Physicians are paid in large part by tying a payment to a code for the operation or management services provided (typically tied to Medicare as described here) referred to as “fee-for-service.” That method of payment is somewhat limiting if you want to make a lot of money, as there are only so many “billable hours” in a day. About 10 years ago physician salaries were stagnating. Practice management consultants came to many cities and held seminars on how to “grow your practice income.”

The answer, it turns out, was ancillaries. The seminar went something like this: “You as a physician can only see so many patients, but if you hire folks to do other stuff that you can order (stuff that is traditionally done by the hospital but can be done in your office) and bill for that as well, your income could go up, up, up!” How high? Turns out, very high:

Holm says the practices with which he works average 20 percent to 35 percent returns on imaging services, such as radiology, CT, and MRI scans. Surgery centers report up to a 40 percent return on their investments, he adds. Indeed, the Medical Group Management Association’s (MGMA’s) 2006 Cost Survey for Orthopedic Practices finds that on average, orthopedic surgery groups realized $45,492 per physician in net revenue (after operating costs) for the physical therapy services they now offer. After implementing diagnostic radiology services including MRI, those same groups earned $47,951 per physician.

It also turns out that doctors are really good at ordering tests. It also seems that neither they nor their patients are good at asking why (or mostly, why not). Today the ABIM in partnership with the American Academy of Family Medicine is asking the patient to be the grown-up. They started a campaign entitled “Choose Wisely” and have posted a list of 48 medical procedures (found here), many of which fall into the category of “ancillaries” that are not evidence-based or even have evidence showing harm, and that in many cases are never necessary. The list ranges from no x-rays for routine back pain (no evidence that it helps, might get cancer from radiation and die) to no routine stenting for heart blockage not causing pain (no evidence  for benefit, might cause death). The list is worth a read for a lay person and ethically ought to be memorized by physicians.

Whether the average person will agree that less is more remains to be seen, as reported on NBC news.  As one “on the street” random person stated, “I don’t know… my friend didn’t have one of those tests and she got cancer 3 years later.” I wonder if high school health classes are going to start covering lead and length time bias?

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