Do salaried physicians make more rational clinical decisions...

[Ivor the Engineer]

...than physicians who get paid mainly on the amount of treatment they provide?

[Ivor the Engineer]

http://www.cmaj.ca/cgi/reprint/160/7/1013.pdf

Quote:

Background: Rates of antibiotic prescription in Canada far exceed generally accepted rates of bacterial infection, which led the authors to postulate that rates of antibiotic prescription depend to some extent on factors unrelated to medical indication. The associations between antibiotic prescription rates and physician characteristics, in particular, method of remuneration and patient volume, were explored.

Methods: The authors evaluated all 153 047 antibiotic prescriptions generated by 476 Newfoundland general practitioners and paid for by the Newfoundland Drug Plan over the 1-year period ending Aug. 31, 1996, and calculated rates of antibiotic prescription. Linear and logistic regression models controlling for several physician characteristics, specifically age, place of education (Canada or elsewhere), location of practice (urban or rural) and proportion of elderly patients seen, were used to analyse rates of antibiotic prescription.

Results: Fee-for-service payment (rather than salary) and greater volume of patients were strongly associated with higher antibiotic prescription rates. Fee-for-service physicians were much more likely than their salaried counterparts to prescribe at rates above the median value of 1.51 antibiotic prescriptions per unique patient per year. The association between rate of antibiotic prescription and patient volume (as measured by number of unique patients prescribed to) was evident for all physicians. However, the association was much stronger for fee-for-service physicians. Physicians with higher patient volumes prescribed antibiotics at higher rates.

Interpretation: In this study factors other than medical indication, in particular method of physician remuneration and patient volume, played a major role in determining antibiotic prescribing practices.

[Dr. Imago]

Huh?

The assumption being that a "salaried" physician can't independently bill for procedures, and thus will do less procedures? This is the probably the most important area that a salaried physician will potentially make a different treatment decision - potentially - over a non-salaried "pay for performance" physician. And, that is a very double-edged sword. If there is no incentive (financial) to do a procedure, and the physician gets paid the same no matter what, then why recommend a procedure? Furthermore, any salaried positions in medicine - it has been my personal experience - leads to laziness and clock-watching. People don't care if the work gets done or not. They show-up at 7:00 AM, they go home at 3:00 PM. If they take care of 10 patients, or 3 patients, in that timeframe, it doesn't matter. They get the same amount of money. This is the nursing "shift" paradigm, and it is incredibly bad for medicine.

I think the study you post is another example of association without causation. However, there probably is more incentive to "please the patient" and get them to come back, whereas a "salaried" physician does not depend on "customer satisfaction" to keep a base.

However, maybe those salaried physicians didn't write necessary antibiotics for a variety of other reasons not addressed or elucidated in this factoid study. Perhaps they are told by their employer not to write such prescriptions. Perhaps they don't care to write such prescriptions, for the reasons I mention above. Maybe the physicians in the study who didn't write the antibiotic prescriptions provided substandard care? The study just doesn't (and can't) answer that.

Again, that's why I hate these kinds of studies. They provide raw information without any elucidation. And, are thus essentially useless.

I can tell you, from firsthand experience, "salaried" positions in medicine hurt patients more than they help them. For example, if we actually had a system that paid nurses for the amount and quality of care they gave, instead of just showing up for their shift, I believe we could substantially impact patient outcome. Nurses are pivotal in effective patient care and getting out of the hospital with minimal morbidity. Right now, the system only rewards them for simply showing up. And, the quality of care given runs the gamut. If we actually had a system that paid them for their performance, I believe patients would have better outcomes.

So, Ed forbid that we employ this flawed "salary" paradigm to remunerate physicians across the board. What a disaster that would be.

~Dr. Imago

[Ivor the Engineer]

Originally Posted by Dr. Imago

<snip>

If there is no incentive (financial) to do a procedure, and the physician gets paid the same no matter what, then why recommend a procedure?

<snip>

Because the patient actually needs it?

If there is a financial incentive to do a procedure, and the patient does not know enough to argue, then why not recommend a procedure?

BTW, thanks for implying I and millions of other salaried workers (such as physicians who work in the NHS) are "clock-watchers" doing a sub-standard job.

[Dr. Imago]

Originally Posted by Ivor the Engineer

Because the patient actually needs it?

You implied, by the title of your thread, that salaried physicians make more "rational" decisions, whatever the term rational actually means.

I'm suggesting to you that there is a mountainous grey area in many medical decisions, and fully dependent on who you ask.

John Q. Public likes to believe that the treatment would and should be the same whether they seek care in Pocatello, ID or New York, NY. While Medicine is universal, treatment decisions are not and not based on always uniform standards. Likewise, some clinicians are clearly more gifted than others in both manual skill as well as diagnostic acumen.

IOW, you can't simply boil this down to "salaried physicians make more rational decisions", which is not what this study indicated but seems to be your interpretation. Check me if I'm wrong.

Originally Posted by Ivor the Engineer

If there is a financial incentive to do a procedure, and the patient does not know enough to argue, then why not recommend a procedure?

I don't follow your logic here. Please explain what you mean.

Originally Posted by Ivor the Engineer

BTW, thanks for implying I and millions of other salaried workers (such as physicians who work in the NHS) are "clock-watchers" doing a sub-standard job.

I don't have the time right now to go into the problems with the NHS. But, I'm sure you know them far better than I.

~Dr. Imago

[Ivor the Engineer]

Originally Posted by Dr. Imago

You implied, by the title of your thread, that salaried physicians make more "rational" decisions, whatever the term rational actually means.

