Donald J. Palmisano, former president of the AMA, is blogging from New Orleans as he's trying to leave the city. Follow his ordeal through this tragic time.

If I Knew Then - Dr. John Morton, MD, Discusses the Field of Bariatric Surgery

The following is a reader take by WhiteCoat, originally published on 4/7/2008.

WellPoint and Aetna are now putting into widespread implementation a refusal to pay for what have been deemed "never" events.

The theory for payment denials is that if medical providers are not paid when certain unwanted outcomes occur, situations leading to those unwanted outcomes will be avoided.

Some events on the "never" list legitimately should "never" happen. I can't think of any way to justify performing surgery on the wrong patient or performing surgery on the right patient, but the wrong body part. The flaw in the insurers' theory is the determination on whether a "never event" has occurred is retrospective, not prospective. The insurers are focusing on outcomes rather than processes.

If it is so important to prevent these "never events" from happening, why have WellPoint, Aetna, CMS, and the "National Quality Forum" refused to create "how to" lists showing health care providers how to avoid these outcomes? Where's the clinical study showing us a practice model on how to prevent 100% of these "never events" in 100% of patients?

Medical providers may not be the brightest bulbs in the pack, but I for one am anxious to learn. In 2007, WellPoint was ranked as the 35th largest corporation in America and had revenues of more than $56 billion. In 2007, Aetna was 85th on the Fortune 500 with more than $25 billion in revenues. With such vast amounts of resources, why haven't WellPoint or Aetna funded a study or created some guidelines for healthcare providers showing us how to prevent these "never events" 100% of the time?

Sure, we can minimize the chances of doing wrong site surgery by using a surgical marker to "cross out" the incorrect surgical site or by having surgical "time outs". But explain to me to prevent pressure sores in 100% of my patients. Show me how to prevent infections from urinary catheters 100% of the time. And how do I keep 100% of my elderly off-balance patients from falling and breaking their hips? Show me how to do it and I'm all over it.

There are two reasons why WellPoint, Aetna, and CMS haven't published such how-to instructions. First, a set of instructions like this is just a fairy tale. Many of these "never events" just can't be prevented. How would insurers look if they published "how-to" instructions, health care providers followed those instructions to the letter, and the "never events" continued to occur? The insurers would get vilified. They don't want that. By focusing on outcomes rather than processes, the insurers can avoid the bad rap.

More importantly, insurers are concerned with profits over prevention. They can try to improve their public image by touting "patient safety", but actions speak louder than words. The reason that insurers aren't paying for these events is because they can then charge patients more and more for insurance premiums, while using the guise of "never events" to pay less and less for the medical care that their patients receive.

By blaming the hospitals for events that some government-sponsored coalition says should "never" happen, they can increase their profits and vilify the "dangerous" health care providers. A win-win situation for the insurers and a lose-lose situation for the medical providers. It's all about the Benjamins. WellPoint and Aetna didn't crack the Fortune 500 by deciding to pay more for medical care.

I try to be on the cutting edge, though. If "never events" are going to become ingrained into our culture, I want to add a few of my own to the list. My mail should "never" be lost. Express Mail should "never" be delivered late. I should "never" wait in line to renew my driver's license. Insurance companies should "never" refuse payments for legitimate claims. Customer service centers should "never" answer customer telephone calls on later than the third ring.

Where do I get in line for my refunds?

WhiteCoat is an emergency physician and blogs at WhiteCoat Rants.

If I Had - High Cholesterol - Dr. Howard Hodis, MD

If I Knew Then - Dr. Alfredo Sadun, MD, PhD - Discusses the Difference Between Academic vs. Private Practice

Their embarrassingly small 1.5% bonus payments have physicians questioning whether the extra record-keeping is worth it:

It took a lot of paperwork and screwed up billing because we had to charge 1 cent per code so that the Medicare carrier's computer would pick up the charges, and then had to manually write off that charge afterward.

In essence, the bonus equaled one extra 99213 office visit every other day. Most physicians would find it easier to squeeze in the extra visits rather than jump through bureaucratic hoops for minimal payment.

