All prices are federally required to be easily accessible.

The Difficult Stuff
Administration: The shear complexity of the health system is extremely expensive. Hundreds of insurance companies, millions of different plans, each with different and changing rules. Collection departments are required to collect unpaid bills from individual payers as well as insurance and government payers. This takes hundreds of people in just one hospital/healthcare entity. Insurance companies themselves are expensive to run, and are a necessary middle man in a private health system.

Popular Reimbursement Schemes: Fee for service mostly incentivizes... services that are reimbursable, as opposed to the actual health of the patient. This has created an assembly line like system in outpatient medicine. Primary care visits are shorter, more and more simple cases are punted to specialists. This is more expensive. Procedures are incentivized, and those that do procedures make more than than those who provide non-procedure services, and arbitrarily so. Dermatologists, for example DermViser, made around the same as internists in the 1980s, but now make many times what internists make. Remember, I am NOT saying dermatologists should make less money. I am NOT saying dermatologists should make less money. I'm merely pointing out we've created a system that arbitrarily reimburses certain services/procedures much much more than others. And it's worth a thoughtful discussion: What would be the best way to reimburse physicians to get good outcomes and also pay physicians what they are worth. A lot rates right now is political stuff between the AMA, CMS, etc., or simply arbitrary.

I think it's important that I express that I DO NOT what physicians to get paid less. I think physicians should get paid a lot for the very specialized service they provide. I think physicians should want to get paid a lot. I will be a physician very soon, and I want to get paid a lot. This is not a bad thing. However, I'd rather be paid a lot because that's what I'm worth. I rather be a dermatologists and get paid what I'm worth, than never know when the arbitrary reimbursements will screw me as the pendulum swings back the other way.

I'd like to see creative ways to use bundled payment in inpatient medicine, and capitation in outpatient medicine. Maybe I'm wrong. The point is: It's worth a discussion.

Once the NY Times is done going after specialists, you don't think they'll go after primary care physicians too?

One day primary care very well be lucrative again, as these things change. The Times might go after them when that happens.

Right now, I really don't know how they could put primary care physicians any lower than they are now.

 

[DermViser]

She should go into GI and try running a practice.

Doubt she cares: http://www.nytimes.com/2013/06/02/h...ld-in-health-expenditures.html?pagewanted=all

 

[bronx43]

The incidence of cancer is higher in adults, it's also more severe with more comorbidities. I don't know if Ortho and ENT pay better - but they do have better hours - which is inherent to their specialty. Don't blame them for that. GI is paid more than ID bc they undertake procedures that are much more invasive and have more malpractice risk.

Malpractice doesn't come close to covering the reimbursement disparity, and "invasive-ness" cannot be a pricing mechanism. There is no logical rationalization for reimbursement schedules. It is in itself a contradiction to espouse the health care payment system while supporting a free market.

 

[DermViser]

Malpractice doesn't come close to covering the reimbursement disparity, and "invasive-ness" cannot be a pricing mechanism. There is no logical rationalization for reimbursement schedules. It is in itself a contradiction to espouse the health care payment system while supporting a free market.

Yes, it does. GI carries MUCH MORE risk in their procedures, while ID has no procedures specific only to ID. So yes, the reimbursement is expected to be higher for GI like it should be and same for Cards.

 

[bronx43]

The healthcare system in the US is quite unique. I don't want to talk about politics at all, so I'll just stick to facts. The system we in the US have is very expensive in comparison to other healthcare systems in developed nations. US healthcare spending, as expressed as percent of GDP, is by far the highest. Period. (This is according to data reporting by WHO).

Combined with the fact that health outcomes in the US are pretty mediocre, but at least comparable to other developed nations. This can be somewhat subjective, and will depend on what metrics you use. So, use you're own judgement. I feel most would agree with the evaluation: We pay much more, and receive reasonably comparable care in the US. This premise would suggest we spend money, that other countries do not, that does not effect patient out comes.

