“It’s ‘Let me do a little snip of tissue’ and then they get

Specialists’ Incomes Soar

CONWAY, Ark. Kim Little had not thought much about the tiny white spot on the side of her cheek until a physician’s assistant at her dermatologist’s office warned that it might be cancerous. He took a biopsy, returning 15 minutes later to confirm the diagnosis and schedule her for an outpatient procedure at the Arkansas Skin Cancer Center in Little Rock, 30 miles away.

That was the prelude to a daylong medical odyssey several weeks later, through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an canada goose uk shop anesthesiologist and an ophthalmologist who practices https://www.canadagoosejacketca.ca plastic surgery. It generated bills of more than $25,000.

“I felt like I was a hostage,” said Ms. Little, a professor of history at the University of Central Arkansas, who had been told beforehand that Canada Goose online she would need just a couple of stitches. “I didn’t have any clue how much they were going to bill. I canada goose clearance had no idea it would be canada goose so much.”

Ms. Little’s seemingly minor medical problem she had the least dangerous form of skin cancer racked up big bills because it involved three doctors from specialties that are among the highest compensated in medicine, and it was done on the grounds of a uk canada goose hospital. Many specialists have become particularly adept at the business of medicine by becoming more entrepreneurial, protecting their turf through aggressive lobbying by their medical societies, and most of all, increasing revenues by offering new procedures or doing more of lucrative uk canada goose outlet ones.

By 2012, dermatologists whose incomes were more or less on par with internists in 1985 had become the fourth highest earners in American medicine in some surveys, bringing in an average of $471,555, according to the Medical Group Management Association, which tracks doctors’ income, though their workload cheap Canada Goose is one of the lightest.

In addition, salary figures often understate physician earning power since they often do not include Canada Goose Online revenue from business activities: fees for blood or pathology tests at a lab that the doctor owns or “facility” charges at an ambulatory surgery center where the physician is an investor, for example.

“The high earning in many fields relates mostly canada goose factory sale to how well they’ve managed to monetize treatment if you freeze off 18 lesions and bill separately for surgery for each, it can be very lucrative,” said Dr. Steven Schroeder, a professor at the University of California and the chairman of the National Commission on Physician Payment Reform, an initiative funded in part by the Robert Wood Johnson Foundation.

Doctors’ Canada Goose Jackets charges and the incentives they reflect are a major factor in canadian goose jacket the nation’s $2.7 trillion medical bill. Payments to doctors in the United States, who make far more than their counterparts in other developed countries, account for 20 percent of American health care expenses, second only to hospital costs.

Specialists earn an average of two and often four times as much as primary care physicians in the United States, a differential that far surpasses that in all other developed countries, according to Miriam Laugesen, a professor at Columbia University’s Mailman School of Public Health. That earnings gap has deleterious effects: Only an estimated 25 percent of new physicians end up in primary care, at the very time that health policy experts say front line doctors are badly needed, according to Dr. Christine Sinsky, an Iowa internist who studies physician satisfaction. In fact, many pediatricians and general doctors in private practice say they are struggling to survive.

Studies show that more specialists mean more tests and more expensive care. “It may be better to wait and see, cheap canada goose uk but waiting doesn’t make you money,” said Jean Mitchell, a professor of health economics at Georgetown University. “It’s ‘Let me do a little snip of tissue’ and then they get professional, lab and facility fees. Each patient is like an ATM machine.”

For example, the procedure performed on Ms. Little, called Mohs surgery, involves slicing off a skin cancer in layers under local anesthesia, with microscopic pathology performed between each “stage” until the growth has been removed. While canada goose coats it offers clear advantages in certain cases, it is more expensive than simply cutting or freezing off a lesion. (Hospitals seeking to hire a staff dermatologist for Mohs surgery had to offer an average of $586,083 in 2010, even more than for a cardiac surgeon, according to Becker’s Hospital Review.)

Use of the surgery has skyrocketed in the United States over 400 percent in a little over a decade to the point that last summer Medicare put it at the top of its “potentially misvalued” list of overused or overpriced procedures. Even the American Academy of Dermatology agrees that the surgery is sometimes used inappropriately. Dr. Brett Coldiron, president elect of the academy, defended skin doctors as “very cost efficient” specialists who deal in thousands of diagnoses and called Mohs “a wonderful tool.” He said that his specialty was being unfairly targeted by insurers because of general frustration with medical prices. “Health care reform is a subsidized buffet and if Canada Goose Outlet it’s too expensive, you go to the kitchen and shoot one of the cooks,” he said. “Now they’re shooting dermatologists.”