A reader writes:

Primary care doctors don’t know all the resources for a given medical problem in their geographical area. They will tend to go to whomever is their acquaintance or on the staff of the hospital that they are on the staff of. I found that two of the leading surgeons in the country for a problem that I had were at the regional academic medical center, but my doctor recommended people at the local community hospital. I have since in discussion found that to be a common pattern.

It is true that I tend to refer to people I know. In my case, that tends to be the community specialists. I've met these physicians, talked with them, and read their consultant notes more frequently. I'm able to gauge patient satisfaction by asking how their experience was with a particular specialist.

I always give the option of going into Boston, or to a larger tertiary care center. The caveat is that I am not familiar with the specialists down there, so other than the reputation of the institution, I can't give a more personal recommendation.

I try to present the pros and cons of both scenarios, but the ultimate choice is the patient's.

DTC drug advertisements are facing increasing scrutiny. To get around this, drug companies are resorting the "unbranded advertising", where the name of the drug isn't mentioned in the commercial. This relieves them of the responsibility of listing all the side effects of the medication.

Banning drug companies from advertising medications would be easier.

In California, these doctors are not required to be licensed within the state, and have the power to veto any diagnostic or treatment plan by a patient's primary physician.

Worse, they cannot be disciplined:

A huge snag in the system is that utilization review doctors without California licenses cannot be disciplined by the Medical Board of California for unprofessional conduct because they aren't under board jurisdiction. Neither can they be prosecuted in the states in which they do have licenses, because those states don't have jurisdiction in California.

These hired guns have a huge say in treatment and diagnostic decisions, and cannot be held accountable.

What a scam.

Think physicians are rich or overpaid? You should read this.

Buckeye Surgeon talks about a difficult case. The statistics are not on the patient's side when they present with this.

This midwife does about 200 to 300 births a year, at $1,000 per birth.

It doesn't sound like she worries about malpractice. Is it because the Amish are less likely to sue?

Miles Zaremski suggests a compromise to health care reform, blending the ideas from the left and right:

Why not provide a basic layer of health protection for all Americans funded with taxpayer dollars, with any additional coverage paid for by the individual, the employer, or both through the private sector? In this way, every citizen will be guaranteed a certain level of health care, while letting market forces take care of levels of health care above a certain floor.

One question needs to be answered before anything gets done. Namely, whether health care a right or not.

The country is split as to the answer to that question, mostly along partisan lines. Simply Googling this question will return a wide array of opinions. I've made my opinion on this quite clear in the past.

The easiest way to settle this would be to hold a national referendum, simply asking voters if there should be a right to health care.

This needs to be resolved first before proposing any health reform plan.

I still have trouble getting those Smiling Bob Enzyte commercials out of my head.

Now the company's founder is going to be doing some hard time.

The switch from ICD-9 to ICD-10 codes is supposed to happen in 2011.

Providers get to look forward to almost a 10-fold jump in number of codes, but also an increase in claim denials:

HHS is predicting that claims-error rates will rise between 6 and 10 percent of all claims at the ICD-10 implementation date, up from a normal 3 percent rate typically seen for annual updates of ICD-9.

The cost of the switch will be $1.64 billion dollars. Isn't the government supposed to take the initiative on saving administrative health care dollars, instead of allowing this bureaucratic nightmare to happen?

A reader writes:

I'm a hospitalist, and the primary care crisis here is getting really scary. Even as a hospitalist, you can't imagine how many times a day I get asked by the lay public, "Are you taking new patients?"

Any thoughts about how the "falling house of cards" is going to appear? My prediction is sometime in the next 2-3 years. The issues just get worse and worse. And even from the inpatient viewpoint, I can tell you *nobody* is happy about the death of the PCP.
Even when we take care of people in-house, we're finding it harder and harder to find someone to send them to on the outside.

It's getting scary all around. I worry about who's going to take care of my own parents - their PCP is in his 70s.

Physicians have been banging the primary care shortage drum for the last few years. Only recently has mainstream media caught on and have started writing articles about it.

