You must be thinking about attorneys or businessmen. For doctors, such violates federal law, if the patient is on Medicare or Medicaid. If no federal money is involved, it is a violation of of state licensure regulations in all 50 states. For the federal aspect, there is both a monetary penalty (reimbursement and fines) and the possibility of prison time. The federal reward to anyone who reports such a doctor is a minimum of $10,000 (a whistle-blower in my town recently received over $600,000 for reporting Medicare infractions). Either way, the doctor will lose his license if kickbacks are proven.

I mentioned a similar situation about violation of patient privacy (on an earlier OB thread), and reader “Douglas Knight” said he didn’t think the penalties were ever enforced. They are. People will report their own mothers for that kind of money.

BTW, where do you think all the doctors who train at the world-class centers, and then set up private practices, are in practice? Why would you think the Maryland and Johns Hopkins grads who didn’t choose to be professors are “not as well-trained”?

I think those studies miss important aspects of clinical practice. The less experienced, less well-rounded a physician is (e.g. a PA or nurse etc.), the more likely they are to practice “defensive medicine”. I admit to not having studies to back this up — although I wouldn’t doubt if they *did* exist — but my girlfriend is a doctor and we have several friends who are doctors, so I do have some insight into the situation. Practicing “defensive medicine” means that, as soon as something outside of the very basic treatable-by-meds condition comes up, which is more prevalent among less experienced and less well-trained physicians, the first thing that a physician does is refer the patient to a specialist. So while the less experienced physician may cost less for his or her services per whatever-unit-of-work, if that same physician refers patients to specialists more often — i.e. at times when it isn’t necessary — the financial burden on patients can quickly become equal to or *worse* than seeing a more highly trained physician in the first place.

Here in Baltimore there are two world-class medical centers – Johns Hopkins and the University of Maryland Medical Center. From what I understand, in these two institutions there’s actually a joke about the “community hospitals” (i.e. non-academic centers where doctors are, more or less and on average, not as well-trained) — that anything other than a stuffy nose will get referred to a specialist. The reason is two-fold: that they simply don’t have the training and expertise to diagnose more difficult problems, so defensively they refer a patient to a specialist; and (this is cynical, but perhaps not untrue) because the specialist gives referral bonuses for patients.

So again, not a scientific study, I admit, but I still think it’s an account that’s missing in the studies you quoted, and complicates the findings. For basic everyday conditions like colds, certain easily-diagnosable infections, etc. that study is almost definitely right-on, but as soon as diagnoses get more complicated I bet the study breaks down.

- Seinberg

The real problem is that patients/clients are trying to buy results from doctors/lawyers who are selling hours. Because the results being sought and the services being sold are subjective it is extraordinarily difficult for normal pricing mechanisms to function effectively. The fact that price signaling mechanisms are muffled, thanks to a mere $5 co-pay for the person making the subjective judgment about the doctor, further exacerbates the problem. That’s why lots of doctors with poor skills but great bedside manner wind up rich while skilled doctors lacking empathy wind up merely well off.

If we could agree on what constitutes “a good result” or outcome for a given ailment/dispute we could quantify and so price the services being sold; and the market would take care of the rest. Until then nothing will change.

Most- the vast majority (sorry for not being more specific) of the people I encountered at an emergency room fit into 1 and 2 above.

The 4′s were usually pretty darn obvious (blood pouring out of somewhere, unconscious,…)
We could save billions and would make medical care much more affordable to all.

Bingo! I think it is also a big factor in the “second half of medical care” that we don’t need, or that is unhelpful. The number one reason in the US for malpractice actions is “failure to diagnose”. If you seek attention, you’ll get tests and “treatment”. No one (almost?) is told, “I don’t think it’s serious; you’ll get better on your own,” as about half should be.

What I can’t understand is why hospitals don’t contract with Minute Clinic or some service like them to reduce costs, particularly for the emergency room.