• I seem to have touched a nerve

    It seems that whenever I question the way physicians practice, I make some new enemies. I should know better by now. My father, a retired surgeon, and I have had some of our most passionate arguments on this issue. He’s absolutely positive that he never, ever let financial considerations come into play with respect to patients.

    Let’s be frank here. I’m a physician. Many of my best friends are physicians. I have family members who are physicians. The vast majority of doctors I know are passionate, dedicated, and want to do good.

    That still doesn’t mean that money doesn’t influence them on some level.

    There’s a reason that ten cent coupons work. Financial pressures, even tiny ones ones, work. This isn’t me being “emotional”. There’s a large body of evidence at work here. Here’s a study which shows physicians care about patients and money when making treatment decisions. Here’s another that shows that compensation schedules do influence physician practice patterns.

    This doesn’t mean that physicians are bad people, or even weak. They’re human. And our whole system of economics is driven by the concept that humans are influenced by the idea of making money.

    What we need to do is recognize this, accept it, and work to minimize its influence. What we don’t need to do is deny it and pretend that we are superior beings who are immune.

    When relatively few physicians think they can be influenced by drug companies, but that most other physicians can, that’s delusional. And when only 3% of physicians think money drives their practice, but that most other physicians would be influenced by money, that’s delusional too.

    • My father is likewise an old-school physician, and I am likewise an economically-minded physician. We have also had our most heated discussions on health care policy on the topic of practice patterns; in his mind, hospitals, drug companies, device manufacturers, insurers, etc., are all driven solely by profit motive, yet it is inconceivable that doctors do the same. That we MDs might be incentivized by reimbersements is heresy.

      Bias is universal, and doctors are no exception.

      • @Aaron Mitchell
        yes, all professions have their blind spots. Young professors at lunch together comment on “dead wood’ among tenured full professors, but quickly add the caveat “I would never do that but we really need post tenure review because everyone else might”.

    • I bet a lot of the physicians claiming they aren’t influenced by money are the same ones who refuse to accept Medicaid….

    • Obviously physicians respond to issues of reimbursement. It comes up with every conversation involving possible provider cuts in Medicare and Medicaid.

    • In the survey it was the physicians themselves who felt that other physicians were motivated to do more by income considerations.

    • But didn’t the data posted here about what costs what in medicine, from before showed that doctors (non-specialists) are over-paid only by about 8%?

    • I don’t think anyone thinks physicians are not affected by money and this is an obvious straw man. Conversations about reimbursement rates, pay, etc. are as common in medicine as in any other profession.

      In addition, I think incentives will matter even more strongly in the future given the high fixed costs of operating practices (e.g., staff and administrative overhead, equipment, insurance, etc.) and the dire prognosis for reimbursement.

      The issues I see with Aaron’s (and many other health policy wonks’) line of thinking is that:

      1. Focusing on physician incentives as a sort of magical elixir of cost reduction ignores the existing framework of medical practice

      The existing Stark laws are rarely mentioned nor the fact that most of the big spending specialties (in terms of test ordering) are already employed (e.g., ER doctors) and so few incentives (other than litigation risk) exist for over-treatment.

      Citing studies showing physicians’ respond to incentives (true to the point of obviousness) doesn’t really answer the question of whether these incentives exist to a significant degree (does any ED physician really care if the hospital administrator gets a better bonus next year?) and whether they have a material impact on health care costs.

    • This leads into my other point:

      2. The minimal intellectual rigor behind statements like ‘doctors make more money if they treat aggressively’ is severely lacking.

      Physicians are not a monolithic group and so this statement is disingenuous and misleading. Few primary care physicians understand health care economics (nor should they be expected to), so sentiments like other physicians are getting rich off aggressive treatment are to some degree understandable. When health care policy experts however make statements that ignore nuances like who gets paid for a CT scan (the professional fee goes to a radiologist who does not order the scan, the technical fee to a facility that owns the scanner and not to the ordering physician usually), then that comes off as emotional and to a degree, intentionally ignorant.

      On that note, mentioning free pens given out by drug reps also doesn’t rise to any sort of meaningful countervailing proof and is much more the sort of rhetoric a politician would use. Studies that show not only direct increases in cost from differential reimbursement (e.g., Lucentis’ sales in ophtho; urologists who are allowed to scan in rural areas) but also that these isolated examples are a significant system-wide problem are needed.

      Given the fragmented nature of the system now and that the main overtreatment offenders don’t seem to fit the profile (i.e., don’t have the incentives), this hypothesis seems intellectually weak…

    • @V,

      It isn’t a straw man if 97% of physicians believe it. Did you read the post this refers to, or the study?

      As for your point about the ED, it is a true straw man to propose that the only kind of influence on the ER docs and nurses worth mentioning is the bonuses of high level administrators.