I don't think we're at total collapse yet. The situation is grim, but it is not perceived by the politicians to be severe enough to warrant action yet. Recent polling has health care trailing Iraq and the economy on the list of voter concerns.

Discussing the issues surrounding the primary care crisis and getting patients on our side is imperative. I try to do this with my blog and the various opinion pieces I write for the USA Today. Political action has to be forced by the public.

I anticipate we will reach another level of urgency in a few years when the first wave of baby boomers reach Medicare age. Total collapse will be 5 to 10 years away, so we need to be ready ready with answers when the inevitable happens and the politicians are forced to face the problem.

How not to do it.

There is a difference, says ENT physician Bruce Campbell, and it rests in the relationships.

A reader asks this question:

I was wondering if you can answer a question on the 250-yard rule. I work in an emergency room and heard on the radio there was a stabbing in the same block as the hospital. Is it my obligation to leave the ER with a the physician and run to the site.? EMS was called and the police were responding.

We have much debate over this situation. Some employees feel it fits into the 250-yard rule, others feel it does not. Can you help us answer this question and set the record straight?

I have no idea. Can anyone help answer this question?

The PSA test for prostate cancer screening has come under fire. First of all, it's not very specific - meaning there is an unacceptable false positive rate (i.e. positive test in the absence of disease) for prostate cancer. This leads to biopsies and surgery that may not be needed.

The implications of this is becoming more widely publicized. Men are starting the realize the downsides of treatment, and understanding that more medicine isn't necessarily better.

Tara Parker-Pope writes about a study where one in five men regretted undergoing prostate surgery. This suggests that the risks and complications of the treatment course were not fully understood by the patients.

There is a clampdown on drug company gifts to physicians. Congress is even getting involved with the regulation.

But when it comes to influencing politicians, the sky's still the limit. Just take a look at the pharmaceutical presence at the national conventions.

Charlie Baker wonders why this simple, effective, cost-saving tool isn't used more often.

The answer is incentives. Hospitals won't change unless there is a financial motive to do so. If you give bonuses, or penalize, hospitals that use checklists or not, I guarantee you'll get results.

Join Dr. A for his one-year anniversary show. Congratulations!

Here's how to listen.

Guess who it is.

In the Clinic - Dr. Alfredo Sadun, MD, PhD, discusses using the ophthalmoscope for systemic disease

A reader writes:

I agree with you completely on the importance of having a physician functioning as the coordinator of care for a patient (I have always assumed that a primary care physician would do that) my experience has been that they resist that role. I have become my own and my wife’s primary care person because of that.

There are hospitals that discourage primary care doctor participation. If you are admitted to the hospital, then primary care is not permitted to participate in treatment even if they on the staff. Rather you are under the care of the “attending physician” or the “hospitalist”. If you are discharged and readmitted a few days or weeks later you have a completely different set of physicians. Your primary care is not permitted to intervene (and doesn’t feel like endangering their position by forcing intervention).

In these situations a third party (in this example it was me) forced coordination by hand caring documents and reports, and running down staff members and having adhoc meetings. Primary care physicians don’t do that.

Welcome to the today's hospitalist model, a trend entirely dictated by the physician payment system. Primary care physicians are now able to stay in the office, where they can see patients more efficiently, instead of dividing their time between the hospital and clinic.

The downside is the lack of continuity, as this reader has experienced. Indeed, if an inpatient is discharged and readmitted, an entirely new set of doctors may assume care. In many cases, the primary care physician does not have say in this matter.

That is why the implications of allowing hospitalists to care for inpatients need to be clearly communicated to patients.

Regarding the coordination of care, this often is done inadequately. Again, the payment system does not offer any economic incentive to do so. Time spent away from the patient coordinating care is done pro-bono, and the already strained generalist can ill-afford to do so in these trying financial times.

Good news is on the horizon. The so-called "medical home" model is being piloted on select Medicare populations, where money is alloted for coordination of care between hospitals and specialists. Initial results are promising, and can help reduce overall health costs.

