The Healthcare Economist is going on vacation for the next week.
In the meantime, I pose to you, my reader, a bet. Do you think the ‘doc fix’ gets passed? Before you read on, make your predictions in the comments section below.
You are currently browsing articles tagged Physicians.
Tags: Doc Fix, Medicare, MEI, Physicians, SGR, Sustainable Growth Rate
On Monday I attended a talk at AcademyHealth on the impact of market consolidation on the cost of health care. Particularly interesting was Robert (Bob) Berenson’s analysis of the effect of provider consolidation on negotiating power and health care prices. Particularly, provider have been gaining market power of late, according to recent CTS site visits. There are three main reasons for this:
- A failure of employers to agree to “narrow networks” of providers and thus be able to drive down prices
- The end of the oversupply of hospital beds
- Provider clout due to name recognition (only for the “have” hospitals, not the have nots.
Further industry consolidation has taken three main forms over the last few years:
- Multi-hospital chains are buying more hospitals,
- Hospitals are employing more physicians directly, and
- Physicians are consolidating into groups.
Physician consolidation is particularly interesting. Physicians consolidate not only to gain negotiating leverage, but a larger practice allows for physicians to start performing ancillary services such as labs and imaging.
Tags: Health Plans, Hospitals, Negotiating Power, Physicians
Doctors have been giving out sick notes for teachers protesting Wisconsin’s threat to disband their union. Not only is this wrong, but Dr. Rich of Covert Rationing argues that it isn’t even a form of civil disobedience. Physicians are often put on a pedestal as the models of professional integrity. Previous studies, however, have found that doctors are not always so honest. More from Dr. Rich:
“In a survey…published in the April 12, 2000, issue of the Journal of the American Medical Association, 39% of American doctors admitted that they sometimes or very often manipulated reports to their patients’ health plans so their patients might gain coverage for needed medical care. These manipulations included exaggerating the severity of the patients’ condition, changing the billing diagnosis, or reporting symptoms the patient did not have. And 72% admitted using one of these tactics at least once in the past year. More than a quarter said that gaming the system was necessary in order to provide high quality care to their patients, and 15% asserted that it was ethical.”
“Another survey, published in the July/August, 2003, issue of Health Affairs, reported that nearly 33% of American doctors admit that they routinely withhold from their patients pertinent information about optimal medical treatments, because they suspect the patients’ health plans won’t cover those treatments.”
Tags: Ethics, Integrity, Physicians
Recently, MSNBC reported that respected cardiologist and United Airlines captain Dr. William Hamman is in fact not a doctor at all. ”The AP found he had no medical residency, fellowship, doctoral degree or the 15 years of clinical experience he claimed. He attended medical school for a few years but withdrew and didn’t graduate.” As a result, “Journals that printed articles listing Hamman with M.D. and Ph.D. degrees are being contacted in case they want to correct the work. Beaumont removed him from a U.S. Department of Defense medical simulation contract that a physician at the hospital had obtained.”
Dr. Hamman lied. He lied about his credentials and should be punished for that.
What news articles are not covering, however, is the quality of work Dr. Hamman did. If Dr. Hamman conducted heart surgery without the proper training, then that is a serious issue. According to the news report, however, “There is no indication Hamman ever treated a patient.”
Instead, Dr. Hamman’s training sessions used an operations research framework from his background as a pilot in order to help Doctor’s improve quality. His training was typically titled, “This is Your Captain Speaking: What can we learn about patient safety from the airlines?” They were so successful, that ”Even after learning of Hamman’s deception, the American Medical Association was going to let him lead a seminar that had been in the works, altering his biography and switching his title from ‘Dr.’ to ‘Captain’ on course materials. It was canceled after top officials found out.”
It is possible that the only way for Dr. Hamman to gain the respect of his peers or even gain entry into the world of medicine is with an MD. Nevertheless, this does not mean that Dr. Hamman could not have conducting high quality training seminars to maximize physician teamwork.
One of my friend’s who is a physician actually worked with Hamman. The physician said that Hamman seemed legitimate. He never talked about clinical issues, only simulation and teamwork issues.
On the personal level, this story is about a man who lied and lacked integrity. On a system level, this story may actually tell more about physicians’ efforts to prohibit non-physicians from providing any services even remotely related to medical care–such as Mr. Hamman’s teamwork training. Physician efforts to protect their turf is legendary…this may be the real story.
Tags: Licensure, Physicians
The NEJM recently reported on physician views about the public option and the possible expansion of Medicare. It turns out, most physicians favor the status quo of a mix of public and private financing.