I didn't think the title implied that, but I suppose my posting the study showing fee-for-service physicians prescribe more antibiotics could.

Quote:

I'm suggesting to you that there is a mountainous grey area in many medical decisions, and fully dependent on who you ask.

John Q. Public likes to believe that the treatment would and should be the same whether they seek care in Pocatello, ID or New York, NY. While Medicine is universal, treatment decisions are not and not based on always uniform standards. Likewise, some clinicians are clearly more gifted than others in both manual skill as well as diagnostic acumen.

IOW, you can't simply boil this down to "salaried physicians make more rational decisions", which is not what this study indicated but seems to be your interpretation. Check me if I'm wrong.

I agree the study did not show that, but it is consistent with the hypothesis that financial incentives distort clinical judgement (to the possible detriment of patients).

Quote:

I don't follow your logic here. Please explain what you mean.

The knowledge and power balance in the physician-patient relationship is often heavily biased toward the physician. What is different about physicians as a group which makes them more honest than the rest of us? How can they work as a salesmen and an advocate for the patient at the same time?

Quote:

I don't have the time right now to go into the problems with the NHS. But, I'm sure you know them far better than I.

~Dr. Imago

That's a whole different thread (in a different section of the forum too), but I'm pretty sure the hours NHS physicians work or how they are paid are not at the top of the list.

[rocketdodger]

Originally Posted by Dr. Imago

Again, that's why I hate these kinds of studies. They provide raw information without any elucidation. And, are thus essentially useless.

I don't know anything about you, Dr. Imago, but my analysis of your reaction here leads me to strongly believe that you yourself have ulterior motives.

Categorizing any study, which does provide raw information, as "essentially useless" seems to be a fundamentally political rather than scientific viewpoint.

If nothing else, such a study should catalyze further studies looking into the very questions you brought up in your initial response.

[technoextreme]

Originally Posted by Ivor the Engineer

BTW, thanks for implying I and millions of other salaried workers (such as physicians who work in the NHS) are "clock-watchers" doing a sub-standard job.

But you have an even better incentive to not screw up. Jail time and bankruptcy. Unless you are performing a bit of fraud by calling yourself an engineer when you legally have no right to.

[John Bentley]

This subject is an eternal debate for those of us who employee medical professionals (and I would imagine there is little difference in any other profession). My wife and I run three veterinary clinics and have hired numerous veterinarians over the years. We started out hiring veterinarians on a straight salary because other clinics in the area hired on the "percentage of what you make" rule and we had seen outrageous abuses. We would get clients from the other clinics with bills that showed B12 injections for dogs hit by cars, or radiographs on dogs with skin disease, or dental cleanings for dogs with diarrhea. All of the vets we hired started out with zeal, determined to stamp out disease wherever they went. However, as time went by and the drudgery of day to day medical practice set in, we had to fire some people for doing the barest minimum to get by, and this included making no effort to be nice to clients when they were difficult. We even had mistakes in the other direction, such as not doing the very best medicine because they thought the client couldn't afford it. Got sued by a client over one of those instances.

During the years, my wife and I have come to the conclusion that it doesn't matter how the professionals are paid, it matters what kind of person they are. If you pay them on percentage, most vets will take the opportunity to gouge the client. If you pay them on a salary, most vets will take the opportunity to be slackers. We have had 3 veterinarians that were simply outstanding. One was paid on salary alone - she left because her husband couldn't find work and they wanted to start a family. One was paid on salary, benefits, and bonuses based on performance. She earned lots of bonuses, the clients loved her, and I never found a single instance where she performed unnecessary medicine to lift her fees - she left because her husband got transferred to another state. The last one was paid on salary, benefits, and free housing. She always did the best medicine she knew, despite not getting paid a dime more for it. The clients loved her. She left because she got pregnant by a married man, and ran off to his part of the state, content to be the other woman.

The "salary or incentive" question doesn't cover just professionals, either. I have hired almost 150 support staff over the years, all on salary. I have 3 that were hired at the beginning of the business and have kept their jobs during all that time because they come in and do their best every single day, and they are outstanding in every way.

Bottom line: Ivor - if you think that doctor's are immune to the "80/20" rule (80% of people in any work force are parasites who are perfectly happy to let the other 20% carry the workload), then you are dreaming. IMO, place all doctors on salaries, and medical practices will degenerate to doing the very least necessary to get by, except for a minority who will do their best despite getting no more reward and a lot more work than the slackers. (and yes, millions of salaried workers, regardless of their profession, are clock watchers doing substandard work. It's simply human nature).

Dr. Imago - if you think doctors are immune to greed and never perform unnecessary medical procedures to up their bottom line, then you are dreaming, also. That's the danger of private practice doctors selling their skills.

[paximperium]

Originally Posted by Ivor the Engineer

I didn't think the title implied that, but I suppose my posting the study showing fee-for-service physicians prescribe more antibiotics could.

In which Dr. Imago has stated that your study is essentially useless. Perhaps they do less for the wrong reasons?

Quote:

I agree the study did not show that, but it is consistent with the hypothesis that financial incentives distort clinical judgement (to the possible detriment of patients).

Sure it can but the reverse is also true. Being salaried, you have a tendency to toe the party line. Why rock the boat? Ask a Kaiser-Permanente physician.

Quote:

The knowledge and power balance in the physician-patient relationship is often heavily biased toward the physician. What is different about physicians as a group which makes them more honest than the rest of us? How can they work as a salesmen and an advocate for the patient at the same time?

