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Going, going, gone . . . too far?

While online auctions are nothing new when it comes to peddling airline tickets and even college tuition, some Web sites now are letting consumers bid for cosmetic surgery and other non-emergency medical procedures.

And not surprisingly, the addition of noses and breasts to the list of goods and services offered in cyberspace has caused a cleavage of sorts in the medical community.

The sites' founders say their systems promote good value, not cheap deals, by empowering patients with a variety of information, including doctors' histories, education and credentials, as well as their costs.

"Because this is elective surgery, the question is, what's it worth to me?" says Roger Friedman, a plastic surgeon and board member of Bethesda, Md.-based CosmeticMDSelect.com, one of the bidding sites. "This is something, excuse the expression, you can shop."

And because insurance doesn't figure into the equation, price is necessarily a factor, he says. "I don't think people can deny that."

Critics contend that whenever price pushes its way into the examining room and the term "patient" morphs into "health care consumer," as well as "doctor" into "provider," something as sacred as the Hippocratic oath goes under the knife.

"The concept is just scary," says Michael McGuire, a Santa Monica plastic surgeon who is past president of the California Society of Plastic Surgeons. If someone has to go to a Web site to find a surgeon, "you have the least sophisticated patients in search of the most desperate or least qualified physicians, so it's a potential disaster waiting to happen."

The sites work in various ways. At CosmeticMDSelect, formerly CosmeticMDBid, potential patients submit a request that includes what kind of surgery they want, where and when they want it, and what they want to pay for it. Interested physicians respond with their own packages, presenting their credentials and histories, and each patient picks one.

Friedman says prices aren't meant to be negotiable, hence the company's name change. During a free consultation, doctor and patient iron out the details.

Friedman says the site educates people on the relative cost of a procedure in different geographic areas. "This is available to anybody, anywhere," he says, for people who think, "Shoot, I'll hop on the train and go down to Washington and have my surgery."

At MedicineOnline.com, based in Huntington Beach, Calif., patients don't submit prices with their profiles. Instead, after requests are made, doctors have 72 hours to review them and post their credentials and costs. Patients have seven days to choose. The auction, dubbed "dynamic" and "interactive" on the site, is ostensibly anonymous, though Medicine Online acknowledges that doctors could masquerade as patients and log on to check what their competitors are charging.

"In plastics, the norm is, if you're interested in a tummy tuck, you go in, get a sales pitch and then find out what the price is," says David Puffer, vice president for business development at Medicine Online. "That really frustrates consumers."

Changing the process

By inverting the process, Medicine Online frees users from taking a day off from work, scouring the Yellow Pages and pounding the pavement, Puffer says. "We have consumers say, 'You know how much time this saves me?' "

Dawn Buchanan was tired of people telling her she looked tired. "I'd get comments," says the medical clinic account manager from Westminster, Calif. " 'Are you sleeping well? Do you feel OK?' " She had thought about eyelid surgery, but before logging on to Medicine Online, "someone could have told me it cost $10,000. I wouldn't know."

Five surgeons bid five fees, ranging from $1,500 to $3,000. After consulting her primary care doctor, Buchanan chose a $1,650 bid.

"I look at it as a really easy way of shopping," says Buchanan, 44. "It's like window shopping, but in my house, with my monitor as the window." Buchanan says she has referred "I don't know how many ladies" to Medicine Online, as well as a few men.

James Wells, treasurer for the American Society of Plastic Surgeons and California Society of Plastic Surgeons president-elect, calls the method "a back-door way to get into surgery." Normally, "people come in, and they literally bare themselves, not only physically, but also emotionally. My concern is the Internet voids that because it's primarily concerned with the dollar," and it's hard to be rigorous about checking credentials. (Most online patients do meet their potential surgeons before making a commitment.)

The California society debated the issue at a May meeting and is drafting letters to state law enforcement agencies, including the medical board and corporations department, asking them to investigate the ethical and legal ramifications of online medical auctions. (State agencies have not decided whether to investigate.)

Getting a cut?

Specifically, the society is concerned about whether the sites promote "capping and steering," profiting from giving or receiving patient referrals or getting a cut by passing along potential customers. California has comprehensive codes prohibiting the practice, though in the unwieldy Web, McGuire says, such laws are tough to enforce.

Meanwhile, the country's largest physician-owned liability insurer, Napa, Calif.-based The Doctors' Co., has issued a bulletin warning physicians of the "impropriety" of conducting business through auction sites. By participating, doctors are putting themselves at risk not only for breach-of-contract lawsuits, but also for denial of coverage for malpractice claims arising from bungled surgeries, says TDC, which insures more than 20,000 physicians across the USA.

Puffer says his site got a clean bill of health from the state after the company had a "large medical law firm scrub our plan top to bottom." The 325 member physicians are not charged, though eventually Medicine Online consumers will pay a 2% fee per surgery. (Patients' transactions are tracked online through accounts.) Puffer says all of the site's doctors are certified with the American Board of Medical Specialties. Still, he acknowledges that "somehow" a psychiatrist posing as a plastic surgeon slipped in.

"He said he did breast augmentation, so he was easy to spot," Puffer says. "We haven't really had more than about one misrepresentation."

But some see one as one too many. "This is like that cartoon from The New Yorker: On the Internet, no one knows if you're a dog at the other end," says Mark Jewell, a Eugene, Ore.-based plastic surgeon with the American Society for Aesthetic Plastic Surgery. "It's really difficult to verify competency or quality or credentials simply by looking at a list."

In a statement released in December, the ASAPS formally flagged the possible dangers of online surgical auctions, making it the first major organization to do so.

Beginning in January, employees of companies that pay to join WebHealthy.com's RequestCare can negotiate online for "standard," non- emergency services, from a gynecological checkup to corrective eye surgery. On QuickBuy, another part of the site, the order is reversed: Providers post their flat fees for such services, and consumers hunt and pick.

WebHealthy's president, Brent Layton, a former insurance regulator, says that in time, the Marietta, Ga.-based company might "evolve to more elaborate things," like purchasing liposuction online.

But, Jewell cautions, "for every person who comes in for cosmetic surgery, there's no one standard face-lift, no one standard breast augmentation, no one standard liposuction." And "just because somebody wants liposuction doesn't mean they're a candidate for it. I mean, you can't hold your thigh up to the monitor. It requires a one- on-one consultation with a plastic surgeon. So flying halfway across the country for it (sight unseen) -- what a waste."

Fueled by demand

Still, most critics concede it was only a matter of time before plastic surgery and the virtual auction room joined scalpels with gavels. The skyrocketing demand for cosmetic surgery across the nation, coupled with a rise in the number of cosmetic specialists, has made plastic surgery a highly competitive field, experts say.

So from billboards to financing schemes to raffles to online bids, cosmetic surgeons are forced to hawk their flesh-and-blood services like, well, plastic commodities.

"We think of it like getting your nails done or going to the spa: Instead of a vacation or a new car or new clothes, we get surgery," says Los Angeles plastic surgeon Brian Kinney, American Society of Plastic Surgeons spokesman.

From 1997 to 1999, the number of breast augmentations performed across the nation jumped 89%, while the number of people having liposuction increased 62%, according to the ASAPS. "We've almost become victims of our own success," Kinney says. "We've become so good at it that we almost don't take it as seriously anymore."