Doctor’s Tip: Physician specialization in the way of reform
In order to achieve optimal health, it is important to understand the intricacies of our current health-care system, and to help our country make the right choices if and when the ACA is tweaked or replaced. This is the third in a series of articles about four powerful entities in the current health care system that benefit financially from the status quo and therefore push back against needed change.
In his book “Mistreated, Why We Think We’re Getting Good Health Care — And Why We’re Usually Wrong,” Robert Pearl, M.D. calls these four entities the “legacy players,” and notes that they have undue influence on our health care system and on members of Congress. Dr. Pearl was trained as a plastic surgeon, is now the CEO of Permanente, and is a respected authority on the business of medicine.
Examples of physician specialty societies are the American Society of Cardiology, the American Association of Orthopedic Surgeons and the American Society of Clinical Oncology. Pearl points out that each society is “dedicated to two objectives: advancing clinical practice and advancing the financial success of its members. Often, these two objectives conflict.” Physician specialty societies “advocate not only for a higher volume of procedures for their members, but also for higher reimbursement per procedure.”
It has been said that we don’t have a health-care system, but rather a disease management system, meaning that instead of preventing disease we wait until it occurs and then try to manage it. This results in needless death and poor quality of life as people age and is unsustainably expensive. If they’re doing their job, primary care doctors such as family physicians, internists and pediatricians prevent disease. We need more of these PCPs, but U.S. has the highest ratio of specialists to primary care doctors in the world. According to “Mistreated,” hospital residency programs train more specialists, because it is these specialists who increase hospitals’ income.
Due to their powerful influence, physician specialty societies have slanted reimbursement toward those who do procedures, “reinforcing the perception that intervening during a crisis is more difficult and more valuable than preventing one.” In reality, the opposite is true, both for patients and for cost to the system.
When I was in family practice, I would often spend an hour with a patient counseling them about heart attack prevention, but got paid more for freezing five pre-cancerous skin lesions at the end of the visit, which took three minutes at most. Orthopedic surgeons and interventional cardiologists in the U.S. earn two or three times more than primary care physicians. Sweden has one of the best and most cost-effective medical systems in the world, and when Pearl visited there he “was surprised to learn how narrow the salary gap was between primary-care physicians and surgical specialists.”
Here are some other issues related to the physician specialty society legacy player culture:
Pearl notes that “the best predictor for higher volumes of surgery in a given geography isn’t the rate of disease but the number of surgeons practicing there.” So more orthopedists in an area results in more meniscus surgeries and total joint replacements, at greater cost to the local medical system.
Recent studies have questioned whether most meniscus surgeries are beneficial at all, versus physical therapy.
Studies have shown that if someone has a small groin or abdominal hernia not causing symptoms, the risk of complications from surgery outweighs the risk of just living with it. Yet if you have such a hernia and see a surgeon, you will end up with an operation.
There is agreement that spine surgery for leg weakness is necessary but much less agreement that surgery for leg numbness or pain is any better than physical therapy and time. And surgery just for back pain is very controversial. Yet in areas with lots of spine surgeons, a lot of spine surgery with questionable indications will occur.
Radical prostatectomy for early prostate cancer is not better than watchful waiting, which includes repeat exams and PSAs, then doing the surgery if the tumor becomes aggressive. Yet some urologists will still operate, and most don’t tell their patients about the nutritional alternative (Dean Ornish, M.D., proved that early prostate cancer can be reversed with a plant-based diet).
Stents and bypass surgery have not been shown to prolong life or improve quality of life when compared to aggressive medical intervention or just lifestyle modification (the exception is in the setting of an acute heart attack). Yet see an interventional cardiologist or cardiac surgeon and it’s likely you’ll end up with one of these procedures.
If you have surgery, your chance of a good outcome is much better if the surgeon and the facility do a lot of that particular operation. For example, the outcome for hysterectomies is better if done laparoscopically. However according to “Mistreated,” laparoscopy “is much more technically demanding. And with fewer hysterectomies being performed, many physicians lack expertise with the new approach, causing higher rates of complication.”
Pearl summarizes the situation like this: “Patients do not experience improved survival or better quality of life if they live in regions with more care. In fact, the care they receive appears to be worse. The reason is simple. Operate on people with minimal indications, and the complications will exceed the benefits.”
Switzerland ranks second in the world for quality of health care. About a dozen orthopedists in the whole country perform all total joint replacements for the county’s 8 million residents, so obviously these surgeons are extremely good at what they do. The U.S. has about 40 times the population. If we set up a system similar to Switzerland’s, we would have 500, highly skilled orthopedists doing all the total joints rather than the 5,000 we currently have.
In this valley, think of the cost savings and improved quality of care if say Aspen Valley did all the shoulder surgeries, Valley View the knees, Grand River the hips, especially if everyone in each hospital got together and chose just one type of joint replacement hardware, instead of each surgeon having their own favorite. There will be more on this next week, when the fourth legacy player will be discussed: the pharmaceutical and medical device industries.
Dr. Feinsinger, who retired from Glenwood Medical Associates after 42 years as a family physician, now has a nonprofit Center For Prevention and Treatment of Disease Through Nutrition. He is available for free consultations about heart attack prevention and any other medical concerns. Call 970-379-5718 for an appointment. For questions about his columns, email him at firstname.lastname@example.org.
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