Sure it can. Medical fraud happens. Are you implying that salaried physicians are somehow less corrupt or less likely to be?

Quote:

That's a whole different thread (in a different section of the forum too), but I'm pretty sure the hours NHS physicians work or how they are paid are not at the top of the list.

I'll go ask my brother who hates the system. But like you mention, its a different discussion.

[paximperium]

Originally Posted by John Bentley

This subject is an eternal debate for those of us who employee medical professionals (and I would imagine there is little difference in any other profession). My wife and I run three veterinary clinics and have hired numerous veterinarians over the years. We started out hiring veterinarians on a straight salary because other clinics in the area hired on the "percentage of what you make" rule and we had seen outrageous abuses. We would get clients from the other clinics with bills that showed B12 injections for dogs hit by cars, or radiographs on dogs with skin disease, or dental cleanings for dogs with diarrhea. All of the vets we hired started out with zeal, determined to stamp out disease wherever they went. However, as time went by and the drudgery of day to day medical practice set in, we had to fire some people for doing the barest minimum to get by, and this included making no effort to be nice to clients when they were difficult. We even had mistakes in the other direction, such as not doing the very best medicine because they thought the client couldn't afford it. Got sued by a client over one of those instances.

During the years, my wife and I have come to the conclusion that it doesn't matter how the professionals are paid, it matters what kind of person they are. If you pay them on percentage, most vets will take the opportunity to gouge the client. If you pay them on a salary, most vets will take the opportunity to be slackers. We have had 3 veterinarians that were simply outstanding. One was paid on salary alone - she left because her husband couldn't find work and they wanted to start a family. One was paid on salary, benefits, and bonuses based on performance. She earned lots of bonuses, the clients loved her, and I never found a single instance where she performed unnecessary medicine to lift her fees - she left because her husband got transferred to another state. The last one was paid on salary, benefits, and free housing. She always did the best medicine she knew, despite not getting paid a dime more for it. The clients loved her. She left because she got pregnant by a married man, and ran off to his part of the state, content to be the other woman.

The "salary or incentive" question doesn't cover just professionals, either. I have hired almost 150 support staff over the years, all on salary. I have 3 that were hired at the beginning of the business and have kept their jobs during all that time because they come in and do their best every single day, and they are outstanding in every way.

Bottom line: Ivor - if you think that doctor's are immune to the "80/20" rule (80% of people in any work force are parasites who are perfectly happy to let the other 20% carry the workload), then you are dreaming. IMO, place all doctors on salaries, and medical practices will degenerate to doing the very least necessary to get by, except for a minority who will do their best despite getting no more reward and a lot more work than the slackers. (and yes, millions of salaried workers, regardless of their profession, are clock watchers doing substandard work. It's simply human nature).

Dr. Imago - if you think doctors are immune to greed and never perform unnecessary medical procedures to up their bottom line, then you are dreaming, also. That's the danger of private practice doctors selling their skills.

Thanks for a great summary. I agree with you on this issue.
Salaried Vs. private have their pros and cons.
In the US, we have many more private docs compared to salaried and we see a very different work ethic.

Anecdotally, I see surgeons at my hospital performing semi-emergent surgery in the middle of the night at times if they realize that the morning OR workload would overwhelm the morning crew, while I have friends in Germany where they would never consider doing such a thing.

Its never a simple black and white answer.

Be like me, a private contracted salaried ER physician that gets a piece of the group's pie depending on how myself and the entire group performs. If I work more than the other group members, I get a larger pie.

[John Bentley]

Originally Posted by paximperium

Thanks for a great summary. I agree with you on this issue.
Salaried Vs. private have their pros and cons.
In the US, we have many more private docs compared to salaried and we see a very different work ethic.

Anecdotally, I see surgeons at my hospital performing semi-emergent surgery in the middle of the night at times if they realize that the morning OR workload would overwhelm the morning crew, while I have friends in Germany where they would never consider doing such a thing.

Its never a simple black and white answer.

Be like me, a private contracted salaried ER physician that gets a piece of the group's pie depending on how myself and the entire group performs. If I work more than the other group members, I get a larger pie.

No thanks. My wife and I ran the local emergency animal service for several years. It was a zoo, and not because of the animals. It was incredibly stressful, and we finally gave it up when we had kids. Hard to have a family life when you work 24-7-365. It was very lucrative, and closing down the emergency portion of our practice cut our income by about 1/2, but the loss of stress was worth it. I can't imagine how much more intense it would be to work on human emergencies.

[blutoski]

Originally Posted by Ivor the Engineer

http://www.cmaj.ca/cgi/reprint/160/7/1013.pdf

You were falsely implying that Canadian fee-for-service doctors are overprescribing antibiotics because of a financial conflict of interest. Probably out of ignorance.

Specifically, in the Canadian jurisdictions examined in this study, there is no remuneration for writing scrips. The fee-for-service physician is paid for the patient visit whether or not he ends up writing a scrip. This is in contrast to, say, a surgeon, who might be tempted to advocate surgeries not fully indicated. (In this age of waiting lists, that's also unlikely to happen).

Fee-for-service practices have different patient demographics than salaried practices, which makes a retrospective comparison uninformitive. Salaried doctors are rarely GPs and usually work in a hospital, whereas most fee-for-service doctors are GPs and usually work in independent practice or small clinics. Right there, you have a selection bias that could explain different antibiotic prescription rates. Antibiotic prescription rates are also sensitive to patient volume (which can be out of a salaried MD's control) and by patient demographic (uneducated patients and parents of young children are more likely to demand antibiotics when they are not indicated).

