Tuesday, January 13, 2009

Who Is Warning Us About a Shortage of Gastroenterologists?

We have frequently discussed the worsening shortage of primary care physicians and the current crisis in primary care. Now, in the NY Times is a story of a different kind of physician shortage:

The United States will face a severe shortage of gastroenterologists as the population ages and the demand for colorectal cancer screening increases, a health care consulting firm has projected.

At current rates of cancer screening, the United States will need an additional 1,050 gastroenterologists by 2020, according to the study by The Lewin Group.

Note that this isn't the proclamation of a current shortage, but the forecast of one to come. The Times did not provide a link to the report, nor explain the rationale for its prediction. Given that gastroenterologists are remunerated much better for their time spent doing colonscopies than primary care physicians are spend for their time spent taking care of patients sans procedures (see: Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link here. ) , it is a little hard to believe that we will not be able to recruit sufficient gastroenterologists in the future, barring any radical change in how physicians are paid.

However, the NY Times article did note:

The projections were reviewed by outside experts and commissioned by Olympus Corporation of the Americas, which manufactures cameras used to screen for colorectal cancer.

Actually, Olympus manufactures not just the cameras, but the colonoscopes themselves (see their web-site, which states the company manufactures "a full line of diagnostic, therapeutic, slim and adult colonoscopes with the highest resolution available.")

Moreover the study was done by the Lewin Group, which was not further characterized in the NY Times article, but does often seem to be a source of authoritative pronouncements on health care policy. So what is the Lewin Group?

It's web-site says it is "a premier national health care and human services consulting firm." It also claims:

The Lewin Group is committed to independence and integrity in our work. We combine professional expertise with extensive knowledge and a rigorous approach to analyzing and solving problems to deliver value to each of our clients and to the larger community as well.

That's a somewhat self-contradictory assertion. It seems that delivering "value" to specific clients might be hard to do while maintaining "independence."

Who are Lewin's clients? We already know that Olympus, a company that makes more money if it sells more colonoscopes, sponsored this study of demand for colonoscopy. The Lewin Group says its clients include "hospitals, health systems and providers;" "payers / insurers;" and "pharma/bio/device." Furthermore, its explanation of its services to the latter group includes:

We provide analysis and results-focused strategies demonstrating the value of medical products to public and private sectors payers, clinicians, health care facilities, patients, and policymakers. We also provide policy insight and guidance to industry clients on evolving trends and their impacts.

"Results-focused strategies demonstrating the value of medical products" somehow seems more akin to marketing than objective policy analysis.

Finally, who owns the Lewin Group? It is not a not-for-profit, and it is not even an independent for-profit corporation. In fact, per the web-site,

The Lewin Group is an Ingenix company. Ingenix, a wholly-owned subsidiary of UnitedHealth Group, was founded in 1996 to develop, acquire and integrate the world's best-in-class health care information technology capabilities.

So, the Lewin Group is in fact part of UnitedHealth, a corporation that was until recently run by a CEO who became known for the more than a million of apparently back-dated stock options he received (see our post here).

For balance, I must note that the same web-page asserts:

The Lewin Group operates with editorial independence and provides its clients with the very best expert and impartial health care and human services policy research and consulting services.

But again, note that the focus is on making clients happy, not providing the public with unbiased knowledge.

One might further argue that it is not in the interests of UnitedHealth, as a commercial managed care organization, to pay for more and more colonoscopies. However, in the current US health care system, in which there have been more and more procedures, UnitedHealth has prospered, perhaps because it has been easy for it to simply past the costs of these procedures along.

At any rate, once again it's hard to tell who the players are in health care policy without a scorecard. As the health reform debate heats up, expect to see more authoritative proclamations coming from groups with vested interests other than simply providing unbiased expertise. Such groups, of course, have the right to make their views known. But it would be a more honest discussion if everyone were willing to put their vested interests on the table.

Thanks to one of our scouts for a tip on the ownership of the Lewin Group, and hat tip to KevinMD.