But what do we spend this money on? If the answer was easy, we'd just fix it. But, I feel there are several areas that are worth discussing, and the over-arching theme is simply: The cost of system complexity.

First of all, some may disagree that this is "waste" spending. It may just be the necessary spending for the type of healthcare system that a large portion of the the US population desires (because of desire for free market, personal freedom/responsibility, etc.). Whether this is "waste" or "necessary" spending is subjective, and I will reserve judgement. The fact remains: It is extra spending that has little effect on patient care, and it can be defined and debated.

The Easy Stuff
Information Systems and Health Records: We have many different healthcare entities, and many different systems to store their information. Different offices, hospitals, insurance companies, etc. Sometimes records don't get places on time, or ever. This can cause duplication in tests, unnecessary procedures, etc. etc. This is not necessarily a problem exclusive to the US.

Preventative Medicine: Either because they cannot afford it, don't have access, don't have time, etc. easy problems become expensive problems.

Lack of Price Transparency: Another problem of complexity. Contracts between healthcare providers and insurance companies decide a lot of the prices in health care, and so do arbitrary price schemes made by some providers. These prices are not commonly communicated to a patient before the service is given, not even in non-emergent care. This seems rather silly when you really think about it. As a result there is a lot of non-payment, imagine that. This is easy to fix: All prices are federally required to be easily accessible.

The Difficult Stuff
Administration: The shear complexity of the health system is extremely expensive. Hundreds of insurance companies, millions of different plans, each with different and changing rules. Collection departments are required to collect unpaid bills from individual payers as well as insurance and government payers. This takes hundreds of people in just one hospital/healthcare entity. Insurance companies themselves are expensive to run, and are a necessary middle man in a private health system.

Popular Reimbursement Schemes: Fee for service mostly incentivizes... services that are reimbursable, as opposed to the actual health of the patient. This has created an assembly line like system in outpatient medicine. Primary care visits are shorter, more and more simple cases are punted to specialists. This is more expensive. Procedures are incentivized, and those that do procedures make more than than those who provide non-procedure services, and arbitrarily so. Dermatologists, for example DermViser, made around the same as internists in the 1980s, but now make many times what internists make. Remember, I am NOT saying dermatologists should make less money. I am NOT saying dermatologists should make less money. I'm merely pointing out we've created a system that arbitrarily reimburses certain services/procedures much much more than others. And it's worth a thoughtful discussion: What would be the best way to reimburse physicians to get good outcomes and also pay physicians what they are worth. A lot rates right now is political stuff between the AMA, CMS, etc., or simply arbitrary.

I think it's important that I express that I DO NOT what physicians to get paid less. I think physicians should get paid a lot for the very specialized service they provide. I think physicians should want to get paid a lot. I will be a physician very soon, and I want to get paid a lot. This is not a bad thing. However, I'd rather be paid a lot because that's what I'm worth. I rather be a dermatologists and get paid what I'm worth, than never know when the arbitrary reimbursements will screw me as the pendulum swings back the other way.

I'd like to see creative ways to use bundled payment in inpatient medicine, and capitation in outpatient medicine. Maybe I'm wrong. The point is: It's worth a discussion.



One day primary care very well be lucrative again, as these things change. The Times might go after them when that happens.

Right now, I really don't know how they could put primary care physicians any lower than they are now.

Easily the best post in the thread.

When it all comes down to it, the issue isn't if the system will collapse, but when. The good news is that I think the relative gravy train will roll on for a bit while longer. I can't see the health care system going under without the world financial system collapsing first.

 

[bronx43]

Yes, it does. GI carries MUCH MORE risk in their procedures, while ID has no procedures specific only to ID. So yes, the reimbursement is expected to be higher for GI like it should be and same for Cards.

