• Physicians care about patients and money, ctd.

    Forthcoming in the Journal of Health Economics, Geir Godager reanalyzes data from a study by Heike Hennig-Schmidt, Reinhard Selten, and Daniel Wiesen, about which I blogged in 2011 (ungated, working paper version of Godager’s manuscript is here). To refresh your memory, here’s a bit from that 2011 post:

    In a controlled setting, the researchers asked medical students to choose the quantity of medical care to provide to hypothetical patients enrolled in either fee-for-service (FFS) or capitated insurance plans [CAP]. Under the former, physicians are paid for each additional unit of care. Under the latter, they receive a lump-sum payment independent of units of care provided. In the experiment, quantity of care is an amount indexed by the integers 0 (no services) to 10 (the most services). In advance of making the quantity selection, the physician has full information about how the quantity selected will affect payment, costs, and profit (or income) and how it will benefit the patient. […]

    A-E are the (abstract) illness types and 1-3 index how much medical care would be optimal. The solid, black dots show the optimal level of care. Patients of type 1 (1A, 1B, etc.) would do best with 5 units of care, etc. Notice that under both payment systems, actual quantity provided is correlated with what would be optimal, highest for type 3 patients, lowest for type 2. So, patient needs matter. Still, patients needs don’t tell the whole story. Provision of care under both payment types differs from optimality, most strongly for types 1 and 2 under FFS and type 3 under CAP. Finally, CAP levels of care are systematically lower than under FFS.

    After reanalysis, Godager reports,

    In this paper, we investigate physician altruism toward patients’ health benefit using behavioral data from Hennig-Schmidt et al.’s (2011) laboratory experiment conducted with medical students deciding in the role of physicians. In particular, we measure individuals’ valuations of patient health benefits when choosing quantity of medical services.

    We find that most subjects attach a positive weight to patients’ health and, further, we observe substantial heterogeneity in the degrees of physician altruism. Our results indicate that some subjects attach a higher value to their own profit than to the patient benefit (26%), while others either attach equal weights to profit and health benefit (29%) or put an even higher weight on the patient (44%).

    Translation: More than half the study subjects (medical students) value their own profit as much or more than their (hypothetical) patients’ health. I neither find this surprising nor alarming. First of all, these are students facing paper patients, not patients in the flesh. Though that’s probably relevant to the findings, I still think that practitioners facing actual patients place some value on their own profit. Some of them probably do value that profit as much or more than their patients’ health.

    Even if we don’t like to think about that (likely) fact, it behooves us to accept it. The model that the doctor always and only cares about what’s best for the patient is old fashioned and, frankly, dangerous. Even if and when it’s true, patients would be better served if they played a more active role in their own care. Don’t presume your doctor’s values and incentives are aligned with your own. Ask questions. Do research. Behave like the consumer you should be. It’s your body, health, and life. And, if your doctor isn’t responding the way you’d like, fire him.

    Full disclosure: I just fired one of mine.


    • Medicine attracts a disproportionate number of type A personalities (that’s a guess not a fact), but not all physicians have type A personalities. And it makes a big difference in the aggressiveness of treatments. For example, I work with many ophthalmologists, where the patients’ conditions are seldom acute but could be improved with surgery. Some view surgery as the first option and some view surgery as the last option. Are those who choose surgery as the first option motivated by greed? That might be the assumption if the treatment options of the different ophthalmologists were plotted on a graph. Working with them over many years I would suggest that it’s more complex than that, and the differences are attributable to many factors including personalities. Of course, the study Frakt alludes to relates to different reimbursement methods, so my comment is a little off topic. However, Frakt’s conclusion, pick a physician who responds the way you like, is highly relevant to treatment options. Here’s another related observation. Some of the physicians I work with have become patients (not mine, other physicians), and I’ve been impressed that the treatment options they pursue for themselves (and the physicians they choose to treat them) correlate to their own personalities: aggressive physicians choose aggressive physicians and treatment options.

    • I’ll add a little scientific data to support my unscientific observation: outpatient surgery centers. I know the number and types of cases for the surgeons because I see the data – who is “producing” what and how much.

    • Austin
      Your closing paragraph is obviously the money shot but it is worth repeating because it speaks to the current trend of patients using the Internet to learn about their health. And the mirror of that, the majority of physicians still uncomfortable with active, engaged, aggressive, and smart patients who question. It would be interesting to look at the above participants to determine if one, medical students today are more interested in active engaged patients and will they foster that. And second to see how it matches the groups above.

      “Don’t presume your doctor’s values and incentives are aligned with your own. Ask questions. Do research. Behave like the consumer you should be. It’s your body, health, and life. And, if your doctor isn’t responding the way you’d like, fire him.”

      What you wrote above is as important as Obamacare, new drug discoveries, bending the cost curve on healthcare, etc. It is how the buyer and the seller find the balance that benefits both.

    • First, we should acknowledge that there are physicians who prioritize money. I think everyone in the trade knows a few, I certainly do. Medicine is a good place to make some money since patients tend to trust us, and most don’t have the knowledge base to question recommendations, let alone the gumption. That said, the bigger issue is that there just arent that many bright lines when making clinical decisions. We also dont have good cost effectiveness info for what we do. So, when it comes time to make a decision, if one is uncertain or the choices are not clear, I think people will gravitate towards the intervention that pays better.

      Robert’s initial point is also important. Most kids go into medicine to help people, to do something. It is actually kind of hard to accept that sometimes the best intervention is observation, or another minimalist approach, especially if the patient or family is asking you to do “something”. (This is a bigger factor than is realized in studies.) Every study in the world shows we use too many antibiotics. Every doc in the country knows it now, yet they keep ordering them (for the most part).


    • The “subjects” in the study(ies) were not physicians, they were medical students, That means they have little experience with patients and even less making real medical decisions. It seems to me risky to extrapolate from these students’ hypothetical decisions about care to real decisions about real patients by experienced physicians. Are there similar studies of the latter in this same context?
      This also reminds me that so many studies in psychology have had students as subjects (as Daniel Kahnemann points out).

    • I have had Kaiser insurance for several years. Their physicians are paid salary (no fee for service). I have always felt that I was getting appropriate care through my internist and referred appropriately for specialty care.
      They don’t order lots of duplicate tests (the have a good EMR). They don’t refer or recommend procedures of questionable value.
      Overall, very happy with them. I no longer have to worry that my doctor is recommending something because it will make him a few more dollars.

    • This brings me to my often made point, that doctors care about their patients and even their patients’ money they also care about their own money but they DO NOT CARE about the government’s or insurance company’s money even a little bit.

      The fact that Doctors have empathy for the patents and even care about their patent’s pocketbooks and that GP’s actually do little of the expense stuff, means that the charge that sick people are in no position to shop for price is much weakener that people think. GP can and would do much of the shopping for their patients That is if the GP knows that the patent will be paying and not some insurer.

      • That would seem to imply that Doctors charge too much and lower prices should be forced upon them if they would (and could) charge uninsured people less.

        I happen to see truth in that. But I’m not sure that’s what you meant to indicate.