Posts
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 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 Ms. 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.”
As you read this article, I invite you to share your experiences by responding to the questions that will appear. Next week, I will publish a follow-up article based on your responses.
— ELISABETH ROSENTHAL, REPORTER
Ms. 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 revenues 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, since insurers pay far less for traditional doctoring tasks like listening for a heart murmur or prescribing the right antibiotic.
Sharp Climb
Salaries in some medical specialties have risen much more sharply than in others.
$350
Diagnostic
radiology
300
250
Hematology
and oncology
200
Dermatology
150
Primary care
100
Figures in thousands, adjusted for inflation to 1995 dollars. The actual dollar figures in 2014 are higher.
50
1995
2012
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, according to the Medical Group Management Association, which tracks doctors’ income, though their workload is one of the lightest.
In addition, salary figures often understate physician earning power since 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 theRobert Wood Johnson Foundation.
Doctors’ charges — and the incentives they reflect — are a major factor in thenation’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, according to 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, according to 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.”
For example, the procedure performed on Ms. 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. While 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 — over 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.”
Pricing 100 Mohs Procedures
A random sample of 100 similar outpatient Mohs surgeries shows an enormous range in how much was paid for the procedure. The difference between the most expensive and the least expensive is more than $7,000.
$7,594MOST EXPENSIVEThe most expensive ones were performed at hospitals and have large operating-room charges.
$474LEAST EXPENSIVE
100 individual Mohs surgeries
The specialists point to an epidemic, noting there are two million to four million skin cancers diagnosed in the United States each year, with a huge increase in basal cell carcinomas, the type Ms. 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 Medical School, “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.”
Patient Given No Choice
A fair-skinned redhead who teaches history at the University of Central Arkansas, Ms. Little had gone to a private dermatology practice in Heber Springs, Ark., to check some moles on her arms when the physician’s assistant on duty noticed a whitish bump — like a “tiny fragment of thread” — on her face, she said. Her family practitioner had told her it was just a clogged pore.
A diligent medical consumer, Ms. Little had read up on the Mohs technique (invented by Dr. Frederic Mohs in 1938) before she and her husband arrived for her surgery in November 2012 in a doctors’ office building at Baptist Health Medical Center here. Pressed for time as the end of the semester approached, she asked Dr. Randall Breau, the dermatologist, why the tiny growth needed the specialized surgery, as she had asked the physician’s assistant earlier. They both answered that it was because it was on her eyelid, a delicate area where Mohs surgery is always required; she repeatedly insisted that it was on her cheekbone below her eye.
After the 30-minute removal, the dermatologist told her that she would have to go across the street to the Arkansas Center for Oculoplastic Surgery, another private doctors’ office on the hospital’s campus, to have the wound closed by a plastic surgeon with “a couple of stitches.”
When Ms. Little protested that she did not want a plastic surgeon and did not care about having a tiny scar, the doctor told her she had no choice, she said. The vast majority of Mohs procedures are sewed up by the dermatologist or just bandaged and left to heal. Yet when Ms. Little arrived at the second practice, nurses took her clothes, put in an IV, and introduced her to an anesthesiologist who would sedate her in an operating room.
Sitting in her cozy office recently, Ms. Little, who has a faint scar under her eye on her right cheek, still fumes at the thought. “It was no bigger than many cuts that heal on their own, and it definitely could have been repaired by one doctor, but at that point what was I going to do?” she recalled. “I have an IV in my arm and a hole in my face that Dr. Breau refused to stitch. And the anesthesiologist is standing there with his mask on.”
Her bills included $1,833 for the Mohs surgery, $14,407 for the plastic surgeon, $1,000 for the anesthesiologist, and $8,774 for the hospital charges.
Mohs surgery is preferable when the removal of a skin cancer is complicated or in a sensitive area, because it typically excises less tissue and leaves less of a scar than other treatments and allows dermatologists to see the borders of a growth and be confident that it is removed entirely. The surgery is generally not used for melanomas, which require more extensive cutting.
Rich Doctors, Richer Doctors
Specialists who perform medical procedures command the highest incomes among doctors. The following are median annual compensation by specialty for physicians who are paid by hospitals or health networks.