Salaried in a hospital would know that the patient would be followed-up, whereas a fee-per-service in a clinic may have no confidence that the patient will return in time to review progress. A prophylactic antibiotic would make more sense in this environment. My impression is that this one study failed to account in any way for patient differences, and is therefore of no value.




The second problem is that salaried usually means insured by employer, whereas fee-per-service more likely indicates insured by private plan. Malpractice insurance is extremely expensive, so a fee-per-service employee is more likely to play it safe and order, say, prophylactic antibiotics for a viral infection.





Various Canadian provincial health ministries have engaged in many experiments over the last thirty years comparing three prevailing remuneration schemes: salaried, fee-per-service, and capitation. My colleague in ON worked for 4 years in a remote community on a capitation basis as part of this experiment, and many outcomes were compared (not just antibiotic prescription rates). A fourth leg called 'mixed' was also included in this experiment. Other experiments have been conducted around the globe.

There is no clearly superior outcome at this time.

As Dr. Imago points out, salaried employees can be over or underemployed, fee-for-service can be unconsciously conflicted, and capitationed resent being penalized for their patients' poor decisions.

Each system looks best on paper, but disappoints in the real world.

Cochrane also concluded such in their recent review: [Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians]

[Dr. Imago]

Originally Posted by Ivor the Engineer

I agree the study did not show that, but it is consistent with the hypothesis that financial incentives distort clinical judgement (to the possible detriment of patients).

I only have to add, in addition to the excellent and elucidative posts above, that it's interesting your assumption is that it's necessarily to the detriment of patients.

Originally Posted by rocketdodger

I don't know anything about you, Dr. Imago, but my analysis of your reaction here leads me to strongly believe that you yourself have ulterior motives.

Categorizing any study, which does provide raw information, as "essentially useless" seems to be a fundamentally political rather than scientific viewpoint.

If nothing else, such a study should catalyze further studies looking into the very questions you brought up in your initial response.

My only ulterior motive is to expose this study as flawed. It is "essentially useless" in trying to draw any meaningful conclusions. And, unfortunately, these types of studies usually only "catalyze" politicians and bureaucrats, who have at best usually superficial understanding of the issues we face on a daily basis on the frontlines, to try to "fix" the problem.

Future similar studies cannot possibly be designed to shed further light. They simply put raw information out there and leave it to wide open interpretation, as is amply illustrated by this thread.

~Dr. Imago

[Ivor the Engineer]

Originally Posted by Dr. Imago

I only have to add, in addition to the excellent and elucidative posts above, that it's interesting your assumption is that it's necessarily to the detriment of patients.

<snip>

Physicians paid on a fee-for-service basis have an obvious conflict of interest with their responsibility of patient advocacy.

I'm sure there are cases when tests ordered for no good clinical reason discover something which is of benefit to the patient. But I'm also sure the vast majority patients are worse off when subjected to such tests.

[Ivor the Engineer]

Blutoski,

Many of your criticisms are not valid. Please read what the study actually looked at and what was controlled for.

John Bentley,

While I can appreciate the appeal of the 80/20 rule, I think it is a gross oversimplification when it comes to summarizing human behaviour with regards to work, particularly for work which is intellectually demanding and/or highly skilled. For example, I doubt many people are forced to become physicians, or that becoming a physician is the only (or easiest) way for them to earn a lot of money. I would think (hope!) most people choose to become physicians mainly for internal reasons, rather than external motivators such as money.

[to.by]

With regard to the OP. Yes some salaried doctors make more rational decisions than some fee-for-service doctors. And vice versa I might add.
I have been a salaried medical vorker most of my working life. Though I say it myself I would think that my decisions regarding treatment were based on knowledge, experience and the patients' prefernces. At least (I hope) I can say that I have never let ulterior motives like payment influence my decisions.
Money is not the only motivation factor. In fact it can often be rather unsignificant.

Edited because of typo.

Likewise

[Ivor the Engineer]

Originally Posted by paximperium

<snip>

Sure it can. Medical fraud happens. Are you implying that salaried physicians are somehow less corrupt or less likely to be?

<snip>

I'm explicitly saying that fee-for-service gives physicians a motive to behave in a way which is to the detriment of their patients. Some may be conscious of their behaviour and not care, some may rationalise their behaviour to make it ethically acceptable to themselves and/or others, others may be totally unaware of the effects their remuneration scheme has on their behaviour.

[Dr. Imago]

Originally Posted by Ivor the Engineer

I'm explicitly saying that fee-for-service gives physicians a motive to behave in a way which is to the detriment of their patients. Some may be conscious of their behaviour and not care, some may rationalise their behaviour to make it ethically acceptable to themselves and/or others, others may be totally unaware of the effects their remuneration scheme has on their behaviour.

Well, the fact is, at least in the U.S., that most physicians are paid by their group or by the hospital with a combination of both salary and pay-for-performance bonus. They have a certain amount of work they have to do and receive a salary for that, and then get a "performance bonus" based on working extra hours, taking extra call, etc.

I think that writing a script for a antibiotic is a poor barometer for "abuse" of medical authority. It takes less than thirty seconds to write a prescription. And, it doesn't affect the physician's bottom line. You may argue that it is bad for society if unnecessary scripts are written, but unlikely bad for the patient. Likewise, this study in no way is able to examine - again - whether salary-only physicians witheld necessary scripts from patients secondary to some incentive by their employer (e.g., keeping formulary costs down, etc.).