All irrelevant in a truly free market, in which prices are determined only by supply and demand - nothing else. How do you price "invasiveness?" With what do you measure "invasiveness?" Why does this metric measure "invasiveness?" What is the price for each unit of such a metric? And how do you know this or test this?
I understand the argument you're trying to make, and realize the superficial logic that it may make to some people. Unfortunately, it is simply a non-sequitur in a free market.

 

[DermViser]

All irrelevant in a truly free market, in which prices are determined only by supply and demand - nothing else. How do you price "invasiveness?" With what do you measure "invasiveness?" Why does this metric measure "invasiveness?" What is the price for each unit of such a metric? And how do you know this or test this?
I understand the argument you're trying to make, and realize the superficial logic that it may make to some people. Unfortunately, it is simply a non-sequitur in a free market.

Medicine isn't a free market genius. Third party payers are involved. Patients don't pay directly for services. Residencies and fellowships are capped, etc.

 

[bronx43]

Medicine isn't a free market genius. Third party payers are involved. Patients don't pay directly for services. Residencies and fellowships are capped, etc.

... and that's my entire point. Everything is ultimately arbitrary and trying to rationalize reimbursement schedules is just asinine. Colonoscopies are reimbursed more than E&M in the office, because colonoscopies are reimbursed more than E&M in the office - invasiveness has nothing to do with it. Likewise, colonoscopies are reimbursed more than an appy, because colonoscopies are reimbursed more than an appy - not because... oh wait, which is more invasive again?

 

[DermViser]

... and that's my entire point. Everything is ultimately arbitrary and trying to rationalize reimbursement schedules is just asinine. Colonoscopies are reimbursed more than E&M in the office, because colonoscopies are reimbursed more than E&M in the office - invasiveness has nothing to do with it. Likewise, colonoscopies are reimbursed more than an appy, because colonoscopies are reimbursed more than an appy - not because... oh wait, which is more invasive again?

Colonoscopies carry much more malpractice risk AND requires more setup/work/labor then talking with a patient (E&M(. The cuts are the ones that are arbitrary due to the 1997 Budget Control Act. Your problem is with Congress for cutting reimbursement.

 

[SouthernSurgeon]

... and that's my entire point. Everything is ultimately arbitrary and trying to rationalize reimbursement schedules is just asinine. Colonoscopies are reimbursed more than E&M in the office, because colonoscopies are reimbursed more than E&M in the office - invasiveness has nothing to do with it. Likewise, colonoscopies are reimbursed more than an appy, because colonoscopies are reimbursed more than an appy - not because... oh wait, which is more invasive again?

Reimbursements are based on a combination of time, complexity, and risk.

However, the relative value of each of these things for a procedure is determined by a human committee that is far from perfect. And despite attempts at change their determinations of value tend to be relatively static over time.

As such, the lucrative areas within medicine tend to be areas where they have miscalculated. Especially when that miscalculation emphasizes the time aspect. this is why you get articles about GI docs billing for 30 hours of work in a single day.

 

[DermViser]

Reimbursements are based on a combination of time, complexity, and risk.

However, the relative value of each of these things for a procedure is determined by a human committee that is far from perfect. And despite attempts at change their determinations of value tend to be relatively static over time.

As such, the lucrative areas within medicine tend to be areas where they have miscalculated. Especially when that miscalculation emphasizes the time aspect. this is why you get articles about GI docs billing for 30 hours of work in a single day.

You would think he would know what RVUs and fee for service are by this point.

 

[bronx43]

Reimbursements are based on a combination of time, complexity, and risk.

However, the relative value of each of these things for a procedure is determined by a human committee that is far from perfect. And despite attempts at change their determinations of value tend to be relatively static over time.

As such, the lucrative areas within medicine tend to be areas where they have miscalculated. Especially when that miscalculation emphasizes the time aspect. this is why you get articles about GI docs billing for 30 hours of work in a single day.