The specialists point to an epidemic, noting there Canada Goose sale are two million to four million skin cancers diagnosed in the United States each year, with a huge increase in basal cell carcinomas, the type Ms. Little had, which usually do not metastasize. (A small fraction of the cancers are melanomas, a far more serious condition.) But, said Dr. Cary Gross, a cancer epidemiologist at Yale University Medical School, “The real question is: Is there a true epidemic or is there an epidemic of biopsies and treatments that are not needed? I think the answer is both.”

Patient Given No Choice

A fair skinned redhead who teaches history at the University of Central Arkansas, Ms. Little had gone to a private dermatology practice in canada goose uk black friday Heber Springs, Ark., to check some moles on her arms when the physician’s assistant on duty noticed a whitish bump like a “tiny fragment of thread” on her face, she said. Her family practitioner had told her it was just a clogged pore.

A diligent medical consumer, Ms. Little had read up on the Mohs technique (invented by Dr. Frederic Mohs in 1938) Canada Goose sale before she and her husband arrived for her surgery in November 2012 in a doctors’ office building at Baptist Health Medical Center here. Pressed for time as the end of the semester approached, she asked Dr. Randall Breau, the dermatologist, why the tiny growth needed the specialized surgery, as she had asked the physician’s assistant earlier. They both answered that it was because it was on her eyelid, a delicate area where Mohs surgery is always required; she repeatedly insisted that it was on her cheekbone below her eye.

After the 30 minute removal, the dermatologist told her that she would have to go across the street to the Arkansas Center for Oculoplastic Surgery, another private doctors’ office on the hospital’s campus, to have the wound closed by a plastic surgeon with “a couple of stitches.”

When Ms. Little protested that she did not want a plastic surgeon and did not care about having a tiny scar, the doctor told her she had no choice, she said. The vast majority of Mohs procedures are sewed up by the dermatologist or just bandaged and left to heal. Yet when Ms. Little arrived Canada Goose Parka at the second canada goose clearance sale practice, nurses took her clothes, put in an IV, and introduced her to an anesthesiologist who would sedate her in an operating room.

Sitting in her cozy office recently, Ms. Little, who has a faint scar under her eye on her right cheek, still fumes at the thought. “It was no bigger than many cuts that heal on their own, and it definitely could have been repaired by one doctor, but at that point what was I going to do?” she recalled. “I have an IV in my arm and a hole in my face that Dr. Breau refused to stitch. And the anesthesiologist is standing there with his mask on.”

Her bills included $1,833 for the Mohs surgery, $14,407 for the plastic surgeon, $1,000 for the anesthesiologist, and $8,774 for the hospital charges.

Mohs surgery is preferable when the removal of a skin cancer is complicated or in a sensitive area, because it typically excises less tissue buy canada goose jacket cheap and leaves less of a scar than other treatments and allows dermatologists to see the borders of a growth and be confident that it is removed entirely. The surgery is generally not used for melanomas, which require more extensive cutting.

In an email, Dr. Breau declined to discuss Ms. Little’s case, but noted, “When I make decisions concerning patient care, I have only the patient’s best interests in mind.” He said that he and one partner own the Arkansas Skin Cancer and Dermatology Center and receive no payments from the hospital or the doctors to whom they refer patients. In most cases, he said, he takes care of the wound left by Mohs surgery himself. canada goose store The plastic surgeon did not respond to requests for comment.

It is often impossible in any one case to canada goose black friday sale determine whether a course of treatment was necessary or cost effective. Even among doctors there are differences of opinion about optimal treatments. That is partly because the guidelines for when to perform many procedures are often ill defined or based on the specialists’ experience rather than carefully controlled research.

“Though Mohs surgery is disseminating rapidly, there are very few comparative studies and the evidence is still evolving about when it’s beneficial,” said Dr. Gross, the Yale epidemiologist. “When people are trained to perform a procedure, and believe in it, and equip their offices to do it, they will do it. That’s just human nature.”

The same specialties tend to appear at the top of physician earners: orthopedics, cardiology, anesthesiology, radiology, dermatology, plastic surgery, urology, gastroenterology and ophthalmology. Physicians in those fields typically earn more than $350,000 annually, according to Canada Goose Coats On Sale American Medical Group Association, a trade organization. In many specialties, income has risen more canada goose coats on sale than 10 percent since 2011, according to Medscape, a Web company that follows the industry.

Physicians often complain that government and commercial insurance reimbursements for seeing patients are decreasing while their office expenses are going up to deal with mountains of paperwork and demands from insurers. Congress currently is considering a bill that would freeze doctors’ Medicare fees for the next decade. Still, many doctors have found alternative income streams that do not show up on surveys.

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Dr. Mitchell of Georgetown University estimates, for canada goose uk outlet example, that many urologists make 50 percent of their income from dealing with patients and the rest from investing in buy canada goose jacket the machines that deliver radiation for prostate cancer or to treat kidney stones. In 2012, urologists had an average income of $416,322, according to Medical Group Management Association data, which often does not include the investment income.