Until this model is widely adopted, the current patchwork of providers providing the majority of the care in this country will continue to be the norm.

Plastic surgeons and dermatologists are abuzz about yesterday's appearance.

A seemingly paradoxical result from a study.

One reason is that patients who are seen same-day are less likely to see their personal physician. Instead, an NP, PA or covering doctor may be providing care.

This lack of continuity may be an explanation for the findings.

Nice op-ed from two primary care physicians in Pittsburgh. Nothing that hasn't been discussed here, but I would have further emphasized the disparity between specialist and generalist pay.

This is the chief reason why medical students aren't entering any generalist fields. Finances and money needs to enter the public consciousness when discussing the primary care shortage.

People writing about their medical conditions have become commonplace, including this young woman blogging about her impending abortion.

Mothers in Medicine: "Delivering the baby, like the first day in anatomy lab, doesn’t suddenly make you a mom, or a doctor, not the way you imagined it would. It takes time, sleepless nights, anxious days, moments of profound resentment and moments of even greater tenderness before you fall in love with this child, a love that evolves and changes as the child becomes more and more complex and separate from you."

Forget about measles, it's polio that has Dr. Farrago worried about the effects antivaccination trend.

It's not just happening with primary care, but with cardiology practices as well.

This makes sense for both the hospital and the physicians, where operating a private practice becomes more difficult by the day.

What does this trend mean for patients?

For athletes considering anabolic steroids, you may want to reconsider.

Reader Takes is a regular feature where selected op-ed style pieces from the audience at Kevin, M.D. will be published on the blog.

Posts are between 500 and 600 words in length, and can argue any opinion related to medicine and health care.

Original articles that are provocative, well-written, free of grammatical or spelling errors, and generally follow these guidelines are preferred.

Once a reader take is published, it will remain at the top of the blog above the fold for one day. A link to the author's book, blog, or website will be included.

Kevin, M.D. receives in excess of 10,000 visits daily, and is regularly read by major media outlets.

The piece will remain exclusive to Kevin, M.D. and may not be republished elsewhere.

If you are interested in submitting a take for consideration, please contact me.

If I Had - My First Seizure - Dr. Steven Schachter, MD

A fairly good article in the NY Times talking about a new blood test screening for ovarian cancer.

Ovarian cancer is normally not detected until the late stage of the disease, so patients have been eager to find an early screening test.

The downside is the unacceptable "false positive" rate (0.6 percent in this case), where the test is positive in the absence of disease. This often leads to removing the ovaries unnecessarily.

At $240 per test, companies profit from the public's fear of cancer and capitalize on the myth that "more testing must equal better medicine."

However, they leave out the thousands of unnecessary surgeries and procedures that arise from false positive readings. Equal weight to this complication should be included in their advertisements.

Both candidates make prevention a focus of their health reform plans. Whether they truly save money or not is unclear at this point.

It seems like retail clinics aren't the gold mine companies thought they would be:

In the past year, Merchant Medicine estimates that 136 clinics have closed up shop, a trend it blames in part on financiers who lost patience when the clinics weren't showing quick profits.

These clinics face the same payment pressures afflicting primary care doctors. If office-based physicians have trouble making ends meet, there's very little chance that the retail clinic model will profit.

This is especially true if retail clinics accept insurance, which dooms them to poor-paying cognitive reimbursement rates.

Also, a single malpractice suit against one of these clinics has the potential to wipe them off the map completely.

In order to survive, they need to be i) cash-only, ii) start doing minor procedures, iii) consider expanding into cosmetic dermatology (like Botox).

Just like a real primary care practice.

Rural Doctoring hosts the weekly best of the medical blogosphere.

See how this physician responded to an anaphylactic reaction at Fenway Park.

Absolutely not. This comment sums it up nicely:

Why, in a country where First Amendment rights are defended so passionately, should physicians–of all groups–have their views censored, either by outside agencies or within their own ranks?

It's sad that this is the easiest way to do it: "If a patient is stable - and can be driven to the other hospital by family or friends, you can gently suggest they sign out AMA and just show up over in the other ER. Then the HAVE to take care of the patient. Ola! No transfer paperwork, calls, or legal issues."

