Sunday, July 22, 2012

The Need to Denigrate Physicians

"The plural of anecdote is not data."

This morning's lead editorial in the Sunday edition of the New York Times was entitled "A Formula for Cutting Health Costs" and contained the byline "Alaska natives have something to teach doctors and patients in the rest of the world."

I read the editorial with interest, hoping that a new perspective, vision, idea, or insight would be mentioned that would provide a sustainable cost solution to our health care crisis in America.   After all, America desperately needs solutions to this conundrum.

We learn in the editorial how the Southcentral Foundation in Anchorage, Alaska treating rural patients " has achieved astonishing results in improving health of its enrollees while cutting costs in treating them."

Sadly, cost saving information was not provided.

Instead, we read that "such a transformation would require upfront financing for training, data processing and the like, but the investment should (emphasis mine) rapidly pay off in reduced costs."

The article states that because of their efforts, "emergency room use has been reduced by 53%, specialty care visits by 65% and visits to primary care doctors by 36%."  The editors claim "these efficiencies have clearly saved money" while saying in the same breath that spending of hospital services grew "by a tiny 7%" and its spending in primary care grew by 30% .  How do they explain this growth as cost savings in the editorial? They do so by claiming that 30% growth  was "still well below the 40% increase posted in the national index issued by the Medical Group Management Association."

But revenues grew too - substantially.  According to Southcentral Foundation's own press release, "total revenue has consistently increased from $120.2 million in 2003 to $201.3 million in 2010, exceeding the Medical Group Management Association (MGMA) 90th percentile in 2010. Third-party payer revenue increased from $7.4 million to $17.9 million in the same time period, also exceeding the MGMA 90th percentile in 2010."

In truth, cost of care was not reduced nor was the quantity of care. What we actually have learned is the health care bill in Alaska has continued to grow at a pace that outstrips inflation while the editors of the sit back in their eames chairs and want to teach doctors a lesson.

After all, is is clear that the editors feel doctors are the problem.  To the editors, doctors are the disdainers, loomers, and miscreants who must be given no place "to which they can retreat."  Instead, if one is to believe the tone of the article, health care providers are optimally corralled, viewed in the open, and perhaps supervised by a lifeguard with a whistle. In the same breath the authors recommend establishing "trust and long-term relationships between patients and providers."  This sounds nice until one realizes trust and long-term relationships between the patients and providers will be built (in their view) by "data mall" graphics that spur the "laggards" into compliance.

The editors continue with their scolding, pernicious nanny-state view by criticizing other providers and health care organizations who can't "summon the energy to transform their operations" to the Utopian vision put forth by this piece.

Perhaps most concerning for physicians is the sinister undertone that is becoming increasingly prevalent in some circles of main stream media.  Presently doctors are facing huge cuts to their pay as part of the health care reform efforts underway.  If the public is going to accept this as best for their own interest, then the editors have firmly established that physicians and hard working care providers are going to have to be subtly and constantly denigrated.

It is a shame that our health care reform discussion has come to this.  Rather than enlisting physicians as part of the solution, we're now the problem.

Remember that when you can't get an appointment.


Addendum 0912 am 23 Jul 2012:

Thanks to those that sent on these other examples of ongoing denigration of physicians:

Whitecoat's Call Room blog: Jim Dwyer New York Times - Irresponsible Journalism?
     A follow-up post appears on the same blog continuing the conversation:
          Jim Dwyer New York Times Pediatric Fever Article Debate

Dr. Malpani's Blog: Doctor Bashing in the Media


Anonymous said...

I've noticed some interesting differences between the way Doctors and Patients view the health care system.

In the mind of most patients, Doctors are in charge of the health care system. When pricing doesn't make sense, when your records get screwed up, when the Rx isn't called in correctly, when you wait 2 hours for a 10 min visit, you blame the people in charge.

Ironically, I sense that most Doctors see themselves are being less in charge and more dragged along for the ride.

It's a huge gap.

Anonymous said...

I did not get the sense that doctors were being castigated in this editorial. It seems to be a straightforward description of a different way to deliver healthcare and one that seems to make good sense.

While we all don't like being measured and compared on our performance, it seems reasonable to attempt some objective measure. In my experience, it is the best self motivator for physicians to improve their game and potentially to bring more innovative ways to improve patient health.

I agree the numbers are difficult to discern, and may represent some cherry picking by the writer to make his case, but 50% reductions in ER visits is enough to impress me.

We can't keep doing the same thing the same old way and expect a different outcome. The current system will indeed lead to the bankruptcy of our federal government unless we try new ways to tackle the relentless growth of medical costs. Undoubtedly a lot of parties will feel very threatened by this change, but I believe this is the type of dynamic change that the the republicans talk about that needs to happen periodically for businesses to thrive. After all, these are all basic business principles that are being applied to medical practice in attempts to obtain better value for dollar spent. Nothing wrong with that!

Anonymous said...

I wonder who set the tone of this conversation...

Doctors cutting off legs of diabetic patients and getting paid $50, 60 thousand dollars.

Doctors cutting out tonsils unnecessarily.

Just take the blue pill at half the price presumably because the doctor has a perverse incentive to give the red pill.

I always figured that using a scapegoat to win an election (blame Bush) or to win an argument is just the Chicago way.

Anonymous said...