Anonymous said...


Another excellent post, and another all-too-clear case of conflict of interest.

Colonoscopies are very lucrative (given the time involved).

Evidence-based guidelines say that average-risk patients should have them only every 10 years, but too many patients have them more often. Meanwhile there are real risks associated with the procedure.

Medicare needs to take a close look at the correlation between extremely lucrative procedures and the rise in volume of those procedures. If you lowered fees, and raised co-pays, would volume continue to rise at the same rate?

In 2007, when Medicare lowered fees for in-office diagnostic imaging, volume continued to rise-but only moderately.

This indicated that lower fees did not mean that patients were being denied access to diagnostic imgaging Meanhile, lower fees meant that the total cost fell.

Anonymous said...

In this 2001 article we see:

The proposal includes a report by the Lewin Group (headed by Dr. Jack Lewin, president of the California Medical Association)

In 2006 we see this:

Jack Lewin, M.D., Named CEO of the American College of Cardiology

Posted on: Monday, 19 June 2006, 15:00 CDT

BETHESDA, Md., June 19 /PRNewswire/ -- John C. (Jack) Lewin, M.D., has been appointed as the new chief executive officer of the American College of Cardiology. Following an extensive national search, Dr. Lewin was selected from a field of outstanding candidates as the right leader at the right time for the ACC. He will assume his new duties in the fall of 2006 following the College's move to Washington, D.C., in September.

"Dr. Lewin brings a lifetime of experience in health care leadership and innovation," said Steven E. Nissen, M.D., F.A.C.C., president of the American College of Cardiology. "His vision and passion will greatly enhance our ability to fulfill our mission: to advocate for quality cardiovascular care -- through education, research promotion, development and application of standards and guidelines -- and to influence health care policy."

Dr. Lewin is a physician, an experienced association leader, and a public policy expert and veteran health care advocate.

Dr. Lewin has a wealth of experience in association management. He is currently the CEO of the 35,000-member California Medical Association (CMA), the largest state medical association in the nation. He has served as chief staff officer there for the past 11 years. During his tenure at CMA, Dr. Lewin led the organization through the purchase of Audio Digest Foundation, the world's largest provider of audio continuing medical education (CME) products. In addition, he founded and serves as Chairman for MEDePass, a digital identity and information trust company designed to provide Internet security, confidentiality and authentication for physicians and other health care professionals over the Web. His experience in professional education will be a valuable resource for the College in its ongoing commitment to offering innovative cardiovascular education.

InformaticsMD said...

Speaking of conflict, see the WSJ article today "UnitedHealth Settles Probe Over Fee Database"

JANUARY 13, 2009

In a settlement that could have far-reaching implications for consumers, UnitedHealth Group Inc. reached an agreement with New York's attorney general to pay $50 million toward a new, independent database that will determine how much insurers pay for doctors and hospitals outside of the insurers' networks.

The settlement stems from an investigation New York Attorney General Andrew Cuomo launched nearly a year ago into a common health-insurance practice. Insurers typically pay hospitals and physicians in their networks a negotiated fee for claims. But out-of-network doctors and hospitals are reimbursed "usual and customary" charges, which are determined by what insurers have calculated is the going rate in a given area. Patients are often billed the difference.

Though the attorney general subpoenaed 16 health insurers, UnitedHealth's unit, Ingenix, was at the center of the probe because it owns the database that contains and provides the price information that insurers use to set out-of-network rates.

Mr. Cuomo alleged that health insurers understated the usual and customary rates through faulty data collection, poor pooling procedures and a lack of audits. That, in turn, forced patients to pay more out of their own pockets.

The investigation found the rate of underpayment by insurers ranged from 10% to 28% for various medical services across New York state.

As an aside:

"Faulty data collection, poor pooling procedures and a lack of audits" - Why is it that anything dealing with biomedical "data collection" always seems to need remediation?

-- SS