I understand how reimbursement rates are derived, but I argue that they are heavily flawed if not entirely arbitrary. Are you arguing otherwise? We can agree that the time variable was largely miscalculated, but I would surmise that complexity and risk are difficult if not impossible to quantify. Are the inherent risks for an appendectomy less than that for a screening colonoscopy? Or less complex?

The problem is that the current system is trying to blend certain aspects of free market with non-free market features, which has largely contributed to the bloated system that we have now. It is entirely unsustainable, and it will change whether we like it or not. The best thing you can do is to best position yourself for the change when it does occur.

 

[SouthernSurgeon]

The problem is that the current system is trying to blend certain aspects of free market with non-free market features, which has largely contributed to the bloated system that we have now.

On this, I completely agree.

I think RVUs do an ok job. I took issue with the designation of "arbitrary" - subjective yes, arbitrary no. There are obviously some areas where they have whiffed, and the hesitance to modify them is a big problem.

But part of the issue is that everyone thinks their procedures are the most important/labor intensive/risky. So everyone overvalues their own field and believes them to be undercompensated.

 

[bronx43]

On this, I completely agree.

I think RVUs do an ok job. I took issue with the designation of "arbitrary" - subjective yes, arbitrary no. There are obviously some areas where they have whiffed, and the hesitance to modify them is a big problem.

But part of the issue is that everyone thinks their procedures are the most important/labor intensive/risky. So everyone overvalues their own field and believes them to be undercompensated.

Fair enough. "Arbitrary" was improper in this case as there are reasons for the prices, whether they are valid or not. The point I was trying to make is that there should be no role for subjectivity in the matter of pricing. You either do away with all state intervention and go the way of free market and let it dictate prices, or you move to total state control. The mutant system we have now is just disaster waiting to happen.

 

[alpinism]

Like what?

Not to mention, I've never seen a country that over treats and over tests as much as the US.

(At least compared to Canada, Europe, and other developed countries).

-Abx for viral colds/sinusitis/otitis media/bronchitis
-Statins for mildly elevated cholesterol and no heart disease
-SSRIs for people with depressed mood (only 20% of people on SSRIs actually have depression)
-opiates for every patient in pain (the US is 4.6% of the world's population but uses over 80% of the worlds opiates)
-muscle relaxants for muscle spasms
-using expensive brand name drugs instead of generics
-giving medications that have no proven efficacy (cough medications)
-XR/CT/labs for every patient that visits the ED
-elective orthopedic surgery in patients over 80 years old
-back surgeries to relieve pain instead of medical management
-using da vinci robots instead of laproscopic surgery which costs significantly less but has equal efficacy
-using $24 dermabond instead of $5 sutures when both have identical outcomes
-using saline instead of tap water for wound irrigation
-harmful screening tests (PSA and mammography)
-And my favorite, general health checks and routine physicals that don't reduce mortality, morbidity, or hospitalizations but do increase healthcare costs, diagnosis of chronic disease, and the use of medications (the backbone of primary care medicine).

http://www.thennt.com/nnt/routine-health-checks-for-reducing-mortality-and-morbidity/

Plus hundreds of other likely ineffective treatments based on publication bias and research fraud.

I'd wager that as much as 1/3 of all medical treatments currently used today either don't work at all or have a statistically insignificant effect. The BMJ recently put the number as high as 1/2 of all medical treatments.

http://www.washingtonpost.com/blogs...ont-know-if-half-our-medical-treatments-work/

Thats 1/2 of the 3.8 trillion dollars we spend on healthcare every year including all the administration costs associated with giving ineffective treatments.

 

[DermViser]

Fair enough. "Arbitrary" was improper in this case as there are reasons for the prices, whether they are valid or not. The point I was trying to make is that there should be no role for subjectivity in the matter of pricing.

Then what "objective" arbiter should set pricing?

 

[bronx43]

Then what "objective" arbiter should set pricing?

Price in itself is a concept derived from a free market. The only objective way to set a price is by way of supply and demand in a market. To remove price setting from the free market simply doesn't work.