So, how you can conclude what you do from this study is beyond me, and speaks more to some bias you have against physicians. How's that for drawing an inference from limited data?

~Dr. Imago

[Ivor the Engineer]

If a patient expects to receive treatment, fee for service physicians have more incentive (e.g., repeat business) to provide treatment than salaried physicians do.

[Rob Lister]

Originally Posted by Ivor the Engineer

If a patient expects to receive treatment, fee for service physicians have more incentive (e.g., repeat business) to provide treatment than salaried physicians do.

I'm not sure where you're going with this; most patients expect treatment; that's why they're there. Can we have a few practical examples. I don't thing the antibiotic example holds much water for the reasons already brought forward; too many confounding factors to draw any conclusion.

[paximperium]

Originally Posted by Ivor the Engineer

If a patient expects to receive treatment, fee for service physicians have more incentive (e.g., repeat business) to provide treatment than salaried physicians do.

...and that's a bad thing?

"Doctor, I have this growth in my arm."
Private Doc: "Let's schedule you for a biopsy."...snip..."It is benign. Have a good day."
Salaried Doc: "We'll watch it for a while. Come back in 3 months."..."Still looks good."..."still looks good"

"Doc, I have heartburn. I've tried all these medicines and they don't work."
Private: "Let's schedule you for an endoscopy."..."You have nothing/ulcer/gastritis/cancer etc."
Salaried Doc: "Let's try this med. I'll see you in 6 months."..."Not working? Let's try this."..."Not working? Let's schedule you for a endoscopy etc."

These are nothing more than caricatures but your argument is as much of a caricature of a complex issue.

Private docs have an incentive to be more aggressive in their treatment both as a payment incentive and a patient satisfaction issue. They suck up more resources than a salaried doc. They tend to work harder because they have to. Their livelihood depends on their productivity.

However, salaried docs, toe the party line. They divvy out resources according to policy and not necessarily for the patient's benefit at times. So don't go crying when a doc does not approve of your MRI because of your back pain or he/she does not give you meds because it is not "indicated".

This is a complicated issue that involves, the balancing of available resources, patient's health, nationwide health policy etc.

You making these broad generalizing statements are infantile.

[Professor Yaffle]

What's the sytem in France? Cos they prescribe all sorts of "tonics" etc to cater to the hypochondriatism(?) there. A visit to the docs is not complete if he doesn't prescribe something.

[Ivor the Engineer]

Originally Posted by Rob Lister

I'm not sure where you're going with this; most patients expect treatment; that's why they're there. Can we have a few practical examples. I don't thing the antibiotic example holds much water for the reasons already brought forward; too many confounding factors to draw any conclusion.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

Quote:

We examined the earnings of 8106 office-based (FTE) physicians in 2002 in Taiwan for evidence of supplier-induced demand (SID). We hypothesize that SID, operating in the form of mutual cross-specialty referral, will cause earnings to increase with total physician density (all specialties taken together), but simultaneously, decrease with increasing competition within specialties. We used multiple regression analyses controlling for high-user population, physician demographics and practice type. The evidence supports our hypotheses. Increasing total physician density (all specialties) is positively associated with earnings. Concurrently, within specialties, increased competition is associated with reduced earnings. The medical appropriateness of increasing health care utilization with increasing physician supply cannot be directly determined from the data. However, evidence of a steady earnings increase with increasing total physician density, which precludes a saturation point (of appropriate care levels) at some optimum physician density, substantiates SID in the office-based practice market. Empirically, our data suggest that the average market effect of physicians on one another is synergic when all specialties are considered together, but competitive within each specialty.

http://www.ncbi.nlm.nih.gov/pubmed/3798165?ordinalpos=1&itool=EntrezSystem2.PEntrez.P ubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pu bmed_Discovery_RA&linkpos=5&log$=relatedarticles&l ogdbfrom=pubmed

Quote:

Approximately one-third of the Irish population receive all medical care services free. GPs (general practitioners) treat both public and private patients, and are remunerated on a fee-for-service basis by the state for public patients, and by the patient, at a higher rate, for private patients. In 1981, the first author conducted a national survey of Irish medical care utilization, asking whether patients' most recent GP visits resulted in a return visit being arranged. This measure of self-referral by GPs is significantly and strongly associated with the ratio of GPs to population, and negatively with the ratio to population of persons eligible for free services, and with area per capita income. All three results are as hypothesized from a theoretical model, and point to significant self-interested physician-induced demand by Irish GPs.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

Quote:

This paper investigates on the existence of physician-induced demand (PID) for French physicians. The test is carried out for GPs and specialists, using a representative sample of 4500 French self-employed physicians over the 1979-1993 period. These physicians receive a fee-for-services (FFS) payment and fees are controlled. The panel structure of our data allows us to take into account unobserved heterogeneity related to the characteristics of physicians and their patients. We use generalized method of moments (GMM) estimators in order to obtain consistent and efficient estimates. We show that physicians experience a decline of the number of consultations when they face an increase in the physician: population ratio. However this decrease is very slight. In addition, physicians counterbalance the fall in the number of consultations by an increase in the volume of care delivered in each encounter. Econometric results give a strong support for the existence of PID in the French system for ambulatory care.

There are plenty more studies which support the idea of physician-induced demand.

[blutoski]

duplicate

[blutoski]

Originally Posted by Ivor the Engineer

Blutoski,

Many of your criticisms are not valid. Please read what the study actually looked at and what was controlled for.