Why would doctors support a public plan? It could be ideological. They may simply believe that more government health insurance would make society more equitable. Or they may believe that they can receive more money from government reimbursement than hard-bargaining private companies. Or it could be that dealing billing rules from multiple private insurance companies is much worse than dealing with billing issues from Medicare.
Tags: Physicians, Poll, Public Option
The New York Times reports (“Doctor and Patient, Now at Odds“) that the doctor-patient relationship is suffering. Patients no longer place absolute trust in their doctor for a variety of reasons. On the physician side, patients know that doctors are pressured by insurance companies reimbursement mechanisms to have shorter office visits. Reports from the media on medical errors and physician kickbacks from drug companies are not helping either. On the patient side, the internet has opened up a vast new store of easily accessible information on diseases and communication with other patients who have the same disease. The prescience of Dr. Rich’s foretold of “the loss of this doctor-patient relationship” in his book, Fixing American Healthcare.
Hat tip: Dr. Jay Parkinson
Tags: Physicians
Your doctor says you have six months to live. How accurate is this figure? Do you really have 4 moths to live? One year?
A paper by Alexander and Christakis (2008) analyzes physicians predictions of patient survival. The authors find that physicians systematically overestimate how long the patient will live. This bias is exacerbated when 1) the physician has a closer relationship with the patient or 2) the physician has to communicate their survival prediction directly to the patient.
In the paper, the authors collect data from a number of large hospices in Chicago. Before the patient was admitted to the hospice, the researchers asked the patient’s physician–usually the referring physician–to estimate how long the patient would survive. This was done using 3 measures:
(1) the point prediction is an answer to a question about the physicians’ best estimate of how long this patient has to live; (2) the communicated prediction is an answer to a question about what prognosis the doctor would communicate to the patient if the patient or the family insisted on receiving an estimate of survival; (3) the subjective distribution prediction is the physicians’ stated percent estimate that the patient would still be alive 7, 30, 90, 180 and 360 days after referral.
The closeness of the physicians to the patient is proxied with measures of the duration of their relationship, the frequency of their contact, and the date of their most recent contact.
Why would doctors overestimate survival? We assume predictions in the general case may be incorrect, but that estimates on average do not over- or underestimate survival probabilities. The lack of bias is due to the fact that we usually assume that individuals hope to reduce the mean-squared error of their prediction. The loss function, however, may not always be symmetric. One example of asymmetric loss functions comes from Varian’s 1974 paper, which investigates property value assessments in California. The paper showed that underestimate of property values cost the town money (in terms of the property tax received), but an overestimate could trigger the homeowner to file a lengthy and costly appeal process. Similarly, one would expect that doctors do not feel guilty giving the patient optimistic survival estimates, compared to the emotional stress which occurs when one has to communicate a pessimistic survival estimate to the patient.
The paper also finds evidence for two other types of biases: information bias and physician referential bias.
Information bias says that overestimates are more likely when the physician has less information about a disease. For this reason, we see that physicians have more accurate, less biased predictions for cancer patients. Why is this the case? Since cancer was the most likely reason why a person was admitted to a hospice, physicians have more experience caring for cancer patients. As the physician’s knowledge of a disease and frequency of dealings with patients who have a disease increase, the physician’s survival estimate becomes less biased.
Also, the physician’s physical observation (physician referential bias) will make predictions less accurate and more prone to overestimation. The authors claim that “[w]hen the patient is physically active, and able to function with little assistance on a daily basis, the physicians’ prognosis becomes more inaccurate and doctors inflate the estimates of their patients survival.”
- Varian, 1974 H.R. Varian, A Bayesian approach to real estate assessment. In: S.E. Fienberg and A. Zellner, Editors, Studies in Bayesian Econometrics and Statistics, North-Holland, Amsterdam (1974), pp. 195–208.
When you are sick and need a doctor, you need hope that you are given the best care possible. Most people assume that doctors will tailor their treatments to the individual patient needs. However, a paper by Frank and Zeckhauser (JHE 2007) explain that this may not be the case. The authors claim that there are four costs which may preclude physicians customizing treatments to individual patients.
- Communication costs: Whenever a physician prescribes a treatment outside of standard protocol, they will have to explain why they are doing this to the patient and this takes time. With patients armed with more information from direct-to-consumer advertising and the internet, communication costs have increased over time.
- Cognition costs: The authors claim that using brain power (cognition) has costs and there may be increasing marginal costs of cognition use. Thus, physicians may use heuristics to simplify the decision-making process.