 

[DermViser]

Not to mention, I've never seen a country that over treats and over tests as much as the US.

(At least compared to Canada, Europe, and other developed countries).

-Abx for viral colds/sinusitis/otitis media/bronchitis
-Statins for mildly elevated cholesterol and no heart disease
-SSRIs for people with depressed mood (only 20% of people on SSRIs actually have depression)
-opiates for every patient in pain (the US is 4.6% of the world's population but uses over 80% of the worlds opiates)
-muscle relaxants for muscle spasms
-using expensive brand name drugs instead of generics
-giving medications that have no proven efficacy (cough medications)
-XR/CT/labs for every patient that visits the ED
-elective orthopedic surgery in patients over 80 years old
-back surgeries to relieve pain instead of medical management
-using da vinci robots instead of laproscopic surgery which costs significantly less but has equal efficacy
-using $24 dermabond instead of $5 sutures when both have identical outcomes
-using saline instead of tap water for wound irrigation
-harmful screening tests (PSA and mammography)
-And my favorite, general health cheeks and routine physicals that don't reduce mortality, morbidity, or hospitalizations but do increase healthcare costs, diagnosis of chronic disease, and the use of medications (the backbone of primary care medicine).

http://www.thennt.com/nnt/routine-health-checks-for-reducing-mortality-and-morbidity/

Plus hundreds of other likely ineffective treatments based on publication bias and research fraud.

I'd wager that as much as 1/3 of all medical treatments currently used today either don't work at all or have a statistically insignificant effect. The BMJ recently put the number as high as 1/2 of all medical treatments.

http://www.washingtonpost.com/blogs...ont-know-if-half-our-medical-treatments-work/

Thats 1/2 of the 3.8 trillion dollars we spend on healthcare every year including all the administration costs associated with giving ineffective treatments.

Yes, and with your entire experience as a medical student you would know.

SSRIs have helped many people who don't have full blown major depression. There are other uses as well (anxiety) as many times those 2 occur at the same time. Try telling people who SSRIs have worked for that they don't need them.

You realize pharmacists AUTOMATICALLY replace brand names with generics unless no substitution is signed for right?

Funny, bc the people who wrote the healthcare bill said that more preventative healthcare checkups would decrease costs due to prevention. Are they wrong? No **** those checkups would diagnose chronic diseases and medications would be prescribed. What did u want to happen?

As far as ER ordering XR/CT/labs on every patient - you can blame the malpractice environment for that that can take all his earnings. Ask the EM physician in Boston who got sued for 5 million dollars and lost.

You're seriously whining over saline water being used instead of tap water? Fine. Next time, you get a wound and the nurse irrigates it from unpurified water from the tap, don't blame and sue when you get a wound infection.

 

[BobbyB]

what other healthcare systems carry the same or greater malpractice risk than the US?

reduce the risk and MDs will adjust accordingly

 

[mercaptovizadeh]

Yes, it does. GI carries MUCH MORE risk in their procedures, while ID has no procedures specific only to ID. So yes, the reimbursement is expected to be higher for GI like it should be and same for Cards.

Why should procedures be valued so much more than knowledge? I am not arguing here that a PCP with 3 years of training should be paid the same as a neurosurgeon with 7. I am asking you why the knowledge that an ID doctor - or a nephrologist, or a pediatric oncologist, etc. - should be so undervalued in comparison to a colonoscopy?

You will say it is invasiveness. But the real question is: what problem is being addressed by the physician and is their skill unique or can it be done as well by someone else? Do you really think the ID/nephrologist/pediatric oncologist/neurologist knowledge and expertise is so fungible that it can be done by just anyone? Why not just do away with these specialties then? Do you think a GI doctor is competent to manage an AIDS patient with TB or accurately diagnose and treat a cryptococcal meningitis case? Do you think an orthopedic surgeon can just put in random dialysis orders without ultimately causing a disaster? Who needs nephrology anyway?