The AMA's Ethics Forum takes on the following question: "Can physician-written blogs meet legal and ethical professionalism standards?"

Maurice Bernstein: "Medical blogs, moderated with attention to civil and open discussion among the visitors and following guidelines for ethical operations, make a significant contribution to the medical education of the public and, I dare say, the profession."

Rob Lamberts: "Physician blogs should not be seen as an attempt to replace other sources of information, but instead as a new kind of medium -- a view into the minds of the rank-and-file members of medicine.

Used properly, blogs can give voice to a group that has often felt powerless to affect change. Ultimately, the responsible use of this medium lies with the blogger."

A physician claims a patient wanted to thank him . . . with oral sex.

The Gone Wild series continues.

Rural Doc focuses on generalists opting for rural positions, but her advice can apply to every graduating resident.

Dr. Rob with tips on giving bad news to patients.

In the Clinic - Dr. Carol Conrad, MD, discusses the causes and treatments of cystic fibrosis

"I've been doing this 25 years and even I've never heard of that one!"

You know it's a rare case when that's the response you get from poison control.

We need to do a better job in managing patient expectations:

Healthcare is not a commodity like a Toyota that can be turned out, day after day, in exactly the same way. Every human body is unique. At any moment, a surgeon may run into a surprise. Your cancer may be hiding in place that makes it very difficult to detect on a mammogram—not impossible, but very difficult. And while the person reading your test probably would have caught it nine days out of ten, this is the day that he didn’t.

Expecting our physicians to be perfect only tempts them to “cover up” any mistakes, which leads, in turn, to worse outcomes.

Remove fault from the malpractice equation. Understand that mistakes happen, and in these cases, patients should be fairly compensated in an expedient manner. The current system is a complex, lengthy legal process that fails patients more often than not.

Instead, we're going the other way. Hospitals are being punished with an increasing list of "never" events - some of which cannot be prevented.

Expecting perfection from doctors and hospitals will further deteriorate the trust patients have in the profession. It's an ideal that can never be realized, which will inevitably lead to patient anger and disappointment.

The disgusting behavior of some on-call physicians.

(via Dr. Wes)

This is one of the ways government can help with the primary care shortage.

However, as Dr. Secretwave points out, the current example of such a program is not adequate.

The $20,000 amount does not influence medical students' decisions, and the fact that this amount is taxed makes this incentive more irrelevant.

Money talks, and so far, the government is barely whispering.

This should be on a pre-medical school screening questionnaire: "If money is you main object, avoid medicine. We make decent money, but we invest so much time getting there, that from a pure financial calculation, medicine is not your best choice.

If you do not like people, and here I mean all types of people, all social classes of people, then you should avoid medicine. If you cannot accept uncertainty, then you should avoid medicine. If you cannot accept that eventually you will make a mistake (or several) that will negatively impact a patient, then you should avoid medicine."

Good point here. Medicare and other payers pay the same for each medical service or procedure, regardless of whether it's done by a new doctor or a 30-year veteran:

Differentiating one physician from another or one surgeon from another is very difficult. Additionally, seniority does not necessarily mean that the product or service is better.

The only way that pay increases with age is the increased efficiency that comes with experience.

This isn't always a good thing, since doing things faster in medicine isn't always better.

It's the real estate:

One strategy some physicians utilize is to buy larger space than they typically utilize. Then they rent out space to other physicians. This is an excellent strategy for those physicians who have the means to do this. In some respects it turns the physician into a real estate investor rather than just a business owner.

Outrage at kids being priced out of these expensive programs:

Several national groups are pressing for government financing or insurance reimbursement for more intensive weight loss treatment for children, including weight loss camps.

Wouldn't it be better use of funds to focus on preventing kids to be so heavy in the first place?

In the midst of their boom, here's an article about an institution considering laying off hospitalists.

Hospitalist programs typically operate at a loss, with the financial gains not apparent for years to come. The benefits of these programs also do not directly impact the bottom line, but instead help with recruiting, as well as the primary care physicians affiliated with the hospital.

