How much money do journal publishers make A lot

Many, including me, have written about who is making money in healthcare. Sure doctors do very well, but not as well as hospitals, hospital administrators, insurance companies and their corporate officers, drug companies, device manufacturers, and others.

Another lucrative area is medical journal publication, especially if you are the publisher. A researcher gets an idea, plans and carries out a study, writes a manuscript, and submits it to a journal. The research may have been funded by the government, i.e., you and me.

An associate editor or a member of the journals editorial board looks at the manuscript, and if it is deemed worthy, it is sent out to two or more people in the same field for peer review. This process may be repeated for papers that require revision.

All of the players in the above scenario—the researchers, most of the editorial board members except maybe the editor, and the peer reviewers—are paid nothing for their work. Factor in that the cost of producing a journal has plummeted in the computer era.

How much money do journal publishers make? Here are some impressive numbers from an article that appeared on a French website called "Rue89." The figures are for the year 2011 and are in euros. They include revenue from all science publishing, not just medicine.



As you can see profit margins range from 32% to nearly 42%. Elseviers profit of over €878 million converts to just over $1 billion.

To put that into perspective, the most recent figures for Apple Inc., arguably the most successful company in the world currently, show a profit margin of 20%.

The Rue89 piece was written as an exposé about the French governments having to pay Elsevier $172 million in subscription fees to access information generated by scientists who were funded by that same government.

But the French have nothing on us.

In his presidential address to the American Surgical Association, Dr. Layton F. Rikkers, editor emeritus of the Annals of Surgery said:

Nearly $10 billion is spent annually by [US] universities and governmental agencies for access to research findings that their scientists and clinicians give to publishers for free, that their faculty peer review for the alleged honor of doing so, and that are funded by taxpayer dollars and charitable trusts. It is unclear why library budgets continue to increase above the rate of inflation when nearly all the journals they now receive are delivered electronically in large packages from the few remaining consolidated publishing houses. Examples are Wolters Kluwers Ovid and Elsevier’s Science Direct each of which contain hundreds of journal titles. Some individual journals not available within these large collections, such as Brain Research, can cost libraries more than $20,000 annually.

There are more than 9000 open access journals, and 3.5 new ones per day are setting up shop. Instead of charging for subscriptions, open access journals are free to the reader, but the authors must pay "processing costs." Many of these publications have exorbitant fees with little or no true peer review.

Before submitting any paper to an open access journal, authors should be sure they understand the fee structure and check Bealls list of predatory publishers, which has recently been updated and expanded.

Dr. Rikkers feels as I do that print journals will gradually disappear. Post-publication peer review is already gaining momentum through blogs and sites such as PubMed Commons and PubPeer. Even major journals like the BMJ have established rapid response systems for immediate feedback to authors.

The heady days of 40% profit margins may soon be over, but for now big bucks are being made.

More about journals:

How are journal articles peer-reviewed?
How journal articles are peer-reviewed: Part 2
Journals, Open Access Journals and More Journals
What you need to know about some open access journals

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Medicare is changing the way it pays surgeons

Starting in 2017, Medicare will end global payments for operations. The current payment scheme combines preoperative, operative, and postoperative care into one fee. When the change occurs, each of those events will have to be billed separately—otherwise known as “unbundling.”

I missed this news when it first appeared late last year and thank one of my blog followers who calls himself Artiger for bringing it to my attention. An Advisory Board piece summarized the situation.

After analyzing a number of claims, Medicare came to the conclusion that it was paying for duplicate services. What a revelation! I could have told them that without a claims analysis.

For many years, certain surgical specialists have been delegating preoperative evaluations for “medical clearance” and postoperative management of everything but the incision to internists and hospitalists. Since the global fee was meant to include pre-and postop care, Medicare was indeed paying twice for the same service.

Representatives of the American College of Surgeons expressed concern that sicker patients would need more in-hospital postoperative visits thereby incurring more bills. [If they receive more care, maybe they should pay more.] They also worried that since postoperative care was covered under the global fee, patients might forgo office visits after surgery because of increased costs.

