• On the honor and conscience of doctors

    Starting as early as today, CMS will publicly release comprehensive data on physician billing practices in Medicare, including information about specific, identifiable doctors. The move is controversial: the AMA, for one, is “concerned” that the data “will mislead the public into making inappropriate and potentially harmful treatment decisions and will result in unwarranted bias against physicians that can destroy careers.” And I’ll bet a few doctors in Miami, with its extraordinary rate of Medicare spending, are sweating bullets.

    CMS hopes the data will “help consumers compare the services provided and payments received by individual health care providers. Businesses and consumers alike can use these data to drive decision-making and reward quality, cost-effective care.” The word choice here—“consumers,” not “patients”—is a cue that CMS wants to enlist market forces to discipline errant physicians. Call it consumer-directed health care, Medicare-style.

    There’s reason for skepticism, though. Information disclosure is a common regulatory tool. It’s been studied a lot. And in most settings, it just doesn’t work. Omri Ben-Shahar and my colleague Carl Schneider have recently released a book, provocatively titled More Than You Wanted to Know: The Failure of Mandated Disclosure, that canvasses the demoralizing evidence. (Their earlier article on the same theme is available here.) Nor is it clear that employers and insurers will leverage the data in shaping their provider networks or honing their cost-control strategies. An extensive 2000 review of the evidence about publicly available information on provider quality concluded that “[n]either individual consumers nor group purchasers appear to search out, understand, or use the currently available information to any significant extent.”

    In any event, why should patients care about how their physicians bill the federal government? Medicare patients aren’t especially price-sensitive—even when Medicare coverage runs out, nine out of ten beneficiaries have supplemental coverage, which is typically pretty generous. And the claims data will offer only a weak signal of physician quality. Sure, the data will reveal some outlier physicians with outrageous billing habits. Patients should avoid those doctors. But what about a cardiologist who bills Medicare for stenting an unusually large number of patients? Is that a “bad” doctor with a penchant for inserting medically unnecessary stents? Or a “good” doctor with a thriving practice and a steady hand who inserts stents only where clinically indicated? How would you know?

    Fortunately, CMS has a better justification for releasing the information: that it will enable informed public debate about Medicare and the program’s future. In practice, Medicare vests doctors with considerable authority to decide when the federal government ought to pay for medical care. Although most physicians wield that authority responsibly, even the decisions of the best physicians can be distorted by the incentives of Medicare’s fee-for-service system. George Bernard Shaw recognized as much more than a century ago in his preface to The Doctor’s Dilemma:

    As to the honor and conscience of doctors, they have as much as any other class of men, no more and no less. And what other men dare pretend to be impartial where they have a strong pecuniary interest on one side? Nobody supposes that doctors are less virtuous than judges; but a judge whose salary and reputation depended on whether the verdict was for plaintiff or defendant, prosecutor or prisoner, would be as little trusted as a general in the pay of the enemy. … [I]t is simply unscientific to allege or believe that doctors do not under existing circumstances perform unnecessary operations and manufacture and prolong lucrative illnesses.

    Shaw’s age-old insight is why most expect the billing data to show that Medicare is shot through with questionable medical procedures, massive variations in billing practices, and rampant fraud. It’s also why connecting Medicare claims to particular doctors could prove so embarrassing.

    When physicians choose to participate in Medicare, however, they assume obligations to the public that finances those expenditures. The public should have a chance to ask hard and sometimes uncomfortable questions about how physicians exercise that authority. Maybe, just maybe, the billing data will help build political support for the reforms that a 21st-century Medicare program so urgently needs.

    @nicholas_bagley

     

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