Health Care Spending: The Basics; How Much Do We Spend on Physicians Services? Could We Spend Less?
As a nation, we are spending well over two trillion a year on health care. What exactly are we paying for? In a December 6 post, I asked how much of that $2 trillion goes to private insurers in order to cover “administration”-- which includes advertising, marketing, underwriting, lobbying, multi-million dollar executive salaries, and profits for shareholders.
As the pie chart below shows, it turns out that in 2006, after taking in premiums and paying out reimbursements, private insurers kept close to $95 billion—or about 4.5 percent of the $2.1 trillion we spent on care—to fund everything from advertising to CEO bonuses. Meanwhile, private insurers paid roughly one-third of the nation’s health care bills. (By contrast, the government picked up nearly half of the $2.1 trillion tab through programs like Medicare, Medicaid, SCHIP while spending only $525 billion —or about 2.5 percent of the $2.1 trillion—on administration.)
Ninety five billion dollars represents the difference between what private insurers received in premiums and what they paid out in reimbursements, and it’s a big number. But as I commented in my December post, even if we eliminated the private insurance industry’s role in our health care system, the $95 billion saved would be wiped out by just one year of health care inflation.
Inflation: that is the elephant in the middle of the room. In 2006, total spending on health care climbed by 6.7 percent, or $132 billion, to $2.1 trillion. In 2007, economists expect an even bigger jump.The pie just keeps on growing, year after year, far faster than the average workers’ wages: up 8.6 percent in 2003, up 6.9 percent in 2004, up 6.5 percent in 2005, up 6.7 percent in 2006…And there’s no end in sight.
This is what is making healthcare unaffordable. Each year, we spend more on every segment of medical care: hospitals, drugs, devices, physicians’ services, nursing homes, etc. And it’s not just that individuals cannot afford the spiraling bills—the economy cannot support runaway health care inflation. In 1960, health care spending equaled 5.2 percent of GDP. In 2006, it represented 16 percent of the goods and services we produce. In seven years, economists project that it could easily account for fully 20 percent of GDP. And at some point, they say, we’ll have to begin choosing between healthcare and other things our society wants to invest in: education, the environment, national security.
In my December post, I promised that in the future, I would continue to fill in the pie chart, spelling out where our health care dollars are going, while looking for places where we might reduce waste and achieve lasting savings.
Today I’d like to focus on physicians. Looking back to 1960, it turns out that the share of the health care pie that we spend on doctors’ fees and clinical services has grown slightly—from 19.4 percent to about 22 percent. In “The Physician’s Role in Rising Health Care Costs,” Robert Stowe England, a fellow at Americans for Generational Equity, points out that “a sharper image of what these changes represent” emerges “if you set 1960 spending levels at ‘100’ and compare accumulating increases since then. Using this approach, spending on physician and clinical services rose from 100 in 1960 to 7,866 in 2006, compared to a rise from 100 to 7,219 for total national health care expenditures. But overall, health care spending and doctors’ fees far outpaced the overall growth of the economy ---which rose from 100 to just 2,366.
Doctors saw their incomes climb in the 1960s and 1970s as more insurance money entered the health care system. Medicare was passed in the mid-sixties; meanwhile, more and more employers were giving workers health benefits that included not only hospitalization, but also doctors’ bills. More patients were now able to go to the doctor. In 1966, the year after Medicare passed, the average physician’s income shot up by 11 percent.
The 1970s saw the rise of the specialist; and this is when fees began to levitate. Medicare had followed the precedent set by Blue Shield, agreeing to pay doctors through a “fee-for-service” schedule while letting them set their fees based on what was “usual and customary” in their community. And as time went by, the definition of “usual and customary” compensation inevitably rose, especially among surgeons. George Lundberg, a former editor of the Journal of the American Medical Association, watched it happen:
“While surgeons were barred by law from fixing fees, they knew what the going rate was [in their region.] When new surgeons entered the community, they learned what prevailing fees were for given procedures, and then set their fees at a higher level. Adam Smith might have predicted that a newcomer to a community would set lower fees in order to attract patients,” Lundberg continues, “but medicine was beyond supply-and-demand market rules. When new surgeons set higher fees, they not only got away with it, but also drove up the prevailing fees for all surgeons.”