So why are ID and nephrology two of the most consulted subspecialties in the entire hospital - and often see the very sickest patients?

I'm not saying non-proceduralists should be paid exactly the same as proceduralists. I'm just asking why physicians with 6+ years of training who are treating very sick people based on knowledge and experience they attained in their fellowship and beyond are being paid no better (and in many cases worse) than a PCP.

 

[bronx43]

what other healthcare systems carry the same or greater malpractice risk than the US?

reduce the risk and MDs will adjust accordingly

With the way the industry has transformed in the past decade, I don't believe that tort reform will have any significant effect on net spending on health care in the US. The large health care corporations would not and cannot tolerate the drop off in revenue they receive from diagnostic testing. Right now, the exorbitant testing that we do is hidden under the guise of "defensive medicine." While defensive medicine is a real phenomenon and is the current driver for testing in the minds of actual providers, it is also a huge revenue generator for the industry. If defensive medicine were to stop, other market forces would take its place - institutions would likely start implementing diagnostic algorithms for each chief complaint. This is painfully obvious when you look at hospital medicine departments around the country which are being subsidized by hospitals for the sole reason that their value add isn't actually seeing patients and billing for medical services provided. Their value is the ancillary revenue it generates from diagnostic testing and treatment procedures. If their diagnostic testing rates dropped by a significant amount, the department would become a liability for the hospital and they would not receive any amount of subsidy.

 

[alpinism]

Yes, and with your entire experience as a medical student you would know.

SSRIs have helped many people who don't have full blown major depression. There are other uses as well (anxiety) as many times those 2 occur at the same time. Try telling people who SSRIs have worked for that they don't need them.

You realize pharmacists AUTOMATICALLY replace brand names with generics unless no substitution is signed for right?

Funny, bc the people who wrote the healthcare bill said that more preventative healthcare checkups would decrease costs due to prevention. Are they wrong? No **** those checkups would diagnose chronic diseases and medications would be prescribed. What did u want to happen?

As far as ER ordering XR/CT/labs on every patient - you can blame the malpractice environment for that that can take all his earnings. Ask the EM physician in Boston who got sued for 5 million dollars and lost.

You're seriously whining over saline water being used instead of tap water? Fine. Next time, you get a wound and the nurse irrigates it from unpurified water from the tap, don't blame and sue when you get a wound infection.

Im talking about giving SSRIs to patients who don't meet the DSM criteria for depression or GAD not using them for GAD itself.

http://www.ncbi.nlm.nih.gov/pubmed/23548817

There was a recent Lancet meta-analysis that showed PCPs (the main people who prescribe antidepressants) actually misidentify more cases than they diagnose.

http://www.ncbi.nlm.nih.gov/pubmed/19640579

 

[AFMD]

Reimbursements are based on a combination of time, complexity, and risk.

However, the relative value of each of these things for a procedure is determined by a human committee that is far from perfect. And despite attempts at change their determinations of value tend to be relatively static over time.

As such, the lucrative areas within medicine tend to be areas where they have miscalculated. Especially when that miscalculation emphasizes the time aspect. this is why you get articles about GI docs billing for 30 hours of work in a single day.

It's a committee in the AMA that sells it's opinion to CMS, who then run it through some formula to get Medicare reimbursement. Medicare reimbursement rates are the bedrock of the many different medical pricing schemes in the US.

This is very subjective and controversial, but many believe that certain interests in the AMA have quite a bit of influence over these opinions. It interesting that primary care physicians have very little control in the AMA. It's also seems strange that a private association of physicians has so much control over pricing in the US. I'm not saying any of this is bad, just pointing it out.

Yes, and with your entire experience as a medical student you would know.

You ad hominem is a bizarre addition to an otherwise lucid argument.