Cash-strapped facilities, like Cape Cod Healthcare, may not have the long-term vision or resources to wait out the initial capital costs of running a hospitalist program.

(via The Hospitalist Blog)

Trust between patients and physicians are at an all-time low. Although we blame a variety of reasons - ranging from third-party payers to malpractice fears - for this, simply being nice and appearing human can do wonders for the medical profession.

An abridged version of my op-ed was published in this morning's USA Today: Doctors' pay cuts save little in health costs.

It discusses whether targeting physician pay as a means to control health care spending makes sense and touches on Congress' recent passage of the Medicare bill.

For those new here, my name is Kevin Pho and I practice primary care internal medicine in New Hampshire. This blog explores the issues facing medical providers on a daily basis. Health care is a major domestic concern, and the public deserves to see what goes on "behind the curtain."

By providing a physician perspective on issues that the mainstream media may ignore, perhaps we can get one step closer to solving the problems crippling our health care system.

Some of my regular features include:

My Take: Quick-hitting quips on pretty much anything that crosses my mind.

Reader Takes: Provocative opinion pieces from the readers of this blog.

MedBlog Power 8: A weekly-updated list of medical blogs that had an exceptional week of blogging.

Of course, you can always jump in and join the debate on controversial issues like health reform, defensive medicine, the primary care crisis, medical malpractice, cancer screening, and emergency room struggles.

My previous opinion pieces and interviews have appeared in national and local media outlets, discussing defensive medicine (Defensive medicine: Cautious or costly?, Wasted medical dollars), primary care (Shortage of primary care threatens health care system), Medicare payments (Cut Medicare payments for doctors, you'll have fewer doctors), and poor communication in medicine (What we have in health care today is a failure to communicate).

Thanks for stopping by, and I appreciate your readership.

Regular blogging will resume on Monday, August 25th.

The story of an illegal immigrant in a coma. He is scheduled to be deported to Mexico.

Tough position for the hospital to be in. With limited resources, it is not financially viable for hospitals to foot the bill for illegal immigrants.

However, any solution is likely to cast a negative PR light on the hospital.

(via WSJ Health Blog)

And touches off a firestorm of debate on the WSJ Health Blog.

If there was a single thing he could do to lose my vote, endorsing single-payer would be it.

If I Had - A Child With Abdominal Pain - Dr. Sanjeev Dutta, MD, MA, FRSC(C), FACS

Hospitals are getting glammed up for nice photo-ops. But the patient and treatment rooms are getting the shaft.

When in the emergency department, sometimes it's best to let the people who normally work there handle the job.

Here's why.

Richard Reece has some ideas, and some obstacles that will be encountered along the way.

Word on how Merck marketed Vioxx throught clinical "studies". Lost of chatter on this topic recently. Roy Poses provides a good place to start:

This article appears to be the first to provide evidence that pharmaceutical companies may deliberately disguise marketing efforts as clinical research. This is a real achievement, since obviously the companies involved make every effort to hide what they are doing, and it only through discovery during litigation did the facts come out.

six until me hosts the weekly best of the medical blogosphere.

Non-medicine related, but Dr. Secretwave gives a fascinating analysis of how the US men won the swimming 4x100 freestyle relay.

Is this genetic connective-tissue disorder the reason for his freakishly unique swimmer's body?

Hospital "never" events are the next big thing in litigation. From a WSJ op-ed:

Hospital infections will cause the next wave of class-action lawsuits, bigger than the litigation over asbestos.

There's discussion over at Buckeye Surgeon and WhiteCoat.

Makes me somewhat thankful that I have an office-only practice.

If I Had - Received a Bite From a Rabid Animal - Dr. Charles Rupprecht, VMD, MS, PhD

The following is a reader take by Matthew Mintz.

Despite being mentioned on ABC News, and the medical blogosphere, the recent study in the Archives of General Psychiatry that shows psychiatrists are less likely to use "couch" therapy hasn't garnered the attention it deserves.