By 1980, a cardiac surgeon writing in The New England Journal of Medicine estimated that members of his specialty were making an average of $350,000 a year on cardiac bypass operations alone. “It is conservative to estimate that their average gross income exceeds $500,000,” Dr. Benson Roe wrote—a handy sum in 1980. At the same time, the surgeon’s work had become increasingly specialized. In the past, he cared for the patient from diagnosis through post-operative care. Now technicians and other assistants took over most of those services—and of course, billed separately. “Under these circumstances,” Dr. Roe noted, “one might expect the surgeon’s fee to have dropped considerably. But it has not. “
To be fair, in the 1970s and 1980s physicians were saving more lives than ever before. Medical science was progressing from “comfort” to “cure.” And Americans were more than willing to pay for spectacular advances.
In the 1980s, doctors’ incomes continued to grow, rising 30 percent from 1984 to 1989, or about twice as fast as the average increase for other full-time workers, according to Theodore Marmor’s The Politics of Medicare. But Medicare was beginning to clamp down. And in the 1990s, with the rise of managed care, HMOs started to question nearly every bill. For a brief period, health care spending plateaued, and many doctors saw their incomes fall.
In 2000 the backlash against managed care forced HMOs to loosen the purse strings. Total health care spending once again began to soar. But doctors remain under pressure, thanks, in large part, to Medicare’s renewed efforts to keep fees flat. Whenever possible, insurers are following suit.
As a result, in recent years, many doctors have found that their incomes are not rising as fast as their costs. While rents, malpractice insurance and the cost of equipment and staff climb, Medicare has been refusing to increase their fees. In an effort to make up the difference between their overhead and their fees, many physicians have begun increasing the volume of work they do. Others are becoming more “entrepreneurial,” investing in clinics and surgical centers.
Many have succeeded in boosting their take-home—which is why, even
if fees for many services haven’t risen, total spending on physicians’
services continues to climb: up 6.2 percent in 2000, up 8.3 percent in
2003, up 7.3 percent in 2004, up 7.4 percent in 2005, and gaining
another 5.9 percent in 2006.
Of course, not all physicians are prospering. As I explained on this blog last week,
Medicare’s somewhat bizarre fee schedule is based not just on how much
time a particular procedure takes but also on the mental effort and
judgment involved, the technical skill and physical effort required,
and the stress entailed. A committee dominated by specialists updates
the fees Medicare pays physicians on a regular basis. Not surprisingly,
specialists are paid considerably more than generalists.
Indeed, Medicare’s fee schedule favors specialists who perform some of the most aggressive procedures. Meanwhile, private insurers use this schedule as a model.
As a result, physicians’ incomes vary widely by specialty. To get an idea of the range, take a look at the tables below published in 2007 by Merritt, Hawkins & Associates, a national health care search and consulting firm that specializes in recruiting physicians. This compendium of “Income Offered to Top 20 Recruited Specialties” shows “low,” “average” and “high “base salaries ( or guaranteed income) offered to the recruits. These numbers do not include production bonuses or benefits. Ninety-one percent of the recruits receive malpractice insurance as well as health benefits, and 72 percent receive a signing bonus.
