The Covert Rationing Blog

Skin in the Game

July 30th, 2008 by DrRich

The New York Times recently took dermatologists to task for creating a two-tiered system of dermatology - one for patients with skin disorders, and one for “cosmetic dermatology.”

As the Times describes it, patients who wish to see a dermatologist for, say, possible skin cancer are put on a waiting list, and when their appointed time finally arrives (generally months later) they are subjected to modern medical hell. To wit: Upon arriving in a lackluster office, the patient is shelved for a while in an unattractive, poorly lit waiting room equipped with a broken TV, old magazines, unruly children of other patients, and surly office personnel. Eventually her name is called by a not-necessarily-pleasant nurse practitioner who will “triage” her to the appropriate category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), have her strip in order to fully expose the large surface-area organ (the skin) for which she has sought assistance, give her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see the actual doctor. At last the dermatologist arrives, mutters a greeting (or some other ritual uttering), glances at a clipboard, and announces, “Show me your [acne, fungus, cancer, warts];” whereupon, having regarded the cause of cutaneous concern and having made a professional determination, he either signs the prescription that has been pre-written for him by the nurse practitioner, or schedules a procedure. Then, shoving into the patient’s arms her bra and other structural and non-structural equipage, the doctor pushes her out into the hall, as the formal interview is over.

Presumably, one hopes, some dermatology practices not visited by the New York Times might not be quite so bad. Still, anyone who’s been seen by an American PCP lately will nod sympathetically at the dermatology patient’s ordeal.

Now observe what the Times observes when the patient, instead of having an actual skin problem, merely is sagging here and there and wishes to be shorn up. That is, the patient has a cosmetic issue. That is, the patient wants Botox.

The same dermatologist will often have an entirely different setup for these patients. This time the patient is seen immediately, possibly the same day, as dermatologists are sensitive to the needs of those who are about to appear in public, say, at an impending dinner party. If this patient is to wait at all, she will wait in a modern, tastefully decorated private room. She will then be seen not by a mere nurse practitioner but by an aesthetician, who will do a formal assessment of the sagging parts, and, aside from suggesting more injection sites than the patient might originally have had in mind, will offer a complete program for long-term cosmetic maintenance, which naturally will include quarterly Botoxification. At just the proper moment the dermatologist comes in, greets the patient warmly and reassuringly; then reviews the recommendations of the aesthetician and discusses those recommendations at length with both the aesthetician and the patient, studying the patient’s face in depth as he does so, pointing, nodding, agreeing, adjusting, all the while smiling confidently. Yes, he indicates, we will all be very happy indeed with the results. Finally the doctor begins to make the now-thoroughly-discussed-and-agreed-upon injections, doing so with the greatest solicitation and sensitivity. The patient is then given as much time as she needs to collect herself, and is invited to “recover” in a room set aside for this purpose with flattering lighting, soft music, a cappuccino machine, and perhaps a glass of wine. She leaves the office a new person. And, just as the dermatologist has promised, all are indeed very happy with the results.

Naturally, the New York Times is scandalized by the dichotomy which its discerning readers will note here. Why should a patient with a mere cosmetic issue be treated so well, when a patient with an actual medical problem, possibly even skin cancer, is treated so shabbily? How can dermatologists openly encourage such a two-tiered system?

DrRich has a word of advice for the commentators and reporters of the New York Times and any other concerned Americans worried that dermatologists, by setting up separate-but-not-equal practices for their two kinds of patients, are moving us one step closer to the dreaded two-tiered healthcare system we all abhor. That word is: Chill.

Allow DrRich to support this friendly recommendation with two observations.

1) We already have a multi-tiered healthcare system, and little or none of it is the fault of dermatologists. It is the fault of human nature. All countries have at least a two-tiered healthcare system, including countries (like Cuba and China) that have specifically embraced egalitarianism (rather than individual autonomy) as the fundamental operating principle. The second tier, like the poor, will always be with us.

2) When a dermatologist spends Tuesday afternoon in her run-down office, treating people who come to her for bona fide skin disorders like they’re widgets on an assembly line, then goes to her other, better office on Wednesday, treating the merely cosmetically-challenged like minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, she is practicing real, true, prescribed-by-society, by-the-book American healthcare on Tuesday, and doing Something Altogether Different on Wednesday.

Injecting Botox is officially and formally not part of American healthcare. How do we know this? Because it is not covered by Medicare or health insurance. If you want Botox you’ve got to pay for it your own self, just as you do if you want a TV or a car. So by all that is sacred, injecting Botox is NOT American healthcare.