- Coordination costs: As more and more physicians specialize, communication between physicians is increasingly important. Using standardized, less customized medical treatments makes communication between physicians regarding patient treatment much easier.
- Capability costs: Some doctors are trained to perform certain techniques. If a superior technique is developed, the physician may still decide to use the “old” technique since they have mastered the “old” technique and do not know how to preform the new, superior technique.
It is likely that customization of treatment varies significantly by treatment. For instance, in my “Operating on Commission” paper I find significant differences in surgery rates based on how physicians are compensated by insurance companies. Since this is a significant medical and financial decision by the doctor, one would expect there to be more customization than in other areas, since the benefits to surgery are so large relative to the costs outlined above.
The authors ennumerate how customization will vary accross patients as follows:
- little is known about a patient and their responsiveness to various treatments
- treatment is expected to be short-lived
- there is little difference in the impact of different treatments on patients
On the other hand, Grand and Zeckhauser look at whether or not there is “norm-following behavior” in the length of office visits and physician prescribing behavior. They use data from the 2004 NAMCS and the Quality Improvement in Depression study. They find that physicians do customize treatment more for chronically ill patients than for patients with acute illnesses. Physicians do tend to spend more time in office visits with new patients, but the time spent with the patients does not vary by illness type or severity. Thus, the administrative and communication costs that new patients impose and not medical necessity seem to be dictating how the length of a visit varies. These results are similar to the ones found in Glied and Zivin (2002).
Thus, the authors conclude that some customization of prescribing practices and prescribing behavior does occur, but this behavior is not based on clinical factors.
- Frank RG, Zeckhauser RJ, (2007) “Custom-made versus ready-to-wear treatments: Behavioral propensities in physicians’ choices” Journal of Health Economics, v 26(6): 1101-1127.
Tags: Cognition Costs, Customization, Physicians
An Annals of Internal Medicine survey sheds some light on physicians opinions regarding universal health care. Overall 59% of physicians support national health insurance and 32% oppose it. Support for national health insurance increased 10 percentage points since 2002 (49%). Unsurprisingly, surgical subspecialties, anesthesiologists, and radiologists, were the only specialities where more than half of respondents did not support universal health care.
Any economist would not be surprised by these findings. Primary care is not highly compensated now and universal health care would likely not alter this. Further, primary care would likely simplify the world of primary care: there would either be one insurance company (as in the case of government provided care), or it would likely be clearer which treatments would be covered. Further, since there would be no uninsured, the primary care doctors would not have to provide any uncompensated care.
For specialists, however, it is likely that national health insurance will reduce compensation for physicians. Some procedures may not be covered, or will be reimbursed at lower rates. More referral restrictions and likely rationing of care would lead to lower profits for specialists.
Even physicians are divided about whether or not national health insurance is a good idea.
GoozNews has more information on the article.
Tags: Physicians, Survey, Universal health care
Physician Influence on Federal Health Spending, 1950s
April 9, 2012 in Books, Licensure, Physician Compensation, Supply of Medical Services | No comments
The 1950s was a time of unprecedented technological advances in the science of medical care. In 1955, epidemiologists at the University of Michigan developed a polio vaccine. These advances lead the federal government to increase funding for research. Between 1955 and 1960, Congress increased the budget of the National Institutes of Health (NIH) from $81 million to $400 million. Physicians did not support increased funding for all aspects of medical care, particularly those what would increase competition.
“More money for research met no objections from the AMA. However, the story of aid to medical education was different, and it is worth recalling the contrast. In 1949 Congress was close to approving a five-year program of grants and scholarships for medical schools to increase the nation’s supply of physicians. A bill had passed the Senate and was reported out of House committee when it hit a small snag. Yet it seemed likely to pass the next year. The House of Delegates of the AMA approved the measure in December 1949. However, two months later, concerned about setting dangerous precedents, the AMA board reversed its position, and the bill died in Congress. Despite wide support from other groups, aid to medical education was blocked throughout the 1950s.”
Although physicians did not support more funds for medical education, medical schools grew tremendously during this period.
“The infusion of money into research and training programs created new opportunities in–and for–medical schools. During the 1940s, the average income of medical schools tripled form $500,000 to $1.5 million a year; by 1958-59 the average schools income was up to $3.7 million and ten year later to $15 million.” Medical schools became sprawling, complex organizations that now saw their missions as three-fold: research, education, and patient care (usually in that order).”
Tags: medical schools, Physicians