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From: B. Harris)
Subject: Re: doctors of the nation - unite?
Date: 02 May 1997

In <> Andrew Chung <> writes:

>i disagree... before managed care, physicians generally did not have a
>significant financial incentive to overtreat...  prescriptions,
>referrals to subspecialists, etc do not involve any kickback to the
>primary referring physician...  ok, there may have been additional
>followup visits to go over any additional findings but they are
>typically the nominal $20-30 office visits only when there is something
>that needs to be discussed face-to-face in person (if the test was
>unnecessary the result will likely be negative and therefore no
>additional follow-up office visit).

    Gee, Andrew, you forgot about people with procedures.  I once saw a
pretty expensive car in L.A. in 1983 with a license plate that said
"EGD PRN".   Obviously a gastroenterologist.  That was right at the end
of the gravy train.  In my internship that year I saw neurologists who
did serial EEGs to follow their patients (charging for each and reading
each), cardiologists who did ordered and read serial nuclear heart
scans the same way (we won't even discuss EKGs-- today the thing is
office ultrasound), pulmonologists whose COPD patients got office PFTs
nearly every month, and so on and so on.  Before DRGs hit that year,
everybody hospitalized medicare patients at the drop of a hat, making
rather fat fees in the process, sometimes for no particularly good
reason.  About the only people I saw in Southern California not making
out like bandits were the endocrinologists, who somehow could not
convince their patients to have multiple thyroid biopsies.....

                                     Steve Harris, M.D.

From: Steve Harris <>
Subject: Re: the over-utilization of American hospitals
Date: 3 Nov 2005 22:20:17 -0800
Message-ID: <>

fresh~horses wrote:
> So much for American for-profit healthcare resulting in better
> treatment, even for those who *do* have coverage. 50 million don't even
> have that.


Your article skewers the US overtreatment problem, all right.

I was actually born in Provo, Utah. It is one of two epicenters of
Mormondom, and a lot of specialist Mormon doctors from Utah congregate
there because they want to live with Mormons.  And this no doubt does
lead to overtreatment, an epidemic problem in America, particularly
when it comes to high-tech imaging and related procedures. Medicare
billing is no doubt exacerbated in Provo by lack of a university
medical program there, so private specialists for the elderly have to
make their bucks almost without academic support of any kind. That can
lead to brutal testing and medicare billing.

In New York City and Miami, there's a similar situation, save that it
is Jewish medical specialists --- Newflash: of which there are a great
many--- that congretate in these areas. Billing of medicare to
over-scan their patients follows, as a sort of 8th plague of Pharoh. Or
perhaps a better analogy is the exiled Hebrew worship of the golden
calf (not that Mormons aren't in on the running for that award, too).

So what is the answer?  We could maybe mount a mass Luddite style
attack on angioplasty suites and MRI machines.  But we do need them for
some stuff. It's the inappropriate use of them, that is killing us. Nor
is rationing that, the answer, since who's going to do that?

Turning over these decisions to doctors dosen't work, because doctors
get paid for overtreating. It's very easy to make a virtue of that
which enriches you.

Turning these decisions over to government doesn't work well, either,
because that merely removes money from patients and returns it to them
from politicians, with strings attached. And politicians use every
dollar that flows through "public programs" to buy votes with (yes, in
Canada, too, shocking as the idea is). None of this particularly helps
the problem of allocation of medical resources to where they are needed
(though it does help to ration them away from centers of
overcongratation of specialists).  In Canada, they don't have enough of
this stuff. In the US, we have too much. There needs to be a meeting of
minds, here.

There's no way to keep specialists from congregating. You'd have to
exile a of religious doctors from where they want to live, and if you
did, they'd all scream about Nazis.

What you CAN do, is remove some of the incentive for doctors to
specialize, so you don't care where they do. Much of this is
financially driven. If you quit paying specialists all that money and
give it instead to family practitioners (so that generalists make a
comparable salary per hour, per year of "generalist" post grad
training), the specialist glut will die on the vine.  I'd like to see

The patient has a role, too. We need good coverage for everybody in the
country, not just the minimum provided by medicaid. But along with
that, we need healthy deductables for everyone for every test and
procedure (perhaps with a means test, so it's a fraction of your
income) to make sure that patients keep a lively economic interest in
whether or not that next heart scan will tell them anything they're
interested in knowing THAT badly.  Consumerism driven by out of pocket
expense is a powerful force, indeed (and one that is lacking in BOTH
Canada and in Medicare in the US).  Nor do consumers need to be exposed
to any but a moderately painful part of what they pay for medical care,
to begin to employ their brainpower on the problem. With a means-test,
nobody need go without something he or she really feels they need badly
enough to spend a fraction of their income on it. There is no need for
medical care to bankrupt anybody, and yet co-payments for SPECIFIC
specialist procedures, can still play a major role.