Furthermore, when one looks objectively, injecting Botox is not even really practicing medicine, at least not in any true sense. In actual truth, it takes very little training or expertise to inject Botox. There’s no reason one must go to college, graduate from medical school, or do several additional years of training in dermatology (or any other specialty) to do this. Anyone with a needle and syringe, an alcohol wipe, and access to Botox could do as well. Just find the wrinkle and stick it. If they made the materials available over-the-counter, folks would do just fine with it.

Of course, doctors in general (and dermatologists in particular) have legally cornered the market on Botox injections. So it’s not like you could just set up a booth at the Mall and hire high school students to do this (as you can for, say, ear-piercing - which, in contrast to Botox injections, is an actual surgical procedure which results in a permanent structural change in a body part). If you set up a chain of Botox Booths, you would be practicing medicine without a license, which is a serious offense.

And consider this. Dermatologists could just as easily have taken up a somewhat different well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the skin itself than Botox injections (which actually do not affect the skin itself at all, only the muscles under the skin), but they chose not to. DrRich speaks, of course, of the tattoo. But unlike making Botox injections, tattooing requires real skill, knowledge, training, expertise and artistic talent. Most dermatologists simply could not manage a highly-technical skill like that.

The point, of course, is that injecting Botox does not involve intrinsic skill, knowledge, difficulty, risk, or any other objective characteristic that necessarily renders this a medical procedure while ear-piercing and tattooing are not. Viewed from this perspective, one must conclude that declaring the injection of Botox to be a medical procedure, which cannot be performed by anyone not having a medical license and years of specialty training, is an entirely arbitrary determination.

Fundamentally, then, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine. Rather, it is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.

Doctors engage in this sort of thing all the time. That is, they partake in activities other than practicing medicine when they could, in fact, be seeing more patients. Some have taken up golf. Others have started side businesses such as restaurants or software companies. Some go to graduate school (usually for MBAs). Still others have opted to work part time in order to raise their families.

Society generally finds such activities acceptable, and - to this point - does not insist that all doctors forego all other human endeavors in order to see as many patients as humanly possible, during all their waking hours. While society seems to be moving closer to declaring that doctors owe this duty, it has not reached this point quite yet.

Until society sees fit to legislate otherwise (which, DrRich supposes, could happen as early as the next president’s administration), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming retainer practitioners.

One last word of advice for dermatologists: Have fun with your Botox clinics, fellas, but please don’t become too invested in them. Injecting Botox is not exactly cardiac electrophysiology. This is definitely a shallow-moat business, and the only thing that gives you any protection at all is your aura as highly trained specialists, with special and secret knowledge about an organ (i.e., the skin) which visibly droops when the underlying muscles become lax with age and gravity. A single action by forces entirely out of your control - say, Congress or the FDA - could render your monopoly entirely moot overnight, and you will be instantly priced out of business by hordes of PCPs, nurse practitioners, Botox booths in Walmart, and even home Botox injection kits. So please remember to at least keep your hand in genuine dermatology, or get your MBA, or perfect your long iron shots - but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.

Posted in New business models for healthcare

12 Responses to “Skin in the Game”

1. Red Baron wrote on 07/30/08 at 5:40 am :

   I am sure you also meant to mention the fact that Dermatologists severely limit their numbers (along with several other subspecialty fields I won’t mention here— but you know who you are). What is the current ratio of medical school graduate applicants to residency openings: 10:1, 20:1?

   If dermatologists were not allowed to limit their numbers so strongly, I think ‘the collective’ might have less of an issue with this kind of stuff, but when the dermatologists create artificial demand by deliberately limiting their numbers AND then functionally lower their numbers further by reducing their availability for medical dermatology to focus on a cosmetic work (in otherwise healthy/attractive patients no less), it seems like yet again another example of the fox guarding the henhouse.

   The solution is simple, force their college to triple the number of training slots, or allow an alternate college to develop to provide alternate training pathways outside the main specialty college.

   Dermatologists will suddenly grow up real fast.

2. Red Baron wrote on 07/30/08 at 5:43 am :

   Dr Rich,

   Do you understand fractals? Do you understand how healthcare spending follows ‘fractal like’ pattterns? Do you understand why it is relevant to the issue of rationing?

3. DrRich wrote on 07/30/08 at 7:18 am :

   Red,

   I am not particularly sympathetic toward dermatologists, or their careful control of the “supply.” This is something that should rightly be addressed through market forces, though, and not by arbitrarily restricting the prerogatives of free individuals. For instance, there’s no reason PCPs cannot do 90% of what dermatologists do, thus limiting the need for dermatologists for acne, warts, fungus, simple rashes, etc. I have made the argument in the past that PCPs ought to respond to their own displacement by nurse practitioners by displacing the fat and happy specialists who lord it over them, and who often get paid big bucks for doing relatively simple tasks. Migrate upwards; it’s the hallmark of a technological society.

