Thursday, June 23, 2011

The Health Reform Jungle: Specialists as Patient Predators

It’s a jungle out there.

Tarzan to Jane

June 23, 2011
- A school of thought exists that says predatory non-professional specialist wolves out there are keeping health costs unnecessarily high. By the school’s estimates, these outliers may cause 30% to 55% waste in the system. Motivated by greed and not by evidence or clinical need, these evil-doers prey on unsuspecting, naive patients and Medicare and Medicaid recipients, causing pain, injuries, and even death.

A Portland, Oregon, neurosurgeon is the poster boy for this school. Visah James Miller, MD, was recently banned from the operating room for performing spinal fusions on 61 Medicare patients, and an additional 24 fusions for 16 of the same patients. Dr. Miller had the highest fusion rate among 3407 surgeons who performed spinal fusions on Medicare patients. For this excessive rate, the Oregon Medical Board banned him from operating (“Hospital Bans Surgeon from Operating Room, Wall Street Journal, April 13, 2011). Which makes sense to me.

I have no doubt a small number of such predatory surgeons exist. But I hesitate to leap to the conclusion that bad apple physicians account for much of the overall rise in health costs, or to the $60 billion in Medicare fraud and abuse.

I could be wrong, of course. I am not as certain as David Kibbe, MD, and Brian Klepper, PhD, who wrote about this problem in a June 22, 2011 Health Affairs Blog, “Physician Fallows Program.” The term “fallow” is a government program for agricultural restoration, i.e., letting the earth remain “fallow” until it enriches itself.

Kibbe and Klepper propose:

• Using data to identify “super-utilizers,” those who utilization patterns exceed two on average two or more two or three standard deviations.

• Paying these over-utilizers to go away by offering the offending doctors not to practice medicine or surgery for several years by offering them 75% to 100% of their average income over the last three years.

• Allowing the offenders to return by being retrained as primary care physicians.

Kibbe and Klepper maintain this fallow approach would improve care, end unnecessary procedures, avoid pain, injuries, and even death.

Why am I dubious?

One, I am leery of the use of the punitive statistics in the hands of federal or private health plan bureaucrats, without investigating the circumstances of “overuse.” Some surgeons, for example, are known to be experts in “re-do” procedures, and the mix of their patients may influence the numbers.

Two, I have yet to see persuasive evidence that comparative effectiveness research, a leading tool in the Obamacare toolbox, effectively brings down overall-costs.

Three, I am sensitive, perhaps over-sensitive, to the notion that specialists are a leading root cause, or a significant cause, of overall health care inflation.

Another cause, largely ignored, is patient demand to have “something,” “anything” done to relieve pain or restore functionality. The practice of medicine depends on emotional factors, as well as statistically-based data.

As I indicated, I could be wrong. I simply do not see this proposal as a realistic, workable solution to bending the cost curve down. Using data to weed the jungle of unsavory predatory doctors strikes me as simplistic. But, as Arthur Miller said in Death of a Salesman, "Attention must finally be paid to such a person. " Miller then added, " But you’ll never get out of the jungle that way.”


Anonymous said...

I think it is the shame of surgeons that they don't police their own. While they may not be the cause of that much overuse, any overuse should be policed just because of the non-monetary and risk cost to patients. In my spouses 30 doctor surgery practice, 5 doctors are well know in the practice for doing unnecessary surgeries and tests. The fellow partners just laugh about and shrug. The outliers "pay the overhead.". Until doctors are willing to police their own perhaps government does need to step in. Very sad.

Richard L. Reece, MD said...

Thank you for your cutting edge remarks. Unfortunately when the government steps in, overhead balloons.

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