Did you read it?

Please throw me a bone and give me something to work with: which of my criticisms do you believe are not valid!

And, they're not just my criticisms: the link I provided was the Cochrane Collaboration's literature review which rejected the article in your original post as inadequate for the lack of controls I cited, plus other reasons I did not mention.

I even went so far as to phone a friend who works in the NFLD system to clarify whether a ffs physician working c 1999 would be able to bill for the act of writing a scrip: he verified that there was no billing number for writing a scrip at the time of the study. These physicians are therefore arguably financially disincented from writing antibiotic scrips, as they are paid the same regardless, but prescribing takes more time and means they take longer per billable visit.

With this in mind, though, the authors are reduced to speculate that the method of incentive is that ffs physicians are more interested in what the customer wants than salaried physicians, and more eager to capitulate to patient expectations and demands to foster a stronger relationship. Possible, but IIRC, in previous posts, you said that this behavior should be encouraged. Now, you're implying that it is unethical. Fish or cut bait.

The reasoning provided by the authors for failing to do any sort of proper baseline comparison of clientele is dismissed away with an unacceptable argument, thus:

Quote:

There are limitations to any study that uses information from administrative databases, because important variables may not be available. It is possible that there are fundamental differences between salaried and fee-for-service physicians that could not be addressed in this study, such as proportion of young patients, who have higher rates of infection. However, given that the sample included all of the physicians in the province, it is unlikely that the overall type of patients seen was markedly different between the 2 groups.

They appear to be arguing that there can't be differences between salaried and ffs practices because they took a large sample? This doesn't wash. I've already listed in my previous post that there are very real differences between patient demographics that distinguish ffs and salaried practices.

And, Ivor... I don't have a dog in the fight. My opinion for 20 years is that the three major remuneration mechanisms have their pros and cons, and don't seem very different in important measured outcomes so they all have their place in Canada's healthcare solution. What I'm bent out of shape about is that this study is simply uninformative.

Specifically, there are not many part-time salaried positions, and the fact that ffs is available to people who want to work limited hours has allowed more women to find their life/work balance and stay in the profession. To the point where now family practice in Canada is a women-dominated specialty. (note: this is consistent with the paper's hypothesis that ffs are prescribing more in response to patient expectations due to stronger patient/physician relationships - is this an indictment of ffs? Should we start to push women out of the profession now?)

[blutoski]

Originally Posted by Ivor the Engineer

There are plenty more studies which support the idea of physician-induced demand.

Sure. And there are lots that show that a ffs provides better overall outcomes. And lots that show that ffs provides worse overall outcomes. And lots that show this, that, and the other thing.

That's the state of the current literature, unfortunately.

Did you actually have a point? ie: are you advocating the replacement of ffs with another remuneration formula? Which one? Why?

[Dr. Imago]

Originally Posted by Ivor the Engineer

If a patient expects to receive treatment, fee for service physicians have more incentive (e.g., repeat business) to provide treatment than salaried physicians do.

Really? Based on what? Your assumption? And, how is that necessarily better for the patient?

And, did you actually read what I wrote here...

Originally Posted by Dr. Imago

Well, the fact is, at least in the U.S., that most physicians are paid by their group or by the hospital with a combination of both salary and pay-for-performance bonus. They have a certain amount of work they have to do and receive a salary for that, and then get a "performance bonus" based on working extra hours, taking extra call, etc.

~Dr. Imago

[Ivor the Engineer]

Originally Posted by blutoski

Did you read it?

Please throw me a bone and give me something to work with: which of my criticisms do you believe are not valid!

These:

Originally Posted by blutoski

Fee-for-service practices have different patient demographics than salaried practices, which makes a retrospective comparison uninformitive. Salaried doctors are rarely GPs and usually work in a hospital, whereas most fee-for-service doctors are GPs and usually work in independent practice or small clinics. Right there, you have a selection bias that could explain different antibiotic prescription rates. Antibiotic prescription rates are also sensitive to patient volume (which can be out of a salaried MD's control) and by patient demographic (uneducated patients and parents of young children are more likely to demand antibiotics when they are not indicated).

All the physicians in the study were GPs. Patient volume was a factor which was included in the study. Different patient demographics between the two groups explaining the large difference in prescribing rates seems to be rather unlikely. For example, the proportion of elderly patients was not significantly different between the two groups.

Quote:

And, they're not just my criticisms: the link I provided was the Cochrane Collaboration's literature review which rejected the article in your original post as inadequate for the lack of controls I cited, plus other reasons I did not mention.

That never works when I claim to be using the arguments of those more informed than myself about a particular issue.

Quote:

I even went so far as to phone a friend who works in the NFLD system to clarify whether a ffs physician working c 1999 would be able to bill for the act of writing a scrip: he verified that there was no billing number for writing a scrip at the time of the study. These physicians are therefore arguably financially disincented from writing antibiotic scrips, as they are paid the same regardless, but prescribing takes more time and means they take longer per billable visit.

With this in mind, though, the authors are reduced to speculate that the method of incentive is that ffs physicians are more interested in what the customer wants than salaried physicians, and more eager to capitulate to patient expectations and demands to foster a stronger relationship. Possible, but IIRC, in previous posts, you said that this behavior should be encouraged. Now, you're implying that it is unethical. Fish or cut bait.

Where did I say that?

