Saturday, August 1, 2009

Can Doctors Step Up to become Healthcare Innovators?

Recently, an article in the New Yorker entitled; “The Cost Conundrum” compared the cost of Medicare per enrollee between two Texas towns, McAllen and El Paso. The author, Atul Gawande, M.D. explored the question as to why two border towns of similar demographics would cost Medicare such enormously different amounts of money per enrollee. The bottom line was McAllen cost Medicare fifteen thousand ($15,000) per enrollee, while El Paso, the same size as McAllen, and with similar demographics, spent $7,500, which was half as much.

What the reader will find is a poignant analysis that was not only made by the author, but by physicians that work in the McAllen area. What concerned me was the comment that was made by a veteran physician in observing that even though the medical community has more technology, “young doctors do not think anymore.” Not only was this a frightening statement, it made me wonder whether physicians whom are supposed to be smarter than most, are really no different than us, in that they are likely to believe that more is better. Nothing in medicine is without risk. In recent years surgeons have markedly increase surgical procedures. In 2006, it was reported that sixty million procedures were performed, what amounted to one for every five Americans. The question posed was; “are we any better off for it?” It was reported that 100,000 people die each year from surgery related complications. That is far more than die in automobile accidents. Unless we control cost, will we be better off?

So I started to think about our industry and asked myself is McAllen a microcosm of the Spine Industry? How many needless spine procedures and tests are performed annually in our industry? I could already hear the uproar, who does theSpine Blogger think he is? Unlike most industry professionals, I know my place, but I also know what I’ve seen during my tenure in the industry. Let’s face facts, like any other profession, there are those surgeons that are craftsmen, and then there are those that want to be businessmen. Unfortunately, the waters can become murky when you are both. How many MRI’s are performed that are not really needed, or, how many bone density test are performed because it is a revenue generator? When does an individual draw the line between what is really needed, and what is padding one’s pocket? Greed is part of human nature. When the head of a physician owned hospital was questioned about the high cost of healthcare at his hospital, he was quick to point a finger at the other facilities and the federal government. When it comes down to understanding the cost of healthcare, most physicians are not evasive, when it comes to understanding the truth, they really just don’t understand the entire picture. How many understand the new Healthcare Bill, let alone have read it? Even then I am not sure one would understand all the nuances of it. Just leave it to the lawyers and the media talking heads to represent individual special interests.

But let’s look at the anatomy of a surgeon. He has the freedom to own a strip mall, real estate, imaging center, surgery center, or he may be a partner in a physician owned hospital. This is America. There are innovative ways to increase revenue in patient care. As one doctor in McAllen stated, “it’s a machine, my friend.” Many physicians have a difficult time in understanding the financial implications that their decisions make. There are those that only see their practice solely as a revenue stream. The reality is that maybe physicians need a course that teaches the ethics of medicine and business.

There is an underlying subculture in the spine industry. Just look at the physicians that represent special interests on the dais. I don’t need to name them, since we all know the Usual Suspects. But how much of an advantage does a company have when they hire these individuals? The day of champion surgeons are over, it’s a thing of the past. Just like our industry, surgeons have become a commodity product. All you have to look at is disclaimer after disclaimer when you attend a scientific and clinical symposium. Are these companies hoping that these champions steer their residents and fellows towards their products? Absolutely.! It’s scary when some of their peers view them no different than sub-prime mortgage lenders treating their patients as profit centers.

Just because doctors make a lot of money, doesn’t mean each and every one of them is a good businessman or a good doctor. By rooting out problems like poor preventive practices, unnecessary back operations and unusual hospital complication rates, maybe quality of care would go up. But Dr. Gawande makes an interesting observation, “are we witnessing a battle for the soul of American medicine?” I will paraphrase his comment; ”somewhere in the US at this moment, is a patient with some type of medical condition, and the damning question that must be asked is whether the doctor is set up to meet the patient’s need or his he looking to maximize his revenue?” As one surgeon in McAllen observed; “we took a wrong turn when doctors stopped being doctors and became businessmen.” So how do we solve our healthcare dilemma? Could it be that until we collaborate as a society on quality of care, over and under treatment, and sheer profiteering do we stand a chance? Someone needs to be in charge, because at the present moment no one is, and the result is a wasteful and less sustainable healthcare system. The Spine Blogger wants to know what you think?


  1. This is a nice article and addresses a lot of real issues. However why do we always turn only to the physician when it comes to the cost of healthcare? I agree that they have moved into the business world and away from the true practice of medicine but is it not US that have pushed them to do so?

    How many times have you heard that "we can't afford medicine because my doctor drives a Porsche?" " we can't afford medicine because doctors are bad businessmen."

    If you look at the total joint side just 15 years ago when surgeons were receiving $5000 per procedure there was very little of the"consulting" going on and it was mostly done in the world and realm of academia. Today they get $1236 for the same procedure and suprise we now have consultants galore.

    Interestingly enough in the time that we cut this re-imbursment none of us have seen any decline in our cost of medicine only a decline in the quality. Did not Einstein say that "continuing to do the same thing but expecting different results is insanity"

    There was a reason doctors were paid well and taught little to nothing about business. We wanted to attract some of the best and brightest to be doctors and we wanted them to focus on the diagnosis and treatment of the patient not the money.

    With the majority of the cuts coming on doctors backs we now have opened the door for them to move their focus from the diagnosis and treatment over to the money or are we are getting close to having the person with the knife about to operate on us doing so because they could NOT get into business school.

    To affect real change we have to get around the strong lobbies and start to look at the REAL cost of medicine. No one seemed to take notice of how quickly the hospitals turned on the president when he discussed taking away their disproportionate payment. And how quickly they then met in private to "resolve" this without letting any of us know the solution. How long are we going to continue to reward hospitals for being bad business people? Is this not a HUGE incentive to "lose" money.

    Does this not encourage the use of funny book keeping and has this now got us to the point that most hospitals can not tell you the real cost of any procedure or service?

    Also when are we going to examine the business of having a non-proprietary status as a hospital yet hire a proprietary hospital management team. This practice has shifted a huge amount of money away from the treatment and practice of medicine right into the executives and shareholders pockets.

    Love the blog and these are just MHO.

  2. Marty: Thanks for the great commentary. I hope that this blog spot serves as a medium so that other participants, than just surgeons and industry related professionals, in the healthcare debate can understand the challenges that each party faces. The Spine Bloggers objective is to provide our readers a forum where differing ideas can be disseminated to our readers not only by those of us involved with the blog, but also by our readers.