Funny, bc the people who wrote the healthcare bill said that more preventative healthcare checkups would decrease costs due to prevention. Are they wrong? No **** those checkups would diagnose chronic diseases and medications would be prescribed. What did u want to happen?

I think the issue here is that we currently do not use an evidence based approach to "check-ups" or annual physicals. Most physicians simply do what is traditional done by others. This is true for a lot for medicine.

As far as ER ordering XR/CT/labs on every patient - you can blame the malpractice environment for that that can take all his earnings. Ask the EM physician in Boston who got sued for 5 million dollars and lost.

And the malpractice environment contributes to waste spending.

You're seriously whining over saline water being used instead of tap water? Fine. Next time, you get a wound and the nurse irrigates it from unpurified water from the tap, don't blame and sue when you get a wound infection.

This is an interesting one, and is a really good example of the American attitude towards medicine. There is simply no difference between using tap water and saline, strictly scientifically speaking. But, there's some emotional component that we can't let go of. Science is not enough for medicine sometimes.

And, if you point out where medicine is not evidence based: You get mocked. You're just "whining", or worse you looked down upon for thinking outside of current tradition.

The same thing happened with hand washing, bacterial causes to ulcers, etc. etc. etc. The men who did the science were completely repudiated by mainstream medicine because they didn't fit in. This attitude is the same one that causes medicine to lag behind science, and the cost is measured in human suffering and death.

 

[DermViser]

Im talking about giving SSRIs to patients who don't meet the DSM criteria for depression or GAD not using them for GAD itself.

http://www.ncbi.nlm.nih.gov/pubmed/23548817

There was a recent Lancet meta-analysis that showed PCPs (the main people who prescribe antidepressants) actually misidentify more cases than they diagnose.

http://www.ncbi.nlm.nih.gov/pubmed/19640579

Psychiatry isn't checking off boxes contrary to your NBME shelf exam. There is this thing called clinical judgement.

 

[DermViser]

And the malpractice environment contributes to waste spending.

Yes, so don't blame doctors for reacting to the malpractice environment in the way they do.

The EM doctor was sued for 5 million dollars for missing viral myocarditis (something you can't diagnose with laboratory tests, imaging, EKG unless it's quite severe, etc. or even has a cure). Even then, he lost. You can bet from now on he will order every test in the book. Doctors will start treating things "scientifically" when the malpractice environment actually supports that. Until then -- tough chance.

 

[BurghStudent]

Yes, so don't blame doctors for reacting to the malpractice environment in the way they do.

The EM doctor was sued for 5 million dollars for missing viral myocarditis (something you can't diagnose with laboratory tests, imaging, EKG unless it's quite severe, etc. or even has a cure). Even then, he lost. You can bet from now on he will order every test in the book. Doctors will start treating things "scientifically" when the malpractice environment actually supports that. Until then -- tough chance.

What do you think about the recent JAMA article that basically said that defensive medicine only accounts for 3 percent of health care costs, extrapolating from 3 hospitals?

http://archinte.jamanetwork.com/article.aspx?articleid=1904758

The LA Times loved it.

http://www.latimes.com/business/hil...y-shows-why-tort-reform--20140919-column.html

 

[DermViser]

What do you think about the recent JAMA article that basically said that defensive medicine only accounts for 3 percent of health care costs, extrapolating from 3 hospitals?

http://archinte.jamanetwork.com/article.aspx?articleid=1904758

The LA Times loved it.

http://www.latimes.com/business/hil...y-shows-why-tort-reform--20140919-column.html

I've lost all respect for JAMA when they started printing articles on NPs being better than physicians and politicians articles on healthcare. Malpractice definitely drives what people order ESPECIALLY if you've rotated in an ER.

 

[AFMD]

Yes, so don't blame doctors for reacting to the malpractice environment in the way they do.

Whose blaming doctors?

I've lost all respect for JAMA when they started printing articles on NPs being better than physicians and politicians articles on healthcare. Malpractice definitely drives what people order ESPECIALLY if you've rotated in an ER.

