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“The country’s dismal rates of vaginal birth after Caesarean”

March 9, 2010 in Nonphysician Clinicians, Physician Compensation | No comments

From the N.Y. Times:

The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.

In fact, the rate of vaginal birth after Caesarean (VBAC) is now below 10%.  Some doctors claim that VBACs risk tearing the mother’s scar tissue on her uterus, but others–including the profiled women on a Navajo reservation–successfully undergo multiple VBACs.  Why are the rates VBAC rates so low?

  • Fears of malpractice
  • Physicians make more money Caesarean rather than a vaginal birth
  • Caesarean’s use fewer physician hours than vaginal births
  • Fewer expected number of pregnancies
  • Patient demand

Why are Caesarean rates so much lower on the Navajo reservation?  On the reservation, physicians are federally insured against malpractice, are paid a salary, and the use of midwives is much more common.  Additionally, Navajo “couples often want more than two children, but repeated Caesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery.”

To see further evidence of how different physician compensation methods can alter surgery rates, see my own study in Health Economics.

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Average Salary of Recent Economics PhDs: 2009

January 15, 2010 in Economics - General | No comments

In the past, this blog has reported the average salaries of recent economics PhD graduates.  For Econ PhD graduates in 2009, we can update these figures as follows using more recent data.  For instance, below are the average (median) starting salaries of recent economics grads by the type of institution by which they were hired.

  • University: $92,600 ($89,500)
  • College: $77,100 ($70,000)
  • Policy/Applied Research: $85,800 ($90,000)
  • Central bank: $105,700 ($110,000)
  • Private Firm: $115,500 ($120,000)

Of the people in the survey, the percentage of individuals who accepted jobs at the following types of institutions were:

  • University: 63.6%
  • College: 8.6%
  • Policy/Applied Research: 10.2%
  • Central bank: 6.2%
  • Private Firm: 11.4%

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How to pay doctors: As a Merchant or a Guardian?

June 18, 2009 in Supply of Medical Services | No comments

The book Systems of Survival (review) describes two moral structures: commerce and guardianship.  Jane Jacobs describes the ethics of Commerce as a moral syndrome equal, antagonistic, and complementary to the ethics of politics, or Guardianship. 

  • Commerce provides the economic engine and the ethical framework for trade, technological advance, and individual rights that combine to make governments worth living under.
  • Guardianship:  Government protects commerce, provides stability, administers justice, and enforces uniform standards.

The two moral systems reflect societies dilemma of how to  pay doctors.   Republicans generally think of doctors as fitting into the Commerce ethic.  They are type-A personalities whose drive leads to medical advances and an increased standard of living.  Doctors are scientific and believe in objectivity.  

Democrats believe physicians should fit more into the Guardianship role.   One could think of doctors as “professionals” who distribute advice similar to a government official.  The doctor’s role is to provide medical care to those who need it, not maximize revenue or only treat those who can pay.

The Commerce doctor should receive FFS payment; the Guardian doctor should work on a salary.  The “guardian” doctor is best for standard day-to-day care, but the “commerce” doctor is needed to advance medical knowledge and technology.  Resolving this conflict between the doctor as a commercial agent and a guardian may hold the key to improve physician payment structures.

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Cochrane Review: The effect of capitation, fee-for-service (FFS) and mixed payment systems on primary care physician behavior

July 21, 2008 in Academic Articles, Physician Compensation | Permalink

Primary care physicians can be compensated in a number of ways. The most popular are capitation, fee-for-service, salary, or some mixture of the three. But how does the physician compensation method affect care levels? This is the question Gosden et al. (2000) try to answer in their Cochrane review. The authors search the literature for randomized trials or controlled before and after studies in order to see how changing physician compensation affects the quantity and quality of care.

A summary of the 4 papers which met Gosden et al.’s criteria is below.

Category Davidson 1992 Hickson 1987 Krasnik 1990 Hutchinson 1996
Country US US Denmark Canada
Type Randomized Trial Randomized Trial Before-and-After Before-and-After
Payment i) age-adjusted capitation; ii) Medicaid FFS; iii) more lucrative FFS i) FFS; ii) Salary Control: Cap/FFS mix; Intervention: Capitation only, changes to Cap/FFS mix Before: FFS; After: mixed capitation, ambulatory care incentive
Physicians Primary Care Providers (PCPs) Residents General Practitioners (GPs) GPs/Family Physicians
Results Comparing FFS and capitation, there was no difference in the number of PCP visits. There was no difference in the number of patients attended The number of face-to-face and phone visits was higher in the control group than the intervention group. Hospital days decrease in all groups, but the change is similar across all payment types.

Controlling for covariates, there were 0.5-0.6 more visits for the capitation group compared to the Medicaid FFS. There were more ER visits for the salaried group compare to the FFS group. After the FFS was implemented in the intervention group, visits increased and converged to that of the control group.

The new, more lucrative FFS increase PCP visits by .8-.9 per patient compared to the Medicaid FFS. Salaried doctors have fewer well-child visits per enrollee After the FFS implementation [intervention group], the number of diagnostic and curative services order increased.

PCPs paid via capitation used fewer specialist and hospital resources After the FFS implementation [intervention group], the number referrals to specialists fell

Patients were less likely to reach recommended visit levels in capitation compared to FFS

The original four articles:

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