$920,555Orthopedic surgery: hip and joint
$820,569Orthopedic surgery: spine
$707,252Surgery: neurological
$583,837Cardiology: invasive-interventional
$516,081Dermatology: Mohs surgery
$488,200Gastroenterology
$425,006Hematology/Oncology
$378,009Anesthesiology
$345,726Ophthalmology
$300,000Obstetrics/Gynecology: General
$264,863Neurology
$220,000Internal Medicine: General
$166,754Pediatrics: child development
In an email, Dr. Breau declined to discuss Ms. Little’s case, but noted, “When I make decisions concerning patient care, I have only the patient’s best interests in mind.” He said that he and one partner own the Arkansas Skin Cancer and Dermatology Center and receive no payments from the hospital or the doctors to whom they refer patients. In most cases, he said, he takes care of the wound left by Mohs surgery himself. The plastic surgeon did not respond to requests for comment.
It is often impossible in any one case to determine whether a course of treatment was necessary or cost-effective. Even among doctors there are differences of opinion about optimal treatments. That is partly because the guidelines for when to perform many procedures are often ill-defined or based on the specialists’ experience rather than carefully controlled research.
“Though Mohs surgery is disseminating rapidly, there are very few comparative studies and the evidence is still evolving about when it’s beneficial,” said Dr. Gross, the Yale epidemiologist. “When people are trained to perform a procedure, and believe in it, and equip their offices to do it, they will do it. That’s just human nature.”
The same specialties tend to appear at the top of physician earners: orthopedics, cardiology, anesthesiology, radiology, dermatology, plastic surgery, urology, gastroenterology and ophthalmology. Physicians in those fields typically earn more than $350,000 annually, according to American Medical Group Association, a trade organization. In many specialties, income has risen more than 10 percent since 2011, according to Medscape, a Web company that follows the industry.
Physicians often complain that government and commercial insurance reimbursements for seeing patients are decreasing while their office expenses are going up to deal with mountains of paperwork and demands from insurers. Congress currently is considering a bill that would freeze doctors’ Medicare fees for the next decade. Still, many doctors have found alternative income streams that do not show up on surveys.
Dr. Mitchell of Georgetown University estimates, for example, that many urologists make 50 percent of their income from dealing with patients and the rest from investing in the machines that deliver radiation for prostate cancer or to treat kidney stones. In 2012, urologists had an average income of $416,322, according to Medical Group Management Association data, which often does not include the investment income.
Oncologists benefit from the ability to mark up (and profit from) each dose of chemotherapy they administer in private offices, a practice increased dramatically in the late 1990s. The median compensation for oncologists nearly doubled from 1995 to 2004, to $350,000, according to the M.G.M.A. One study last year attributed 65 percent of the revenue in a typical oncology practice to such payments.
When policy makers reduce one type of payment, some specialists find another. Though orthopedists’ reimbursement from Medicare for performing joint replacements has gone down in the last two decades, the Medscape survey on physician income showed that orthopedists’ average compensation has risen 27 percent since 2011. They are still paid handsomely by many private payers for many minor procedures, and — more important — often own the surgery centers, scanners and physical therapy offices they use.
In a country where top hospital executives typically make more than a million dollars a year, American physicians may feel entitled to high fees, especially because they face costs that their European counterparts do not: Medical school is expensive and new doctors graduate with an average of about $150,000 in debt. Likewise, some specialists face malpractice premiums of over $100,000 a year.
Though medical societies tend to point to the long haul of medical training and the unpredictable hours to justify generous salaries, health economists point out there is often little correlation between compensation and that investment of time. Obstetricians, for example, arguably have the most rigorous schedules but are relatively modest earners. A number of high-income specialties — radiology, ophthalmology, anesthesiology and dermatology — are often called the “lifestyle specialties,” because training is more compatible with a home life than some other disciplines and there are fewer emergencies in these fields. Eighty percent of dermatologists see patients 40 hours or fewer each week, according to a 2013 Medscape report, less than the average doctor.
0 comments:
Post a Comment