Quote:

The reasoning provided by the authors for failing to do any sort of proper baseline comparison of clientele is dismissed away with an unacceptable argument, thus:



They appear to be arguing that there can't be differences between salaried and ffs practices because they took a large sample? This doesn't wash. I've already listed in my previous post that there are very real differences between patient demographics that distinguish ffs and salaried practices.

There were no difference in the proportion of elderly patients between the two groups, and it seems unlikely (to me) that there would be enough of a difference in patient demographics of the two groups to explain the large difference in prescribing practices. But, as you point out, this is a weakness in the study.

Quote:

And, Ivor... I don't have a dog in the fight. My opinion for 20 years is that the three major remuneration mechanisms have their pros and cons, and don't seem very different in important measured outcomes so they all have their place in Canada's healthcare solution. What I'm bent out of shape about is that this study is simply uninformative.

Specifically, there are not many part-time salaried positions, and the fact that ffs is available to people who want to work limited hours has allowed more women to find their life/work balance and stay in the profession. To the point where now family practice in Canada is a women-dominated specialty. (note: this is consistent with the paper's hypothesis that ffs are prescribing more in response to patient expectations due to stronger patient/physician relationships - is this an indictment of ffs? Should we start to push women out of the profession now?)

What's the point in going to see a physician if she simply capitulates to the prior treatment expectations of her patients? E.g, “We’re not lousy parents. Our child needs Ritalin.”

I agree fee-for-service has a place in health care. However, I would suggest it is not an appropriate scheme of remuneration for those who both diagnose and recommend / implement treatment.

[Ivor the Engineer]

Originally Posted by Dr. Imago

Really?

Yes.

Quote:

Based on what?

Self-interest. Don't piss-off your customers.

Quote:

Your assumption?

No, normal human behaviour.

Quote:

And, how is that necessarily better for the patient?

It allows the physician to be an advocate for the patient and not have to suppress the incentive created by fee-for-service to promote and sell their services.

Quote:

And, did you actually read what I wrote here...

Yes. Why do you think most physicians are remunerated that way?

[blutoski]

Originally Posted by Ivor the Engineer

All the physicians in the study were GPs. Patient volume was a factor which was included in the study.

And...?

Originally Posted by Ivor the Engineer

Different patient demographics between the two groups explaining the large difference in prescribing rates seems to be rather unlikely.

That's the assumption I'm rejecting. Why do you think the distinction is unlikely? Notice that my examples of demographics did not include age, which probably is mostly regionally uniform, but included factors such as whether the patients are educated and have children.

Originally Posted by Ivor the Engineer

For example, the proportion of elderly patients was not significantly different between the two groups.

This isn't surprising, so I don't know why they recorded it. Especially when other demographics are more relevant.

Originally Posted by Ivor the Engineer

That never works when I claim to be using the arguments of those more informed than myself about a particular issue.

It sometimes works when you actually select objective sources. In the past when you have presented Cochrane Collaboration studies, I have accepted them as good evidence. When you submit studies from people widely regarded as cranks, I reject them.

Originally Posted by Ivor the Engineer

Where did I say that?

Not in this thread. Other threads, where you shared the opinion that conventional medicine suffers from a weakness that alternative medicine exploits: it's impersonal.

Originally Posted by Ivor the Engineer

There were no difference in the proportion of elderly patients between the two groups, and it seems unlikely (to me) that there would be enough of a difference in patient demographics of the two groups to explain the large difference in prescribing practices. But, as you point out, this is a weakness in the study.

That is pretty much my entire point. Physicians in NFLD have only one payer, but can choose to apply to a public employer and be salaried, or start their own practice. What's important to know is that the government only posts certain positions. GPs working for the health ministry are either working in an urban hospital or travelling to cover remote underserviced communities. Having lived in NFLD, that means the clients are mostly the chronically unemployed, mentally ill, prisoners, uneducated &c. A GP who has his own ffs practice will be working in a medium-sized community with a more employed and educated demographic, with less of the former categories, and no prisoners.

These positions have very different patient demographics, and the fact that the reviewers flat out ignored this is the primary weakness in the paper that causes me to reject it. It is very easy to see how a systematic bias could be in place that would lead to different rates of prescription per patient.

The reviewers also made no attempts to test their assumption about this bias. My opinion is that this would be very easy to resolve prospectively with employment of double-blinded standardized patients instead of retrospective analysis of pooled data and WAGs.

Originally Posted by Ivor the Engineer

What's the point in going to see a physician if she simply capitulates to the prior treatment expectations of her patients? E.g, “We’re not lousy parents. Our child needs Ritalin.”

False dichotomy. A physician should have the discretion within specific scenarios; where one outcome has the upside of improving the physician-patient relationship and trivial downside it should be a legitemate option.

It should also be mentioned that this is only a speculative rationale: it is undemonstrated whether ffs' higher antibiotic prescription rates are discretionary or if they are in fact quite rational based on the demographic distinction I outline above. A properly designed study to identify an underlying mechanism would have a different approach.

Until the underlying mechanism for the distinction is properly identified, we are arguing about how many angels can dance on the head of a pin.

Originally Posted by Ivor the Engineer

I agree fee-for-service has a place in health care. However, I would suggest it is not an appropriate scheme of remuneration for those who both diagnose and recommend / implement treatment.

I find this statement confusing, and possibly inconsistent. I believe it is the case that all physicians both diagnose and also prescribe and treat. It is hard for me to imagine that you mean ffs has a place in health care, but that this place is not to pay physicians.



