One factor: what doctors believe, including false beliefs:
We find patient demand is relatively unimportant in explaining variations. Physician organizational factors (such as peer effects) matter, but the single most important factor is physician beliefs about treatment: 36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence.
Writing in Slate, Justin Matis has a novel idea: slash health care costs by letting doctors from India provide low-cost medical care on American Indian reservations. Although his article was meant as satire, Maris inadvertently hit upon a great idea. India is a low cost, high quality medical tourism destination — but it’s far away. American Indian reservations are not subject to the plethora of federal and state laws that restrict the practice of medicine to only physicians licensed by the state. So here is Matis’ proposal:
What if those Indian doctors came to us? Foreign doctors can’t operate on U.S. soil without extensive recertification, but they can work in any country that transfers their qualifications. Doctors from India already work abroad in the Middle East; they treat Qataris and Kuwaitis for a fraction of what these patients would have to pay here. What if some of those doctors set up shop in our nearest semi-autonomous states: Native American reservations, some of which already administer their own health care programs.
In a nutshell, Matis’ solution is domestic medical tourism. Of course not every American lives close enough to an Indian reservation to receive all their medical care at one, but they wouldn’t have to. If health plans began selectively contracting only with facilities that offer package prices and compete on price and quality, it would not be long before other local hospitals began competing for health plan business. The key to fostering competition involves the ability to steer patients to low-cost providers by exposing patients to: 1) better information about prices, and 2) cost-sharing incentives that cannot be ignored. We wrote about how WellPoint, working with CalPERS, used similar incentives to bring down the cost of joint replacement procedures.
This is from Aaron Carroll. Entire piece is worth reading.
It’s not that a gastroenterologist can make more than a primary care physician. It’s that a gastroenterologist himself can generate more revenue in less than two hours doing screening colonoscopies than he could providing cognitive services all day. What do you think happens? Doctors are human.
Doctor services:
For years the United States has been training too few doctors to meet its own needs, in part because of industry-set limits on the number of medical school slots available. Today about one in four physicians practicing in the United States were trained abroad, a figure that includes a substantial number of American citizens who could not get into medical school at home and studied in places like the Caribbean.
But immigrant doctors, no matter how experienced and well trained, must run a long, costly and confusing gantlet before they can actually practice here. (NYT)
The number of physicians who have stopped accepting Medicare has nearly tripled over the last three years.
Source: Wall Street Journal.
One way the [Relative Value Update Committee (the RUC, pronounced “ruck” by health wonks)] figures out how much doctors should earn is by estimating how long it takes to do a particular procedure, like the average time of a colonoscopy. Those estimates, Whoriskey and Keating’s analysis suggests, are inflated. If those numbers are right, 78 doctors in Florida must work more than 24 hours a day to perform all the medical procedures they bill. One especially impressive doctor finds time for 50 hours worth of procedures in a given day. (More from Sarah Kliff)
Unknown to most, a single committee of the AMA, the chief lobbying group for physicians, meets confidentially every year to come up with values for most of the services a doctor performs.
Those values are required under federal law to be based on the time and intensity of the procedures. The values, in turn, determine what Medicare and most private insurers pay doctors.
But the AMA’s estimates of the time involved in many procedures are exaggerated, sometimes by as much as 100 percent, according to an analysis of doctors’ time, as well as interviews and reviews of medical journals. (Washington Post)
On 13 April 1990, in an unprecedented action, the U.S. National Institutes of Health faxed a letter to every physician in the U.S. on how to correctly prescribe a breakthrough treatment for acute spinal cord injury. Many neurosurgeons were skeptical of the evidence that lay behind the new recommendation to give high dose steroids, yet when two respected organizations released a review and a guideline recommending the treatment, they felt obliged to give it. Now, over two decades later, new guidelines warn against the serious harms of high dose steroids. This case and others like it point to the ethical difficulties that doctors face when biased guidelines are promoted and raise the question: why do processes intended to prevent or reduce bias fail?
Doctors who are skeptical about the scientific basis of clinical guidelines have two choices: they can follow guidelines even though they suspect doing so will cause harm, or they can ignore them and do what they believe is right for their patients, thereby risking professional censure and possibly jeopardizing their careers. This is no mere theoretical dilemma; there is evidence that even when doctors believe a guideline is likely to be harmful and compromised by bias, a substantial number follow it.
Full article in the BMJ worth reading.
This is Aaron Carroll:
The genius of this study is that it was conducted in the VA setting. Because it’s the VA, and the docs are salaried government employees, there no profit motive involved. If they do more, they don’t get paid more. Moreover, because they work for the federal government, malpractice is handled differently. Almost all cases are handled administratively. In fact, only three judgments were recorded against the U.S. for malpractice tort cases in 2010. Therefore, there is really no impetus to practice defensive medicine. Logic would tell us, therefore, that there is no reason to order unnecessary tests.
This study chose to look at myocardial perfusion imaging, which is often used inappropriately. In a four and a half month time period, they identified 332 patients who got the study in the VA system. Only 78% were clearly appropriate. 13% were inappropriate, and 8% were uncertain.
Why are docs doing this? My guess is that it’s just incredibly hard to change physician behavior. But what’s clear is that it’s not simply greed, and it’s not simply fear. Ironically, those things are easier to fix. We’ve got our work cut out for us.
Doctors were up front about their patients’ estimated survival 37 percent of the time; refused to give any estimate 23 percent of the time; and told patients something else 40 percent of the time. Around 70 percent of the discrepant estimates were overly optimistic.
This optimism is far from harmless. It drives doctors to endorse treatments that most likely won’t save patients’ lives, but may cause them unnecessary suffering and inch their families toward medical bankruptcy.
Source: The New York Times.