      Its also not true that most specialists that order a lot of tests are salaried.

    • @V. Supply side moral hazard needs to be covered. While changes in physician reimbursement have changed over time so that they are (in some cases) assuming more financial risk and in others being salaried or otherwise distance from financial rewards, there still are perverse incentives for the amount of treatment given. And your example of ED docs might be a bit off base as emergency care accounts for ~2% of healthcare spending.

      But I do agree that physician compensation is given more attention than it’s worth, especially when one considers that almost a third of every dollar spent on healthcare goes to administrative costs.

    • This is funny really. Yeah, I’m a physician. I’m not a young one either. Still the idea that we’re not influenced by money …

      Jeez. Not just a river in Egypt.

      Politicians are just as bad. We think they’re just lying when they say they’re not influenced by special interest donations, but, really, they’re mostly telling the truth. They’re simply in denial.

      Sadly, most physicians are not very good at understanding data.

    • I stumbled across a debate between Ewe Reinhardt and Arnold Relman (NEJM editor and nephrologist) a few months back in which Relman argued for the exceptionalism of medical practice if not physicians that makes them unique and threatened by economic forces in the marketplace, whereas Reinhardt took the view that physicians are really no less influenced by marketplace incentives than businessmen. I showed this to my wife remarking about its current relevance, only to be chastised that the conversation took place over 20 years ago.
      A few days ago Austin Frakt posted about the overuse of screening colonoscopy recorded in a recent paper, a practice that is apparently not controlled by medicare, and for which the incentives are obvious. The interesting aspect of that paper was that there were reported regional differences in adherence to standard screening colonoscopy guidelines. Until somebody is able to drill down and understand why gastroenterologists in Texas overprescribe this test, with an adherence to guidelines rate of less than 50%, and gastroenterologists in other locations hit guidelines 95% of the time, I don’t think we’ll understand these issues. As far as I know, there are no regional variations in incentives so what gives?
      Incidentally, incentives are highly likely to be variable from one subspecialty to another. The behaviors of ER docs and family practice physicians are motivated to a different extent by risk aversion in all likelihood.

    • “When health care policy experts however make statements that ignore nuances like who gets paid for a CT scan (the professional fee goes to a radiologist who does not order the scan, the technical fee to a facility that owns the scanner and not to the ordering physician usually), then that comes off as emotional and to a degree, intentionally ignorant.” OK, agree to some extent, especially that the health care cost driver is typically the primary doc who orders consults and tests, not the radiologist, but let’s not also be naive and assume that the same guy who reads the film doesn’t own a share of the facility. Anyone who has had experience in this realm knows that it is extremely easy for the radiologist to self refer for more testing in this setting, as in: “subcentimeter hepatic lesion recommend repeat scan in 3 months” when the item could easily be identified as a benign cyst or the simple task of comparing prior imaging is not taken.

    • @Jonathan H:

      I read the post and study. I suggest you reread my post where I explicitly agree about financial rewards being important. My point is that this is an unjustified logical leap to assume that this is a significant driver of healthcare costs when the correlation between incentives and spending is so weak. Talking about physicians being greedy is emotionally satisfying but intellectually vapid…

      As to your specific points, 97% of docs believing it doesn’t make it less of a straw man argument as my point is this is irrelevant. Specialists are not the source of most testing so their lack of salaried status is also not that important in the scheme of things. Finally, I mentioned the hospital administrator bonus argument to illustrate just how weak this line of thinking is. Apparently, that wasn’t clear …

      • The word “greed” appears in none of my posts. I explicitly state that I don’t believe this is malicious, but human. I also do not state that this is the main driver of costs. In fact, I have done a 10-part series on why I think costs are too high, and “greed” isn’t a factor in that, either. I’ve also posted previously on how physician salaries comprise a relatively small part of health care spending. Feel free to look before you assume.

        I note only the delusion that doctors do not believe that money impacts their own behavior at all (3% do) while believing that most other physicians are impacted by money.

        Finally, this is at least the third time you have managed to insult my intelligence in a comment. I have no problem with you disagreeing with me, but the personal attacks will stop, or your comments will not be approved any longer.

    • @Max: That is a good point about the ED spend. They were only used as an illustrative example but still very interesting to learn.

      I am a skeptic of supply-side hazard being important on a systemic level. That isn’t to say it shouldnt be highly discouraged anyway though…

      @Jeff Hoffman: Very interesting point about screening colonoscopy and I think that feeds into my sense that this discussion too often ignores complexity.

      As to your point about the CT scan, I would say the main driver for the “subcm hepatic lesion” CYA-like CT reads is liability. I would doubt there is a systematic connection between cautiousness in a radiologist and his financial incentives but am open to being persuaded on this…Ultimately, they are not the ordering physician anyway so theoretically this sort of behavior could and should be ignored.