As mentioned, I don't have a dog in the fight. If anything, my bias is actually to defend the article rather than criticize it - the primary author is a fellow Canadian microbiologist - a colleague whom I otherwise respect, and I share his zeal for raising the alarm of antibiotic overprescription, which is the underlying motive of this paper. Furthermore, I am a big advocate of capitation, which I believe is an underexplored remuneration strategy.

But I also think it's important to put my biases aside when evaluating whether a paper is of good quality, and this one isn't.

[Ivor the Engineer]

Originally Posted by blutoski

Originally Posted by Ivor the Engineer

All the physicians in the study were GPs. Patient volume was a factor which was included in the study.

And...?

Those were some of the criticisms you made against the study which were addressed by the authors.

Quote:

Originally Posted by Ivor the Engineer

Different patient demographics between the two groups explaining the large difference in prescribing rates seems to be rather unlikely.

That's the assumption I'm rejecting. Why do you think the distinction is unlikely? Notice that my examples of demographics did not include age, which probably is mostly regionally uniform, but included factors such as whether the patients are educated and have children.

I’ll get to this later.

Quote:

Originally Posted by Ivor the Engineer

For example, the proportion of elderly patients was not significantly different between the two groups.

This isn't surprising, so I don't know why they recorded it. Especially when other demographics are more relevant.

Would you be criticising the study for not recording it if it had not?

Quote:

Originally Posted by Ivor the Engineer

Where did I say that?

Not in this thread. Other threads, where you shared the opinion that conventional medicine suffers from a weakness that alternative medicine exploits: it's impersonal.

There’s a difference between a physician employing good communication skills to achieve an accurate diagnosis and appropriate treatment, and using them (and any disparity in knowledge) to increase trade.

Quote:

Originally Posted by Ivor the Engineer

There were no difference in the proportion of elderly patients between the two groups, and it seems unlikely (to me) that there would be enough of a difference in patient demographics of the two groups to explain the large difference in prescribing practices. But, as you point out, this is a weakness in the study.

That is pretty much my entire point. Physicians in NFLD have only one payer, but can choose to apply to a public employer and be salaried, or start their own practice. What's important to know is that the government only posts certain positions. GPs working for the health ministry are either working in an urban hospital or travelling to cover remote underserviced communities. Having lived in NFLD, that means the clients are mostly the chronically unemployed, mentally ill, prisoners, uneducated &c. A GP who has his own ffs practice will be working in a medium-sized community with a more employed and educated demographic, with less of the former categories, and no prisoners.

These positions have very different patient demographics, and the fact that the reviewers flat out ignored this is the primary weakness in the paper that causes me to reject it. It is very easy to see how a systematic bias could be in place that would lead to different rates of prescription per patient.

The reviewers also made no attempts to test their assumption about this bias. My opinion is that this would be very easy to resolve prospectively with employment of double-blinded standardized patients instead of retrospective analysis of pooled data and WAGs.

Aren’t the chronically unemployed, mentally ill, prisoners and uneducated often less healthy than those more educated and employed? If so, shouldn’t the study have shown the exact opposite? I.e. the salaried GPs handing antibiotics out like smarties, while the ffs, with their healthier, more informed clients receiving less treatment?

Quote:

Originally Posted by Ivor the Engineer

What's the point in going to see a physician if she simply capitulates to the prior treatment expectations of her patients? E.g, “We’re not lousy parents. Our child needs Ritalin.”

False dichotomy. A physician should have the discretion within specific scenarios; where one outcome has the upside of improving the physician-patient relationship and trivial downside it should be a legitemate option.

I thought the physician-patient relationship was based on trust. How can trust be established or maintained if patients have to keep in the back of their minds that their physician has a financial or business incentive to recommend treatment? Should patients be forced to get second or third opinions?

Quote:

It should also be mentioned that this is only a speculative rationale: it is undemonstrated whether ffs' higher antibiotic prescription rates are discretionary or if they are in fact quite rational based on the demographic distinction I outline above. A properly designed study to identify an underlying mechanism would have a different approach.

Until the underlying mechanism for the distinction is properly identified, we are arguing about how many angels can dance on the head of a pin.

I agree. Most of the studies I’ve found seem to leave out measurement of important potential confounders.

Quote:

Originally Posted by Ivor the Engineer

I agree fee-for-service has a place in health care. However, I would suggest it is not an appropriate scheme of remuneration for those who both diagnose and recommend / implement treatment.

I find this statement confusing, and possibly inconsistent. I believe it is the case that all physicians both diagnose and also prescribe and treat. It is hard for me to imagine that you mean ffs has a place in health care, but that this place is not to pay physicians.

Physicians are not the only people involved in health care. I can imagine plenty of roles in and around physicians’ offices which could use a fee-for-service remuneration scheme and not create a conflict of interest between patients and providers.

Quote:

As mentioned, I don't have a dog in the fight. If anything, my bias is actually to defend the article rather than criticize it - the primary author is a fellow Canadian microbiologist - a colleague whom I otherwise respect, and I share his zeal for raising the alarm of antibiotic overprescription, which is the underlying motive of this paper. Furthermore, I am a big advocate of capitation, which I believe is an underexplored remuneration strategy.

But I also think it's important to put my biases aside when evaluating whether a paper is of good quality, and this one isn't.

Fair enough. While there are plenty of papers showing effects which could be explained by PID, there are none I’ve seen which do not leave out measurements of important potentially confounding variables. Having said that, to me the more extraordinary finding would be ffs does not lead to PID. Such a finding would require a major rethink of economic theory!