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Pⁿ Blog
The Pⁿ Blog is a forum for opinions, questions, controversies, and instructive discussions across the field of pathology and its relevant subspecialties.
Monday, January 27, 2014
The Skin Game
In the past I have discoursed (ranted) in this blog space about pathologists' sins, primarily relating to the overuse of immunohistochemistry.  The result of this practice has been across the board, "draconian" cuts in 83342 reimbursements, following on the heals of last year's cuts in 88305's.  It could (and has) been argued that we brought this on ourselves. 
However, we can take some perhaps perverse comfort in the fact that pathologists are real pikers when it comes to the occasional practice of procedure padding.  I refer you to the following article in a recent issue of the New York Times dealing with unnecessary procedures and charges in the world of dermatology.
The story focuses on a history professor at the University of Central Arkansas who saw a dermatologist for a small lesion on her cheek which turned out (I think) to be a very small basal cell carcinoma.  By the time she had undergone resection with Mohs surgery and a plastic surgery closure the resultant bill topped $25,000!  The charge for the plastic surgery closure alone (two stitches) was over $14,000! To say that the article takes a dim view of this approach and the physicians who follow such therapeutic overkill would be a major understatement. 
As the article points out, procedures no matter how small are the big money makers in the medical world today.  The easier they are and the faster you can perform them, the more likely you are to make large amounts of money.  A good cardiac surgeon can perform, at most, two bypass surgeries a day but other specialists can do dozens of small procedures (biopsies, excisions, endoscopies, etc) in the same amount of time, often generating even more revenue than a busy heart surgeon.
Although the article deals in part with the rise and unnecessary use in many cases of Mohs surgery and the dramatic rise in dermatologist incomes in the last decade, they are not the only ones in the "cross hairs."   The article notes, for example that oncologists make a substantial part of their income based on their ability to mark up chemotherapy charges.  Urologists, the article mentions, often make 50% or more of their income from radiation administering equipment that they own, or from laboratories on their premises.
Those of us who are salaried academic physicians have been rather insulated from this phenomenon.  It's undoubtedly true that patients in academic hospitals sometimes get more studies and procedures than they absolutely need due to a variety of causes including system inefficiencies, obsessive compulsive academic clinicians, trainees ordering unnecessary tests, intellectual curiosity, etc.   At least phycician greed isn't a motive in the salaried physician model.  Hospital administrators may be another story!
The vast majority of physicians of all types are dedicated, ethical, honest individuals who have devoted their life, often at considerable personal sacrifice, to help the sick.  It's unfortunate that some really "bad apples" seem to be getting most (or all) of the press these days.  
About the Author

Stacey E. Mills, MD
Stacey E. Mills, MD, a graduate of University of Virginia (UVA) and the UVA Medical Center, has authored nearly 230 articles, 20+ books, atlases and monographs—including the renowned Sternberg's Diagnostic Surgical Pathology. He has been a practicing Professor and Staff Pathologist at UVA for 30+ years and is Director of Surgical Pathology and Cytopathology. His clinical specialty is general surgical pathology with emphasis on neoplasms and neoplasm-like lesions. Dr. Mills is also Editor-in-Chief of The American Journal of Surgical Pathology.