The unbundling of the global fee may have other unintended consequences. Since preoperative and postoperative care reimbursement will be separated from the fee for the operation itself, surgeons will be paid less for performing surgery.

Most surgeons would rather operate than make rounds and may look to perform more surgery to make up for the loss of income. This could end up costing Medicare more money.

With global payments, there is no incentive for a surgeon to keep a patient in the hospital longer than absolutely necessary. When the payment method changes, the exact opposite will exist. And surgeons who aren’t very busy might schedule more postoperative office visits to make up the difference caused by the reduction in the surgical fee.

This might all become moot anyway because Health and Human Services Secretary Sylvia Matthews Burwell has proposed that 30% of Medicare payments be converted to a non-fee-for-service model by the end of next year rising to 50% by the end of 2018.

According to a news@JAMA article, doctors may be given incentives to join Accountable Care Organizations. Quality indicators such as readmissions and infections currently applied to hospital fees might be imposed on doctors too. More bundled payments for acute care illnesses may be created. [This of course is the exact opposite of the plan to unbundle global surgery fees. Im getting confused].

One thing Im sure of is that none of this is making me regret that I retired.

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Medicare spends a lot of money unnecessarily

You may find this story hard to believe, but its true.

A 75-year-old non-smoking man with no serious medical problems and a relatively low-risk family history [father, a life-long smoker, died of a stroke at age 76] has been undergoing routine physical examinations by his primary care physician in Florida every 6 months for several years.

The visits include a full battery of laboratory studies, nearly all of which have been completely normal on every occasion.

The patient told me that he has been on a statin for about 20 years. At the time it was started, his total cholesterol level was 201 mg/dL. The genrally accepted upper limit of normal is 200 mg/dL.

After his last visit, the doctor told him to take his pill every other day because his most recent total cholesterol was 109 mg/dL.

Can hypocholesterolemia cause health problems? How low is too low? No one knows for sure, but cholesterol is a constituent of cell membranes and many hormones.

Ive blogged before about the overuse of medical care, particularly Pap smears, in Florida.

Why does Medicare pay for all these unnecessary tests and drugs? Medicare probably has no way of knowing that a statin was started and is being continued for no good reason. But what about the cost of the office visits and routine blood work every 6 months?

Its probably not much money per person, but of all the states, Florida has the greatest proportion of people who are at least 65 years old (17.3% in 2012).

The population of Florida in 2012 was 19.32 million so it has 3.28 million people over the age of 65. Theres potential for a lot of money to be wasted.

As one of its Choosing Wisely items, the Society of General Internal Medicine has recommended that routine general health exams not be done for asymptomatic adults.

A Cochrane Review of 14 studies comprising 182,880 patients came to the same conclusion and noted that important harmful outcomes of routine check-ups were often not studied or reported.

In June I wrote about the doctors who received seemingly excessive Medicare payments identified by various journalists and wondered why Medicare couldnt have discovered these obvious outliers on its own.

Routine check-ups every 6 months seem easy enough to identify and squelch. Why cant Medicare do something?

PS: For all you fans of rating doctors according to patient satisfaction scores, the patient in the above anecdote really likes his doctor and is worried that, because he is fed up with everything about the practice of medicine, he may retire.

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Appendicitis Continuing debate about treatment

The other day on Twitter, Kenny Goldberg (@kghealth), a health reporter at KPBS News in San Diego, asked me, "Why all the stories on antibiotics vs. surgery for appendicitis? Are appendectomies inherently dangerous?" My answer was "Great question. The answer is a resounding No. The complication rate is very low."

Yet the papers keep coming.

A new systematic review of all the randomized controlled studies on appendicitis found important shortcomings in all of them. Here are a few:

Bias in selecting patients was a problem in all six of the studies reviewed. Diagnostic criteria for inclusion in the studies were not standardized. Some of the studies enrolled patients with clinically diagnosed appendicitis only. Since some patients may not have had appendicitis, they would probably have improved regardless of how they were treated.