Specialists have a hard time overcharging and overtreating where it
hurts the consumer pocketbook, and where the government is poor at
paying good rates also, for use of high tech. Overuse is a disease of
government payment guarantee without government oversite. Time to scale
back on the first, and increase the second. Both can be done without
anything like the Canadian system.


From: Steve Harris <>
Subject: Re: the over-utilization of American hospitals
Date: 3 Nov 2005 23:14:04 -0800
Message-ID: <>

fresh~horses wrote:

> Since you don't actually know anything about the Canadian system you
> wouldn't know it is heavily reliant on diagnosis and course of
> treatment laid out by relevant specialists.

I know more about your system than you think. It matters not a whit
what specialists you have, if they can't get their fancy machines or
O.R. time for their expensive procedures. You also pay specialists
relatively less, with the result that you have a smaller specialist
fraction and 50% primary care providers (a fraction we only *wish* we
had).  Alas, you pay THEM crap---instead of giving them what the
specialists don't get, you just keep it--- so you get an absolute
undersupply EVEN of primary care. Your problem is not enough money into
the system. We don't  have that, obviously, but we do have
maldistribution problems. As I said, you need to quit being skinflints
to your primaries, and we need to quit being sugar daddy to our
specialists. We'll both come out better.


From: Steve Harris <>
Subject: Re: the over-utilization of American hospitals
Date: 4 Nov 2005 18:10:46 -0800
Message-ID: <>

fresh~horses wrote:

> You also pay specialists
> > relatively less,
> How again, would you know? Have you checked with all the provincial
> colleges?

These are averages we're speaking of. GP earnings vary from state to
state in the US, but it's the US average which counts in comparing

> with the result that you have a smaller specialist
> > fraction and 50% primary care providers (a fraction we only *wish* we
> > had).  Alas, you pay THEM crap---
> You've have to have done a canvas of all the 10 provinces and three
> territory college pay schedules to know that. Since you haven't....

I don't need to, since the average is known and available. I have
checked a few provinces and they fit. But since I'm tired of doing your
homework for you, I'll let you look it up on the web yourself. Tell me
it's not there. When you do, I'll show you were it is. No?  Then quit
being lazy.

FYI, average Canadian full time FP/GPs bill 100 to 120 K a year. But
have overheads about a third of that, so their real gross business
income (before tax) is about 75 K (75% of them are over 60 K, and 25%
under).  Just about half what US "primary care" GP/FPs, internists and
pediatricians make.

Canadian specialists make a little more than the GPs but not much. In
the US, for incomes tack on 100 K for even cardiologists and much more
for radiologists. I'm leaving surgery out, since it's not fair to
compare it to non-surgical specialties. In the US, there's about a 100
K bonus over primary care for being a any kind of surgeon, and tack on
more for the surgical subspecialties (none of which I have a problem
with--- I don't fume about surgical salaries, only radiological ones).

> Again, like your system and country, that differs for region.

Again, the differences within country aren't significant when comparing
the very large difference between countries.

> I have a rough idea what my last gp made. Based on her patient load and
> work hours, I'd say she was underpaid. Based on her method of
> practise--medical education by detailer, I'd say she owes the system
> money.

LOL. But try not to be too influenced by your n of 1, even if you saw
her income tax return (which, due to the overhead, might have shocked


From: Steve Harris <>
Subject: Re: the over-utilization of American hospitals
Date: 4 Nov 2005 19:47:34 -0800
Message-ID: <>

notritenoteri wrote:
> The undersupply of primary care providers is an engineered one. I remember
> when the OMA and the CMA told both levels of govt that here would be too
> MANY doctors in a decade.It was bullshit but the govts had faith and
> curtailed university funding to fit the medical trade's predictions.  Most
> people don't know that or coveniently forget it.  Cnada has hundreds of
> foreign trained doctors who are unable to practice because of artificial
> licensing barriers that eh medical unions are manning with great vigor.
> How much money is enough. USA's GDP figures are alot higher than Cnada's yet
> it has 50 million peole qwho have financially restricted access to primary
> care. That's about what, 1/6th of the population?
>  Which is better some getting none or everyone getting a bit?

What's better is something in between, as I've been saying.

In any case *once again* it's not true that 50 million people in the US
who have no private insurance, have no primary care. Rather, if they
can't or don't want to pay out of pocket, and don't want to go through
paperwork, they are restricted to hospital ED/ERs for primary care.

If they're willing to do paperwork, the non-elderly and non-disabled
poor who are not already covered by medicare, can get medicaid. Total
US medicaid spending in 2004 was $288 billion--- not small potatoes---
and much of which was targetted on those 50 million uninsured.  Compare
with Canada's health spending budget of around $100 billion for its
entire 30 million citizens.  Do some division and you will find US
medicaid folks aren't entirely being left in the street by their
government. Rather, the money is being spent very inefficiently, on
emergent care and nasty problems left to the last minute. And on a lot
of unnessesary paperwork and testing and scanning and whatnot.


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