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By David Pittman, Washington Correspondent, MedPage Today

July 24, 2013



Physicians feel that other major players in healthcare — lawyers, insurance companies, hospitals, drug companies, and patients — bear greater responsibility for reducing healthcare costs than doctors do, a survey found.

Furthermore, doctors are hesitant to back substantial financing reforms such as eliminating fee-for-service, but they support reducing unnecessary treatments, Jon Tilburt, MD, MPH, of the Mayo Clinic in Rochester, Minn., and colleagues found.

“More aggressive — and potentially necessary — financing changes may need to be phased in with careful monitoring to ensure that they do not infringe on the integrity of individual clinical relationships,” the authors wrote in the July 23 issue of the Journal of the American Medical Association.

The researchers mailed surveys to U.S. physicians randomly selected from the American Medical Association’s Masterfile to assess physicians’ attitudes on addressing healthcare costs. A total of 2,556 of 3,897 replied.

Respondents said trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing healthcare costs. However, just 36% reported practicing physicians have the same duty.

Only employers (19%) and physician professional societies (27%) bear less responsibility than individual physicians, the survey found.

“This is a denial of responsibility,” Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, both of the University of Pennsylvania in Philadelphia, wrote in an accompanying editorial. “Of course, physicians do not want to be blamed for the country’s major problem. But can they really be both the captain of the healthcare ship and cede responsibility for cost control to almost everyone else?”

Emanuel, a noted thought leader in health reform efforts, has spoken before about and pushed for physicians taking the lead on changing healthcare in light of the nation’s financial crisis.

“Unless physicians want to be marginalized — unless they are willing to become just another deckhand — they must accept and affirm that they are responsible for controlling healthcare costs,” Emanuel and Steinmetz wrote.

However, despite their other views, 85% of respondents agreed with the statement that “trying to contain costs is the responsibility of every physician.”

Also, three-quarters reported they were “very enthusiastic” for promoting the continuity of care. A majority support expanding quality and safety data (51%), promoting head-to-head trials of competing treatments (50%), and limiting access to expensive treatments with little net benefit (51%). Nearly four out of five respondents support the discouraging of interventions that have a small advantage but cost much more.

Doctors were decidedly less supportive of efforts that impact the way they are paid. For example, 70% weren’t supportive of eliminating fee-for-service payment models, 65% opposed bundled payments, and 59% opposed penalties to providers for avoidable hospital readmissions.

“The findings of Tilburt et al. confirm this ingrained human behavior by showing that physicians are hesitant, if not unequivocally opposed, to taking bold steps to re-engineer incentives in the system — steps that may well have the most meaningful effects on controlling costs,” Emanuel and Steinmetz wrote.

Tilburt said his findings suggest policymakers may want to start with less dramatic reform efforts such as reducing fraud and abuse and promoting chronic disease care coordination before moving to more extreme physician payment reforms.

“[Physicians] are most enthusiastic about those cost-containing strategies that improve the quality of care, that bring evidence to the bedside, and that are a clear win-win for the doctor, the patient, and the health system,” Tilburt told MedPage Today in a video interview. “They get more nervous when their bottom line is at stake.”

More than three-quarters of physicians reported being aware of the costs of the tests they ordered, while 78% said they should be devoted to their patients’ best interests even if that is expensive.

Other findings included:

  • 43% reported they generally order more tests when they don’t know the patient well
  • 70% worried about malpractice liability
  • 55% agreed that following cost-conscious guidelines in practice would be the right thing to do
  • 70% said decision support tools that show costs would be helpful

Tilburt said respondents were slightly older than nonrespondents, but reported no other differences in sex, region, race, or specialty.

“Our results suggest there are subgroups within the profession with distinct identities and professional self-conceptualizations that shape their judgments about addressing healthcare costs,” the authors wrote. “In particular, physicians who share a common way of receiving payment, a common type of work context, may share a similar sense of professional obligation. Such relationships are worthy of further investigation.”


Primary source: Journal of the American Medical Association
Source reference:
Tilburt JC, et al “Views of U.S. physicians about controlling health care costs” JAMA 2013; 310(4): 380-388.

Additional source: Journal of the American Medical Association
Source reference:
Emanuel EJ, Steinmetz A “Will physicians lead on controlling health care costs?” JAMA 2013; 310(4): 374-375.


Photo: Suzanne DeChillo/The New York Times  —  MelaFind’s imaging system uses pattern-recognition algorithms to help a dermatologist decide whether to do a biopsy on a skin spot 


The New York Times


Published: July 20, 2013


TO the casual observer’s eye, the small brownish mole on Tanna Oppel’s upper left arm looks like an insignificant, ovoid blotch. But on the screen of MelaFind, a new computer vision system for imaging skin lesions, a jagged blue line shows the actual border of the mole, revealing an irregular lesion roughly the shape of Texas.



Photo: Suzanne DeChillo/The New York Times  —  A spot is checked in Dr. Doris Day’s office.



Ms. Oppel is a medical assistant in Manhattan in the office of Dr. Doris Day, one of the first dermatologists to buy the machine. Developed by Mela Sciences of Irvington, N.Y., the system uses pattern-recognition algorithms to help a dermatologist who has picked out a suspicious pigmented spot to decide whether to perform a biopsy. The device may find an audience among sun-seekers worried about developing an aggressive skin cancer: the National Cancer Institute estimates that about 9,500 Americans this year will die of melanoma of the skin.

Yet the device is polarizing the field of skin-cancer detection.