2007 REVIEW OF PHYSICIAN AND CRNA RECRUITING INCENTIVES
Low Average High
Family Practice
2006/07 $120,000 $161,000 $250,000
2005/06 $115,000 $145,000 $220,000
2004/05 $125,000 $150,000 $200,000
2003/04 $120,000 $146,000 $195,000
Family Practice with Obstetrics
2006/07 $145,000 $159,000 $200,000
2005/06 $140,000 $158,000 $180,000
2004/05 N/A N/A N/A
2003/04 N/A N/A N/A
Internal Medicine
2006/07 $135,000 $174,000 $275,000
2005/06 $130,000 $162,000 $250,000
2004/05 $130,000 $161,000 $210,000
2003/04 $125,000 $152,000 $200,000
Hospitalist
2006/07 $145,000 $180,000 $250,000
2005/06 $140,000 $175,000 $190,000
2004/05 $150,000 $171,000 $210,000
2003/04 $140,000 $162,000 $200,000
Radiology
2006/07 $250,000 $380,000 $500,000
2005/06 $240,000 $351,000 $500,000
2004/05 $250,000 $355,000 $500,000
2003/04 $240,000 $336,000 $450,000
Orthopedic Surgery
2006/07 $250,000 $413,000 $650,000
2005/06 $250,000 $370,000 $515,000
2004/05 $250,000 $361,000 $650,000
2003/04 $240,000 $330,000 $500,000
Cardiology
2006/07 $250,000 $391,000 $500,000
2005/06 $175,000 $342,000 $500,000
2004/05 $234,000 $320,000 $525,000
2003/04 $230,000 $292,000 $500,000
OB/GYN
2006/07 $200,000 $247,000 $345,000
2005/06 $175,000 $234,000 $450,000
2004/05 $200,000 $247,000 $320,000
2003/04 $185,000 $242,000 $325,000
General Surgery
2006/07 $225,000 $301,000 $350,000
2005/06 $150,000 $272,000 $350,000
2004/05 $220,000 $255,000 $310,000
2003/04 $210,000 $248,000 $300,000
Emergency Medicine
2006/07 $150,000 $239,000 $300,000
2005/06 $130,000 $210,000 $270,000
2004/05 $140,000 $246,000 $270,000
2003/04 $120,000 $218,000 $260,000
Psychiatry
2006/07 $160,000 $186,000 $230,000
2005/06 $130,000 $174,000 $230,000
2004/05 $140,000 $176,000 $250,000
2003/04 $130,000 $164,000 $260,000
Gastroenterology
2006/07 $200,000 $365,000 $450,000
2005/06 $175,000 $315,000 $500,000
2004/05 $230,000 $298,000 $340,000
2003/04 $210,000 $250,000 $325,000
Urology
2006/07 $275,000 $400,000 $500,000
2005/06 $250,000 $320,000 $375,000
2004/05 $250,000 $329,000 $340,000
2003/04 $220,000 $294,000 $325,000
Pediatrics
2006/07 $115,000 $159,000 $200,000
2005/06 $115,000 $151,000 $180,000
2004/05 $110,000 $151,000 $180,000
2003/04 $110,000 $145,000 $170,000
CRNA
2006/07 $130,000 $164,000 $200,000
2005/06 $87,000 $156,000 $210,000
2004/05 $75,000 $150,000 $190,000
2003/04 $70,000 $145,000 $190,000
HEM/ONC
2006/07 $300,000 $339,000 $500,000
2005/06 N/A N/A N/A
2004/05 N/A N/A N/A
2003/04 N/A N/A N/A
Neurology
2006/07 $170,000 $234,000 $275,000
2005/06 $150,000 $210,000 $250,000
2004/05 $155,000 $209,000 $230,000
2003/04 $145,000 $191,000 $220,000
Otolaryngology
2006/07 $200,000 $312,000 $400,000
2005/06 $175,000 $272,000 $350,000
2004/05 $235,000 $304,000 $350,000
2003/04 $230,000 $278,000 $350,000
Anesthesiology
2006/07 $220,000 $300,000 $425,000
2005/06 $275,000 $306,000 $375,000
2004/05 $240,000 $303,000 $340,000
2003/04 $220,000 $300,000 $325,000
Dermatology
2006/07 $200,000 $318,000 $400,000
2005/06 N/A N/A N/A
2004/05 N/A N/A N/A
2003/04 N/A N/A N/A
Neuro Surgery
2006/07 $350,000 $527,000 $850,000
2005/06 $300,000 $489,000 $650,000
2004/05 $350,000 $424,000 $575,000
2003/04 $350,000 $420,000 $550,000
As you can see, high-end physicians who cut you or irradiate you (neurosurgeons, orthosurgeons, urologists radiologists, cardiologists) can make $500,000 to $850,000 a year, while physicians responsible for preventive and primary care (family docs, internist, pediatricians, and psychiatrists) may earn as little as $115,000, and can expect, at the high end, no more than $275,000. Even ER docs—who may have your life in their hands—make only about $150,000 at the low end of the scale.
