The pressures are real

"It's quite difficult in a medical necessity case to get to a place where all those things come together to paint a picture where (the doctor) is actually sinister."In most cases of unnecessary surgery, there is no sinister character or criminal intent. The driving factors are more complex and more subtle."I think there are a very small percent of doctors who are crooked, maybe 1 or 2 percent," silk road group tour says John Santa, a physician and former health system administrator who became director of the Consumer Reports Health Ratings Center in 2008."I think there's a higher percentage who are not well trained or not competent" to determine when surgery is necessary, Santa says. "Then you have a big group who are more businessmen than medical professionals doctors who look at those gray cases and say, 'Well, I have enough here to justify surgery, so I'm going to do it."The pressures are real. Doctors' income can hinge largely on the number of surgeries they do and the revenue those procedures generate. Those numbers also can determine whether doctors get privileges at certain hospitals or membership in top practices.There's no way to know what portion of unnecessary surgeries are related to these more subtle pressures, as opposed to poor training or fraud. Researchers simply know they're happening.Some of the most widely cited evidence comes from Dartmouth College's Institute for Health Policy and Clinical Practice, which uses data from Medicare and other sources to document large variances in the rates at which surgeries are done in different parts of the country.Data from 2008-2010, examining common surgeries that carry a risk of being done unnecessarily, show Radical Prostatectomy: Medicare patients in Lansing, Mich.,Kashgar tours were 10 times more likely to have surgical prostate removals than those 500 miles away, in York, Penn. Lansing's rate for the surgeries was the nation's highest, 2.7 times the average; York's was lowest, less than a third of the average. Gall bladder removal: Medicare patients in McAllen, Texas, were three times more likely to have a surgical gall bladder removal than those in Mason City, Iowa. McAllen's rate for the surgeries was the nation's highest, 1.6 times the average; Mason City's was lowest, closer to half the average.Knee replacement: Medicare patients in Lincoln, Neb., were nearly four times more likely to have knee replacement surgery than those in Honolulu. Lincoln's rate for the surgeries was the nation's highest, nearly 55 percent above the national average; Honolulu's was lowest, less than half the average.