For decades, dermatologists have used their eyes, along with a magnifier called a dermatoscope, to try to distinguish abnormal but benign lesions from potential melanoma in order to avoid unneeded biopsies. Some dermatologists argue that these low-tech tools are still the most useful and worry that their colleagues are falling for expensive, cool-looking gadgets that may simply offer extraneous, and perhaps incorrect, data.

“This technology should still be considered to be in the developmental stage,” said Dr. Roberta Lucas, an instructor of clinical dermatology at the Northwestern University Feinberg School of Medicine in Chicago. “We are better off when the system supports doctors who are thorough and unhurried; who examine and listen carefully and who empower patients to practice good surveillance and sun protection.”

In fact, some members of an expert medical panel asked to review MelaFind a few years ago for the Food and Drug Administration warned that the device had the potential to give doctors and patients a false sense of security. While MelaFind can analyze small pigmented spots identified by dermatologists as having signs of melanoma, it is not designed to evaluate other problems: large melanomas, colorless melanomas or two other types of skin cancer — basal and squamous cell carcinoma.

Dr. Amy E. Newburger, a dermatologist in Scarsdale, N.Y., who was a member of that F.D.A. panel, told me that she was concerned that a doctor could inadvertently use MelaFind on a non-melanoma skin cancer, receive a score indicating that the spot was not irregular, and erroneously decide not to biopsy it. She voted against recommending the device for F.D.A. approval.

Some biostatisticians are also critical of MelaFind, saying the device can recognize a high percentage of melanomas correctly because it also falsely scores as positive so many non-melanomas — potentially prompting doctors to perform unnecessary biopsies.

To help me visualize that issue, Jason Connor, a biostatistician at Berry Consultants, a biostatistics consulting firm, compared the accuracy of MelaFind in distinguishing non-melanomas to a hypothetical pregnancy test which, used on 100 nonpregnant women, would mistakenly conclude that 90 of them were pregnant.

“My concern with MelaFind is that it just says everything is positive,” Mr. Connor said. A member of the F.D.A. panel, he abstained on a vote about whether the device’s intended uses outweighed the risks.

“I don’t think this helps an aggressive doctor,” Mr. Connor told me, “and unaggressive doctors could do just as well if they were more diligent without the device.”

To develop MelaFind’s current algorithm, researchers trained the system on digital images of more than 10,000 pigmented lesions, programming it to recognize irregularities like asymmetry, color variability and cellular disorganization characteristic of melanomas. Company executives said Mela Sciences deliberately calibrated the machine to catch as many melanomas as possible, understanding that such a high setting could lead doctors to biopsy normal tissue.

“It will err on the side of caution,” said Claudia Beqaj, director of commercialization at Mela Sciences. “We wanted to set the system to have such a high sensitivity that we didn’t miss any melanomas.”

(In a company-financed study submitted to the F.D.A., the device missed two out of 127 evaluable melanomas. One F.D.A. reviewer concluded: “There is inadequate data to determine any true value added for MelaFind for use by a dermatologist or other provider.”)

Ms. Beqaj emphasized that MelaFind was intended as a supplementary test that provided extra information about a mole, not as a substitute for a dermatologist’s own expertise.

“If they blindly followed MelaFind, they would be biopsying more,” Ms. Beqaj said. “The doctor has to make their own clinical judgment.”

Dr. Day finds the system quite informative. Last week, she gave me a demonstration in her office on the Upper East Side of Manhattan.

Dr. Day picked out what she called an “ugly duckling” mole on the left arm of Ms. Oppel, who had kindly agreed to play the role of patient. Another medical assistant removed a hand-held scanner from the MelaFind console and pressed it against the mole.

The device uses 10 different wavelengths of light to see up to 2.5 millimeters deep into the skin and capture images of its different layers. Within a minute, the machine displayed a numerical score, indicating that Ms. Oppel’s mole was irregular, but not highly likely to be a melanoma. Since the images on the screen indicated that the darkest part of the mole was concentrated around a hair follicle, an expected pigmentation pattern, Dr. Day concluded there was no immediate need for a biopsy.

“It helps me see what I cannot see with my eye,” Dr. Day said. “I have great comfort that I am not missing a melanoma.”

(Dr. Day has been a paid device investigator and speaker for Mela Sciences; she appears in promotional videos on the MelaFind Web site).

In late 2011, the F.D.A. approved MelaFind for sale in the United States. But, given the concerns that general physicians not trained as skin experts might miss a skin cancer, the agency restricted the use of the device to dermatologists — and then only after the doctors had successfully completed a MelaFind training program. So far, Ms. Beqaj says, the company had sold about 150 of the devices, which cost about $10,000, in the United States and Germany.

Since health insurance does not currently cover the service, patients are paying $25 to $175 for the first mole evaluation and around $25 for subsequent moles, doctors say.

WHETHER or not MelaFind eventually gains traction among dermatologists, the device is nevertheless significant, said Dr. Hensin Tsao, the director of the melanoma and pigmented lesion center at Massachusetts General Hospital in Boston, because it introduces the idea of artificial intelligence in dermatology.

Unlike an X-ray or mammography device that requires a medical professional to read the images and identify abnormalities, Dr. Tsao said, MelaFind both captures images and analyzes the likelihood of melanoma. That extra intelligence, its accuracy notwithstanding, is bound to change doctors’ interactions with patients.

Dr. Tsao’s clinic is participating in a post-marketing study of MelaFind, financed by Mela Sciences. And he said he and his colleagues were thinking hard about how to develop a role for such new devices in informing physicians and patients.

“Until now, you trusted the doctor to make the decision,” Dr.  Tsao said. “Now you’ve got a three-way interaction. It’s a brand new paradigm.”