Your argument is: "Evidence is wrong and my opinion is right". While you are untitled to this opinion, but we'd be doing you a disservice by neglecting to point that out to you. It may be worth actually reviewing and pondering the evidence.

 

[DermViser]

Your argument is: "Evidence is wrong and my opinion is right". While you are untitled to this opinion, but we'd be doing you a disservice by neglecting to point that out to you. It may be worth actually reviewing and pondering the evidence.

No. My point (which you obviously missed) is that it's hard to divine why someone ordered something when you're not the person who ordered it. One person will say he ordered it bc it was medically necessary or for rule out on his differential the other will say it's bc of malpractice concern. Doesn't change the bill.

 

[AFMD]

No. My point (which you obviously missed) is that it's hard to divine why someone ordered something when you're not the person who ordered it. One person will say he ordered it bc it was medically necessary or for rule out on his differential the other will say it's bc of malpractice concern. Doesn't change the bill.

I missed it because that was not included in the original post I quoted and responded to. How exactly was I supposed to divine your point?

You call some doctors at 3 hospitals evaluating THEIR OWN practice patterns EVIDENCE?!?!

What next? Are you going to reference an article in which 3 drug company executives evaluate whether their drugs are overprescribed, and then site that as evidence that we don't overprescribe drugs?!?!

Good gravy.

Are you saying it's not evidence? I think we'd both agree that it would be more correct to say that it is insufficient evidence to draw the sensationalized conclusion. I was merely prompting dermadviser to make an actual argument.

 

[DermViser]

+1

3% my hindparts. The most common conversation I have with my EM attendings goes something like this:

Attending: Do you think your patient really needs all these labs and CT scans?

Me: No.

Attending: Then why did you order them?

Me: Because I don't feel like getting sued.

Attending: Ok then.

Me: I'll cancel them if you want.

Attending: Heck no, I would have ordered them too. I was just curious if you think this patient really NEEDS them. Light 'em up, I'm not getting sued either.


I can say quite honestly that with a Canada style malpractice environment in place, I wouldn't do 1/4 of the testing I do now.

3% my increasingly saggy hindparts.

Yes, that's exactly how it goes. I can't imagine wearing one hat as to what is medically necessary and one that is malpractice necessary on every single patient that walks thru the door. That's why you'll have tons of educated idiots who say that malpractice costs don't make up a huge part of medical costs, but they're only counting malpractice judgements, not the TONS of cases where labs were drawn, imaging was ordered, procedures were done, to avoid malpractice.

Just ask any physician that purposefully doesn't order a lab test (PSA), bc if he does order it and it's too high regardless of reason, he is obligated to follow up and go thru the proper procedure to investigate why.

 

[DermViser]

I missed it because that was not included in the original post I quoted and responded to. How exactly was I supposed to divine your point?

No one expects you to divine anything. However, I do expect a medical student to understand that things aren't as black-and-white and the solution isn't as easy as they think it is and to understand that somethings have a lot more nuance and depth that aren't initially reported in journal articles that aren't "scientific". That's not something that has to be stated directly in order to understand.

Think that malpractice doesn't have as much of an effect? Ask this Emergency Medicine physician who left Massachusetts and now will be ordering every lab test, imaging, procedure in the book, including a heart biopsy, for every young man that comes in with fever and cough. Congrats, now at least we can tell them they can be assured they don't have viral myocarditis along with their huge medical bill.

http://www.kevinmd.com/blog/2014/03/doctors-practice-cover-ass-medicine.html

 

[notbobtrustme]

SSRIs have helped many people who don't have full blown major depression. There are other uses as well (anxiety) as many times those 2 occur at the same time. Try telling people who SSRIs have worked for that they don't need them.

you missed the point. The vast majority of those people would have done fine on any pill you gave them. You could have given them anything (eg lisinopril), told em it was an anti-depressant, and their symptoms would have improved.