You often cite the huge cuts in pay faced by doctors. Could you please cite some numbers? Every list I've seen, puts doctors at the very top of pay rates. Perhaps you are caught in the same decline that the rest of the 99% have experienced - wages have been flat or declining for quite a number of years. Maybe you ought to think about changing political parties.

Anonymous said...

I'm sympathetic to your reaction regarding the choice of words in certain instances in the editorial. However, I would guess your response about triples the "negative" word count.

While I dislike the authors choice of "laggard", let's keep in mind the result was a very positive one in that yearly eye exams are now being scheduled for her diabetic patients. Can't we call that a win?

DrWes said...

Anony 10:25 AM:

A reference for you:

Anony 10:50 -

The editorial does nothing to support the premise that any of the solutions advanced will offer sustainable savings for our health care system. Rather, they are a re-hashing of the "medical home" model with top-down, large-scale, big data EMR-driven, check-box style corporate initiatives that aim to "reduce cost" by shifting costs to the infrastructure by building more clinics, more buildings with comfy-couch fancy facades. It is no wonder ER visits decline once more clinics are built, but does it save money? And regarding the diabetic eye exams: do reminders about eye exams save money for the system or drive more business to it?

In other words: what's the return on investment in all of this for the patient?

It all depends on where one sits in this debate. Doctors who are tasked with the day-in day-out 24/7 nature of health care, the so-called "savings" described with these overly-bureaucratic, regulatory initiatives are very good at feeding the system but do little to reduce the overall cost of care.

It's far easier for those unfamiliar with the complexities of physicians' imcome to blame our health care cost crisis on the high paid "laggards" without mentioning the fact that they remain subject to large malpractice premiums and excessive educational costs.

Keith said...


You are absolutely correct that it depends on where you sit in this debate. We on the primary care side would like to see more resources directed to primary care in the hopes of preventing recurrent hospitilizations and high cost tertiary care that at times may not be in the patients best interest. To provide enough resources that we can hire nurse practitioners (like almost all the specialists seem to have following them around) seems like a fair proposition so we can devote more time to the complex cases. Presumably this is how it works in your end of the business. But this model depends on the specialist performing more of their "procedures" while the nurse proactitioner trundles around seeing patients and conducting their history and physical ( the less well compensated tasks). This is why this does not necessarily work for primary care since it does not increase the size of the pie as it does for specialty care (more hi tech care while the nurse is doing the low tech stuff). We need a new paradigm for primary care, or we simply get rid of general internists and family practioners and turn everything over to nurse practitioners and PAs.

Secondly, the problem has long been that the reward is considerably outsized for the additional years of training and cost. A specialisst doubles the amount they can make by adding 3 years of training, and the cost for this training is nominal given these are salaried positions, albeit at slave wage, but I will allow that the difference between what a fellow makes and what a priamry care makes as lost income during that period. So for and investment of say 300,000 in lost income, you end up making twice as much as a generalist for th erest of your career. And many of these specialties have 9-5 hours with no on call duties (or minimal chance of on call activity). Any wonder that no one goes into primary care!? So either primary cae needs to increase in compensation, or specialty pay wil have to decrease in order to balance things out and save our end of the profession. Not only will models like the medical home make the job of primary care easier and more enjoyable, it seems like the right thing to do given the neglect it has suffered for so long.

Jay said...

I saw this comment in the NYT editorial and had to share. I have no way of knowing whether it is factual and do not attest to that fact. I just though it would be interesting for you to read:

Native Alaskan Medical ProvidorAnchorage
Guess what? I'm one of those physicians that work at the Southcentral foundation/Alaska Native Medical Center. I have to admit...I didn't even recognize the system that the NYT wrote of.

The waste here is incredible...millions are lost yearly because they simply forget to bill or bill incorrectly. There is rather shallow coverage...the complicated cases go to Seattle at huge costs to the system here. There is a staggering turnover: The best physicans leave because they get frustrated about the obstacles to provide quality care. The administrators leave too...I think we've had 4 CEO's in 3 years. The reason there are no nurses stations or doctors offices in the outpatient side is because we have no room: it's crammed cubicles, shoulder-to-shoulder. It it weren't for the Public Health providors (MD's, Pharmacists...) providing free service here on the taxpayer's dime, the whole system would be on life report.

Some GOOD things not mentioned: It's nearly impossible to sue that cuts down on some costs. Also, many of the specialists (myself included), travel to the bush and see patients there a couple of days at a place, anywhere from one to three times a year. It saves a lot on travel and time. We're paid roughly 1/3 what they get in the private sector.

Overall, this is not a model that will work for the rest of the USA: It would be an unparalled disaster. But it works well-enough here. The reality is, our patients are some of the unhealthiest in the entire USA.


There are two sides to every story


Anonymous said...

Surely we don't have to argue about the merits of yeaarly eye exams for diabetics. My sister went blind as a result of the disease. There is no doubt that she'd counsel other diabetics that a yearly exam was a damn good ROI.

Anonymous said...

I have seen first hand the denigration of a wonderful physician with a heart of gold who went into medicine for all the right reasons. His patients love him but the system he works for makes sure he never gets a pat on the back and office staff are often dictating what he can and cannot do for his patients. It saddens me to see how demoralized he has become after so many years of practice. I am sickened by the fact we have sacrificed years as a family and have this be the outcome.

As for the high paid laggards, they are sitting in administration.