From rdrugge@netaxis.comWed Jan  3 14:21:04 1996
Date: Fri, 8 Dec 1995 11:40:43 -0500 (EST)
From: "Rhett Drugge, M.D." <rdrugge@netaxis.com>
Reply to: rxderm-l@ucdavis.edu
To: rxderm-l@ucdavis.edu
Subject: Re: Managed care dangers for dermatology

Comparative analysis of the Canadian and US systems demonstrates
that the US has three times as many dermatologists per capita.  Why
should there be such a discrepancy in the supply of dermatologists?
Economies are driven by supply and demand.  Doesn't this overhang
of dermatologic expertise in the US represent a dangerous condition
in an era of decreasing demand?  Does this represent greed on the 
part of academic centers who want more low cost resident labor, 
poor foresight on the part of the American Board of Dermatology
which is constantly lobbied by dermatology training centers, the 
triumph of academic dermatologists, or an enlightened policy to meet 
a future demand for services that the aging US population will bring to 
dermatology?  Will we soon be retraining dermatologists to fit primary
care rolls?  Should we decrease the dermatology training slots in
the US?  Quo vadis?   


Rhett Drugge, M.D.



At 06:53 AM 12/8/95 -0500, you wrote:
>I agree that patients or those they designate to act on their behalf 
have a
>perfect right to refuse any treatment, and cost is certainly a good 
reason
>for refusal.
>
>I still point out [in cases where it would make a significant 
difference]
>what the "best", "second best", "third best" choices would be, so that
>patients are properly informed and can have "informed refusal".
>
>I don't want someone coming back later saying "If only you had TOLD me 
about
>the BEST treatment, OF COURSE I would have found the money."
>
>The problem I see is that some MCO's are explicitly or implicitly 
limiting
>free doctor-patient communication about therapeutic alternatives, and 
I have
>heard that some MCOs have an explicit prohibition on discussing 
non-formulary
>treatments without getting prior authorization for the DISCUSSION! Is 
this
>true? Does someone know of an example of this?
>
>I've had a few patients come [from as far away as Philadelphia and 
Cleveland]
>because they felt that their Derms in the U.S. weren't giving 
[couldn't
>give?] straight answers. [Nothing special about me, its just that I'm 
handy
>because I live on the border.] These were nice people, not "trolls", 
so I
>have the sense that a subset of people in the States do not trust 
their docs
>[and maybe they shouldn't, considering the array of conflicts of 
interest the
>docs have - eg. MCOs, dispensing from the office, ass-covering to 
avoid
>litigation and regulators, etc.].
>
>I should point out that plenty of Canadians go to the States for 
medical
>care, because they don't trust OUR system [and sometimes they are 
right not
>to trust it] so we are no paragons of virtue. Good thing Canada and 
the U.S
>have aech other as "safety valves" for the wary and the dissatisfied!
>
>Kevin C. Smith, MD, FRCPC
>
>
Rhett Drugge, M.D.
founder, Internet Dermatology Society
50 Glenbrook Road
Stamford, Connecticut 06902 USA
voice 203-324-5719
fax   203-323-7485
email rdrugge@netaxis.com
http://www.telemedicine.org