• A good idea, but refocused

    Austin has a post up this morning discussing a Victor Fuchs and Arnold Milstein NEJM Commentary from last week. As he notes, it’s a long critique, with blame for everyone, getting at why cost-effectiveness research is slow to diffuse. I think Austin is also correct that Drs. Fuchs and Milstein eventually get around to pushing the idea that physicians should be at the forefront of this endeavor, since they have the clout and trust to accomplish it.

    That may be, but it’s not going to happen.

    I don’t disagree that they could; I disagree that they will. With few exceptions, physicians are not trained to think in these terms. In my seven years of medical training, I can count on one hand the number of hours I spent learning about the costs of care, how the health care system works, or how economics comes into play at all. That’s not hyperbole. Moreover, physicians are inherently trained how to do things. And doing things costs money. We want to make people better, we want to do it fast, and we never, ever want to miss something. So all of a sudden, asking physicians who have been practicing this way for a long time, to change everything they do is not going to work.

    As I’ve noted before, it’s hard to get doctors to change their behavior even when money is not involved. Asking them to practice like this is also asking them to change their behavior in a way that will potentially cause them to make less money. Doctors are human beings, and there’s a reason that ten cent coupons work. Small monetary incentives can influence behavior, even if only subconsciously.

    I don’t think this is hopeless, though. I think that, instead, we should be focusing on insurers. If we want someone to fight for cost-effectiveness, it should be the stakeholder that has the most to gain from it.

    If I were head of AHIP, one of my top priorities would be to push for a large and powerful Institute of Cost-Effectiveness Research. Insurers absolutely, positively do not want to pay for things that don’t work or that work too poorly for what they cost. Insurance companies say, though, that they fear making coverage decisions of this nature because of the potential backlash. So let cost-effectiveness research give them the cover. Let them agree to make decisions based on how cost-effective therapy is.

    In other words, they should be pushing for this type of research so they can create value-based insurance around it.

    Even if insurance companies were jittery, why aren’t large employers who self-insure fighting for this? Create plans based on cost-effectiveness research and then offer it to employees at reduced rates.

    Insurance companies win, because they will hopefully wind up saving money. Patients win because they will hopefully get more cost-effective care. The country wins because we can hopefully bend the curve on health care expenses.

    Please note, before you scream “death panels” or “rationing”, that I haven’t included government in this post at all.


    • The more a doctor does, the more a doctor gets paid. They don’t get paid for helping people get better, they get paid for doing more. Unless we find a way around this, costs will continue to explode. It would be good if we could change doctors’ incentives.

      Limiting payment for unnecessary or not cost-effective treatments sounds like a good first step.

      What’s wrong with rationing? Absent unlimited resources, some allocation mechanism is needed.

      Two recent anecdotes that depress me:

      1) Doctor prescribes some antibiotic for my wife. It costs us about $25 (after insurance). I read the package insert and find my wife is covered by the black box warning. Doctor then prescribes some penicillin type generic. Our cost is $0.10. Doctor says it is just as good. Then why prescribe the other one?

      2) Doctor prescribes antibiotics for a friend with a cold/flu/URI and no unusual symptoms or risk factors. My understanding is that published best practice is not to prescribe on an initial visit (they’re usually useless and over-prescription helps evolve antibiotic resistant infections).

    • This is a big and complicated topic. I think you are mostly, but not entirely correct Aaron. It is difficult to advocate against your own financial interests. Most docs, while bright, have little interest or training in economics. Most just want to leave things as they are, except for some PCPs. In my own writings, I routinely advocate for freezing specialist pay while maintaining increases for PCPs, but if my group knew, they would probably kill me. I think you are also correct in that CER should be a big part of the answer and insurance companies and business should support it.

      That said, I do think that there are a number of docs who are interested in health care reform. I also think that, and this is just personal observation, most docs are very heavily motivated to provide good care, separate from financial incentives. (Why else would they go into peds, or work in low pay states?) If we can integrate the idea of health reform with the idea of docs also providing better care, I think they would buy in and be good advocates. If the research is there, I think we will support it, but we really need the research.


      • Steve,

        We have to get past this.

        I’m not disputing that there are doctors that are good people, and want to do good things. I think the vast majority of them are. I also think that most doctors are providing care, without consciously trying to provide money-making care.

        But do you dispute that money doesn’t come into play at all? If so, then doctors are a very special class of people.

        I agree that I went into pediatrics fully cognizant of the fact that I would make less than in other specialties. But I’m not a saint. I also knew that I would be gaining lifestyle benefits, as well as getting to do something I enjoy more. I wasn’t martying myself.

        I think you will find that doctors are resistant to pay cuts in the same way most people are resistant to pay cuts. Make no mistake about it. If we spend less on health care, someone is going to take a pay cut.

        • No, I am definitely not saying that physicians are not subject to financial incentives. I know quite a few who seem to hold that as their primary incentive. However, I also know an awful lot who regularly pass up the opportunity to make more money when they think the care is not justified.

          What I am saying is that I think most docs will do the right thing if we can provide them with the data. If we can show that a given treatment is more cost effective and works as well or better, they will do it. Absent such data, docs will make decisions based upon practice patterns they learned as residents, local practice and, yes, financial incentives. Also, I understand that I am probably overly optimistic in this belief, but I am influenced by what I see in my little microcosm of the world.


      • most docs are very heavily motivated to provide good care, separate from financial incentives.

        Every doctor I know says this. This does not mean that doctors don’t respond to financial incentives, even if unconsciously. I recall seeing studies to this effect, but can’t think of any examples at the moment.

        I believe many would give up a fair amount of revenue to avoid insurance company hassles (billing, etc.). Depending on the numbers, net income could be higher and quality of life improved (who wants to deal with insurance companies).

        Why else would they go into peds, or work in low pay states?

        Because these have value to some. For example, cost of living is often lower in low pay states, so standard of living can be higher even with lower pay.

        The issue is, given where they are (a ped in Idaho, for example), whether they respond to financial incentives.

        • “Every doctor I know says this. This does not mean that doctors don’t respond to financial incentives, even if unconsciously. I recall seeing studies to this effect, but can’t think of any examples at the moment.”

          There are lots. We are affected by financial incentives. However, my hope is that if we address these explicitly, that docs would respond appropriately. Most physicians do not know what their care really costs or have any idea what is truly cost effective.


    • Societal Perceptions of Physicians: Knights, Knaves, or Pawns?

      “The modern US physician is regarded as either a knave or a pawn and is seldom regarded as a knight.”

      Very brief, and oft quoted 2010 JAMA piece.

      I was reminded of it as this weeks JAMA puts the patient in the K, K or P role.

      Very relevant to above.