The study found that for patients who saw psychiatrists, the percentage of visits involving psychotherapy (where the physicians talk to you) decreased from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005. This is despite that fact that psychotherapy has been found to be effective for many mental health disorders. The authors and commentators note that the way in which psychotherapy is reimbursed ("reimbursement for one 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits"), but the findings go far beyond that and are a good indication of the future of primary care.

What is not clearly stated in the study is that in 1996-97, about 55 percent of patients who paid out of pocket received psychotherapy compared to about 40 percent who paid with insurance. In 2004-05, the percentage slightly increased for patients paying out of pocket (59 percent), but dropped by almost half (23 percent) for patients using insurance. The reality is that over the past decade, the way in which psychiatry is practiced and delivered has dramatically changed based on reimbursement structures. We now have two types of care delivery for mental health services.

In general, there are two types of psychiatrists whose practices are remarkably different: those that accept insurance and those that do not. For those that do not take insurance, psychiatrists prescribe medication, administer psychotherapy, or do both. Those psychiatrists not taking insurance generally manage medication only, using other health care professionals (psychologists, licensed psychiatric social workers, etc.) to administer counseling and other forms of "talk therapy."

For many insurances, mental health is a carved out benefit. In other words, instead of getting a referral from your primary care physician to a specialist who accepts your insurance, patients needing mental health care must call the central number of the company their insurance contracts with, and speak to an intake person, who is usually a nurse or social worker. This person will then authorize therapy and direct the patient to a covered provider. Sometimes they determine whether or not a psychiatrist is really needed or whether a non-physician provider can do the job. Alternatively, some mental health benefits direct all patients to a psychiatrist initially, whose main job is to manage medication and direct patients in need of counseling to non-physician providers.

This description is by no means intended to discredit psychologists or psychiatric social workers, who provide excellent and effective care. In fact, I am not even arguing that this is a bad system. With limited health care dollars, maybe it makes sense for MDs to focus on medication, and non-MD professionals to deliver cognitive services. The point is that the low reimbursement for cognitive services from both government and private payers has dramatically changed the way mental health care is delivered in the US, transforming it into a two tiered system. More importantly, the same is likely to happen to primary care, where much of the work of the primary care physician is non-procedural.

The rise of concierge care is only the beginning. Unless there are substantive changes to the way cognitive services are reimbursed, specifically for primary care, general health care will similarly develop into a two-tiered system for those patients who pay for primary care with health insurance and those that pay out of pocket. Having a primary care physician that knows you as an individual, calls you back on the phone to answer questions, fits you in to an appointment when you are sick and takes the time to talk to you in an unrushed visit will only be available to those that can pay for these visits out of pocket.

Those paying for primary care with insurance should expect (in the not too distant future) limited access, routine care delivered by PA's and NP's, and rushed visits with the MD, whose primary focus will be medication management and directing you to non-physician providers for counseling and discussing your various health concerns. Health care reform that does not address the central issue of low reimbursement for cognitive service and high reimbursement for procedures and diagnostic studies will only encourage this shift.

In fact, this trend has already started.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz' Blog.

In the Clinic - Dr. Stuart Goodman, MD, PhD, discusses how knee pain can be associated with the hip

Blogging will be intermittent for the next 10 days as I'm on vacation.

Update:
BTW - thanks for all the feedback on the new blog template. Some answers to FAQs:

i) If the template doesn't look right, please refresh the page to clear your browser's cache.
ii) Comments are located at the upper right corner of each post.

Or rather, the lack of:

Women now account for more than 50% of American medical students, but only 10% of neurosurgery residents . . .

. . . Women account for less than 6% of the neurosurgery ranks.

Studies show that female physicians prefer flexible hours, which leads women to pursue part-time jobs out of residency.

Neurosurgery, with often unpredictable hours and long surgeries, is simply not conducive to this kind of schedule.

The lack of female role-models or discrimination within the field are unlikely reasons for the dearth of female neurosurgeons.

Lifestyle is king, and it is the dominant priority with the current generation of doctors.