Patients were treated with a variety of antibiotics, Since most of the studies were done in Europe, open appendectomy was the more common surgical intervention. Laparoscopic appendectomy results in fewer complications and shorter lengths of stay than the traditional open procedure.

Follow-up in five of the six studies was one year with only one study following patients as long as a median of 17 months. Rates of recurrent appendicitis necessitating appendectomy ranged from 24% to 60% with an average of 35.4%. What will the recurrence rates be at 3 years? 5 years?

The authors concluded that although more evidence for treating appendicitis with antibiotics has emerged, the comparative effectiveness of that strategy is still unknown. They recommend that patients should be enrolled in clinical trials or registries to help answer this therapeutic question.

The second recent paper involves two issues I have commented about many times—research and medical reporting.

Its a study of 102 pediatric patients between the ages of 7 and 17 with uncomplicated appendicitis as judged by CT scan parameters. After informed consent was discussed, parents were permitted to choose the therapeutic arm, antibiotics or laparoscopic surgery.

Of the 629 patients who presented with acute appendicitis during the study period, only 102 (21%) met the studys inclusion criteria of whom 37 were selected for antibiotic therapy by their parents.

During the median follow-up period of 21 months, 9 (24.3%) patients initially treated with antibiotics had to undergo appendectomy.

I blogged about this studys preliminary results when they were published back in 2014. If you would like more details about its limitations, read that post.

The inadequacies of medical reporting on this paper were rather glaring. Under the headline "Not all kids with appendicitis need surgery. Antibiotics can work just fine," the Boston Globes new website Stat News said the following:

“Their parents began to question whether they needed surgery [for appendicitis], said [lead author] Dr. Peter Minneci, a pediatric surgeon at Nationwide in Columbus, Ohio. Minneci decided to answer the question with a controlled study." Sorry folks, this wasnt a controlled study.

The New York Times reported: "The surgery group had more complications and two of those who chose antibiotics had to be readmitted to the hospital for appendectomies in the first 30 days." This is misleading because although 5 of 65 patients in the surgery group had postoperative complications compared to none of the 9 who eventually had appendectomies in the antibiotic group, the difference was not statistically significant (p = 1.0, Fishers exact test).

But the most interesting thing about this paper was an entire page explaining why allowing parents to select the therapy was a better method than randomizing patients to one group or the other. Its very clever and must be read to be appreciated.

Here is an excerpt: "The patient choice design allows a therapy to be aligned with the preferences of the patient and his or her family, thereby minimizing the potential negative effects of preferences."

I dont know about you, but if I or anyone in my family had appendicitis, my preference would be for a laparoscopic appendectomy.

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The solo general surgeon is a dying breed What is next

This is a guest post by Dr. Paul A. Ruggieri, a general surgeon in Fall River, MA and author of a new book “The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry.”

A potential casualty of employment in a hospital system may be the ability to openly disagree with the organization. Will surgeons, as highly paid employees, be confident enough to speak up against hospital policies affecting patient care without worrying about corporate retaliation? Will employed surgeons be able to speak out against hospital cost-cutting measures that infringe on patient care without being labeled whistleblowers or troublemakers? Can they voice their displeasure without worrying about the security of their job? If you are branded “not a team player,” referrals may dry up. Or, you may suddenly be “asked” to take more emergency room call. You may also be asked to travel farther to see patients and generate surgical business in another town. You may be replaced. You could end up as a surgeon without a practice. If let go, you may discover that the clause in your contract prohibiting you from practicing within the area drives you out of town.

Will employed surgeons be able to openly highlight waste and fraud without fear of losing their jobs? As highly paid employees, surgeons risk much if they criticize the organization that employs them, even when the intent is improved patient care. Knowing the economic stakes of speaking against the corporate team, I suspect many may choose to be silent.