   I studied fractals in the late 1980s and early 1990s, as I thought the mathematics of chaos was a key to understanding ventricular fibrillation. It was a key, as it happens, and that knowledge subsequently helped my clinical research in electrophysiology.

   I also believe that the healthcare system displays many characteristics of nonlinear mathematics (though, overall, increases in healthcare spending seem to behave reasonably predictably).

   Finally, I believe that any real solution for our healthcare problem will more likely arise from a singularity than from some organized political process. For one thing, attempts at the top-down regulation of fractal patterns never works very well. For another, the growing frustration and anger of American patients represents an opportunity. If a critical mass of Americans can be made to understand that the healthcare system has systematically and purposefully marginalized them, stripping away their doctors’ ability to advocate for them and to take their part, and leaving them to fend for themselves, it will be like dropping a tiny crystal into a supersaturated solution - the entire structure of the system will change in a very short time.

   I’m sure I’m missing something about fractals and rationing, though, so feel free to enlighten me.

   Rich

4. BladeDoc wrote on 07/30/08 at 9:46 am :

   The problem is that you can’t support a practice on the BS medicare payments that you get for minor procedures.

   It costs me more in supplies (lidocaine, suture, sterilization of instruments, staff time, etc.) to excise a lesion in my office than I get paid to do it by insurance. This can be somewhat ameliorated by volume savings — i.e. if I get 50 scheduled in a day and run them through like cattle I might be able to break even or make a profit. That’s what dermatologists do. Conversely since I don’t get enough of this type of patient (I’m a general surgeon) for anything but the smallest procedure I schedule the patient for outpatient surgery in the main hospital. Thus I get paid the same and use none of my own supplies technically making a profit (although the fee is still so small the only reasons I see this type of patient are that 1. someone has to and 2. to teach the new interns how to cut and sew) and the hospital gets to charge a facility fee. So basically because medicare pays crap they get to pay double — covert rationing at work!

   This btw is the same reason that PCPs don’t do these minor procedures — they can’t make money on them either.

5. DrRich wrote on 07/30/08 at 10:06 am :

   BladeDoc,

   You are correct. Dermatologists (and other doctors) are simply behaving rationally, in response to the system they have been presented with, and which so obviously incents them to do exactly what they are doing. The more you tax, regulate, or implement cost controls for anything, the less you get of it. This basic law of economics (and of human behavior) seems to be beyond the understanding of more than half the population, and a large majority of the political class.

   Rich

6. Family Doc wrote on 07/30/08 at 12:40 pm :

   Maybe they’re behaving rationally, and are within their rights to do so, but when we entered this profession it was meant to be with the understanding that we would make ourselves available to people who are ill. It’s permitted, and legal, but is it ethical? I had a patient in the hospital with toxic epidermal necrolysis and because it was a Saturday I couldn’t get a dermatologist to come in until Monday. Thank goodness for UpToDate! Maybe we don’t need these specialists after all.

7. DrRich wrote on 07/30/08 at 12:47 pm :

   Family Doc,

   “Maybe we don’t need these specialists after all.”

   Now you’re talking. Go get ‘em!

   Rich

8. Red Baron wrote on 07/31/08 at 11:36 am :

   DrRich said… “I believe that any real solution for our healthcare problem will more likely arise from a singularity than from some organized political process”

   I couldn’t agree more. The solution to the tragedy of the commons was always an emergent property of the system itself (again, for another blog…)

   As for how fractals relate to healthcare spending… Remember a fractal is something that no matter how much you fracture it/change it/break it apart, it still looks the same.

   Do me a favor, look at the curve for how we spend our healthcare money in this country, i.e. the one that shows how the top 1% of patients consume 25% of the money, the top 5% spend 50%, etc… Ask yourself what kind of curve is this?

   In fact, do this for any country you have historical data. Again, what kind of curve is this?

   Now, d the same thing over ANY time frame you can think of that you have data on: 1 hour, 1 day, 1 week, 1 year, 10 years, 50 years, 100 years.

   Again, do the curves look all that different?

   Once you see what I am getting at, let me know

   

   As for primary care vs. dermatology- ‘yes’ and ‘no’.

   Remember, the whole professional credential thing is really based on the idea that we are using certification as a surrogacy for competency. I have always believed one of the main reasons patients prefer to see specialists over primary physicians in the first place is because of the (often incorrect) patient beleif that patients are getting ‘the best/someone who knows what they are doing’ when they see a specialist.