Now that more surgeons are giving up their independence and joining the ranks of the employed, will they have the ability to unionize? Historically, surgeons have been an extremely independent breed of physician, perhaps too independent for their own good. For whatever reasons—ego, stubbornness, a view of themselves as well above the average working stiff, money, competitive juices—surgeons have never been able to use their local muscle to influence hospital behavior. Instead of being able to unionize freely decades ago, surgeons may now be forced to in order to survive.

Will unionized surgeons be given collective bargaining rights when negotiating with their employers? Will surgeons be able to strike if they feel the hospital systems they work for are not negotiating salaries or working conditions in good faith? Can you see it now, a Teamster walking the picket line in solidarity with a white-coated surgeon over improving health benefits? Will there be appeal boards to contest unfair firings? As employees, will surgeons be able to negotiate for vacations, sick time, or family leave?

The writing is on the wall for all surgeons, including me. The era of the independent surgeon is drawing to a close. More and more patients will be cared for by surgeons whose economic and surgical lives are directly influenced by the corporate entities that employ them. What, if any, impact will this dramatic shift in the surgeon’s professional world have on the access and quality of surgery practiced in the future? It remains to be seen, but there is a reason the American Medical Association (AMA) specifically addressed this shift in 2012 with new guidelines for physicians selling their practices. Tellingly, the AMA stated that “patients should be told whenever a hospital provides financial incentives that encourage, discourage, or restrict referrals or treatment options.” The AMA statement continued: “Physicians should always make treatment and referral decisions based on the interests of their patients.” Isn’t this how physicians and surgeons already practice, and have for hundreds of years? Or is it?

As a patient, should you know who your surgeon works for before agreeing to an operation? If you’re interested in a dinosaur’s perspective, the answer is “Yes!”

What do you think about Dr. Ruggieris view of the future?

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Hospitals Mess Up Medications in Surgery—a Lot

Yes, that was the inflammatory headline on Bloomberg Business News last week. It is great click-bait, but factually off base because the research it refers to was done at only one hospital.

Heres what the study found. During 277 operations with 3,671 medication administrations observed at the Massachusetts General Hospital, 193 (5.3%) involved a medication error or an adverse drug event. One or more errors or adverse drug events occurred in 124 (44.8%) of the procedures.

In all, 40 (20.7%) adverse drug events were not preventable—for instance, an allergic reaction to a drug that was not known about before. Of the remainder, “32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed adverse drug event and an additional 70 (45.8%) had the potential [emphasis added] for patient harm."

Sounds bad, but the Bloomberg article goes on to say "While all the errors observed in the study had the potential to cause harm, only three were considered [potentially] life-threatening, and no patients died because of the mistakes. In some cases, the harm lay in a change in vital signs or an elevated risk of infection."

The hospitals own press release, published on the science website EurekAlert, said this: "The most frequently observed errors were mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patients vital signs, and documentation errors."

Mistakes in labeling syringes, occurring 24.2% of the time, were the most common type of error despite the presence of a bar code-assisted labeling system. This begs the question, how valuable is a bar code system that only prevents problems 75% of the time?

A website called FierceHealthcare took it up a notch saying, "While the research was conducted on procedures that took place at MGH, it indicates that similar failures happen at hospitals around the country."

It indicates no such thing. The paper actually says "our findings may not be generalizable to nonteaching hospitals." Or as is the case with most papers from a single institution, the results may not be generalizable to any other hospital.

Finally, the lead author of the study poured more gasoline on the fire with this comment, "Patients don’t need to go into surgery thinking that they’re going to have lasting permanent harm every second operation."

The study found nothing to suggest that 50% of patients suffered "lasting permanent harm." In fact, it isnt clear that any patients suffered lasting permanent harm, and most (66.7%) of the medication errors and adverse drug events were only potentially harmful.

Google “medication errors” and click on “News” for links to several more hand-wringing reports about the MGH study.

Although the paper and its accompanying media blitz may have overstated the severity of the problem, too many potentially harmful errors are occurring in the operating room and anesthesiologists need to clean up their act.

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