   (The fact that in the US salary differentials between subspecialists and primary physicians have increased has not helped this any either; it creates a reinforcing feedback loop where the ‘most impressive’ medical students are more likely to enter subspecialties further validating the patient’ perception.)

   Anyway, the deramatology credential is a suggogate of competency (in the eyes of a patient). The primary care certification is not (at least as far as skin is concerned, again, from the point of view of a patient).

   Our professional colleges, as well as the states and national governement are complicit in protecing the monopoly on this certificate without also balancing larger national issues.

9. Red Baron wrote on 07/31/08 at 2:43 pm :

   One last thing to remind you to help guide your thinking as you look at the fractal (i.e. ‘non-linear’) graphs I suggest: fractals behave according to power laws/are scale invariant.

   Now think about scalability and the problem of ‘the frequent flyer’.

   Unless people recognize this fundamental feature of healthcare spending, they will continue to waste a whole lot of energy making changes so that ‘things can look the same’.

10. DrRich wrote on 07/31/08 at 7:04 pm :

    Red,

    First, I want to make it clear that as a matter of principle I do not do homework assignments, having sworn a sacred oath not to do one ever again the day I graduated from college, well over 35 years ago. Fortunately, my children were also against doing homework so I was never challenged by them to violate my principles for their sakes.

    So needless to say I have not actually constructed the curves, etc. you assigned to me.

    But I do understand that healthcare spending displays fractal characteristics, which is almost predictable since healthcare spending is not determined by logic or any other linear factors. Rather, like the stock market, healthcare spending is determined by millions of individual daily decisions made by people (doctors and patients) who base their decisions on a myriad of unmeasurable factors like estimations of what is medically necessary, emotional issues, wishful thinking, and a host of outside coercions to do this or do that. No matter which level you analyze the results of such a process, you’ll see what looks a lot like chaos.

    And, like the stock market, you’ll have gurus who pretend to understand it, and who prescribe simple fixes for the whole thing. (The difference is that the stock market gurus get formally graded on their predictions each year. So each year, half the gurus beat the average, etc., etc, so that only a percent or two will have beat the average 5 years in a row, and their “success” will have been based on pure chance. These few fortunate guys are declared actual geniuses, and they are the ones you see on CNBC.)

    What is needed is a singularity, some movement that arises unexpectedly out of the matrix itself, and that immediately transforms the system to a new state of equilibrium. I can imagine what one such singularity might look like, and have written about it. But at the same time I realize that if it were really predictable then it wouldn’t be a singularity.

    Rich

11. Red Baron wrote on 07/31/08 at 8:04 pm :

    My apologies, I did not intend a ‘homework assignment’, I certainly see how you can see it that way… I’ll see if I can pull the curves off the web. I simply assumed you had them at your fingertips do to the nature of your interests.

    Although chaos and fractals are two sides of the same coin, I am actually not trying to emphasize the chaos aspect of the fractals. Instead I am suggesting you look at the scale invariance properties. When looked at this way, I personally have never seen anything explain so clearly why healthcare spending has gotten out of control.

12. Jeffrey Frentzen wrote on 08/15/08 at 1:54 pm :

    The Times’ piece has been widely republished internationally and has done much to sully the reputation of the dermagtology field.

    In addition, the dermatologist who was roundly quoted in Natasha Singer’s article, a Dr. Richey, has since complained loudly among colleagues in the organization that represents dermatologists, the AAD, after the article was published. He reportedly claimed that Singer skewed her questions in order to justify the article’s conclusions, which may have been decided in advance — by the Times’ editors — that dermatologists should be “taken to task” for doing what any businessperson does all the time in every line of work you can imagine. Specifically, the old bugaboo of greedy doctors caring more for money than their patients, a.k.a. that old-time, anti-business diatribe that liberal newswriters are notorious for. The Times editors and Singer do not help the cause of journalism in adopting such a simplistic, ignorant attitude.

    For example, when you buy an airline ticket you can buy the coach fare, the cheapest fare that you can get and which offers basic services, or pay a premium and buy a first-class ticket, in which you are offered much higher levels of service. Apply this same concept to not only medical offices but hotels, grocery stores (e.g., the 99-cent store vs. Trader Joes), etc.

    Singer has been known to write half-baked “media stories” that serve to throw panic and loathing into its readers — the paper in this way does not educate, but instead does its utmost to keep its readers stupid, and perpetuates the ignorant myth of greedy doctors.

    Incidentally, the AAD is to be criticized here, as well, for producing a research study last year that props up the Times’ hypothesis. As such, Richey has been told to stop complaining and the AAD has decided to keep quiet and not respond publically to the Times’ article.

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