Who is paying these doctors? In 2007, 43 percent of Merritt, Hawkins, & Association recruits were placed in hospitals, while 35 percent found jobs in group practices. The company reports that in the face of an internists and generalist shortage, demand for family doctors is growing along with their income. But as the table below shows, in the past year, urologists saw the biggest hikes in pay. (Fear of early stage prostate cancer keeps urologists busy—even though the National Cancer Institute says there is no evidence that early diagnosis and treatment alters the course of the disease.) Finally, Merritt, Hawkins & Associates reports that in 2006/2007, anesthesiology was the only specialty where incomes declined.
Specialties Showing Highest Gain in Base Income Offers/2005/06 – 2006/07
Base Income 05/07 Base Income 06/07 Percent Increase
Urology $320,000 $400,000 25%
Otolaryngology $272,000 $312,000 15%
Cardiology $342,000 $391,000 14%
Emergency Medicine $210,000 $239,000 14%
Orthopedic Surgery $370,000 $413,000 12%
Family Practice $145,000 $161,000 11%
In my next post, I’ll look at how much specialists in the U.S. are paid when compared to specialists in other countries, how much debt they have to pay off, and how hard they work compared to doctors abroad.
I’ll also ask how patients are faring as doctors boost the volume of work that they do, and how increasingly entrepreneurial physicians are affecting both health care spending and the quality of care.
Finally, I’ll look at how we might redistribute the dollars we spend on physicians services to cut waste while improving outcomes.
Bev M.D.
I've never suggested that "one Pap Smear" would do the trick. I think everyone knows that we are talking about annual Pap Smears.
But you're right, if I said 100% I shouldn't have. It should be "nearly all."
But the fact that the lead reseracher on the vaccine said that it wouldn't be needed in these Scandanvian countries is impressive.
Re the Health Affairs article: You can access it by going to www.dartmouthatlas.org. (You might have to pay for that one article, though I don't think so. In any case, it's well worth it.)Or you could read the long cover story I wrote about it for the Spring 2007 issue of Dartmouth Medicine. (Google my name and title of magazine)
No one has proven that tort reform would save 5% to 9%--this is merely the number that has been thrown out by those who want tort reform. If you look at the history of what has happened in states with reform, it's pretty clear that caps aren't the answer.
Though, as I've said before, I think lay juries are a terrible idea.
Finally, if you talk to people who have spent the last 25 or 30 years studying the problems with in our healthcare system--people like Dr. Don Berwick of IHI, Dr. Jack Wennberg, or Dr. Steve Schroeder, former head of the Robert Wood Johnson Foundation and now at UCSF, they will tell you that emphasizing "fear of malpractice" as one of the big problems is the oversimplification. (Also, to get a better idea of the major factors driving overtreatment, read Shannon Brownlee's excellent book: "Overtreatment."
They would also tell you that some doctors like to empahsize fear of malpractice because it absolves them of all responsibilty for over-treatment. They can say:"The lawyers made me do it."
Doctors who are more candid admit that much of overtreatment is connected to docs jacking up volume in recent years. Young doctors working with older doctors tell me that the older doctors give them "quotas" as to how many x-rays they need to read in a given day, how many patients they need to see--and the quotas exceed what they can do safely.
Finally,those who have studied health care spending in the U.S. and abroad in a systematic way point out that in other countries the number of suits and size of settlements is rising, but governments still manage to keep a much better lid on health care spending becuase they don't pay fee-for-service, they have global budgets, they don't allow med schools to graduate so many specialists, they put a limit on how many very expensive procedures a specialist can do in a given year, etc.
These are the things we need to do to put a brake on health care inflation.
Some doctors don't like the idea of government putting a brake on health care inflation: one man's overtreatment is another man's income stream.
So they keep try to bring the conversation back to "the lawyers made me do it."
And conservaives and libertarians strenuously object to government curbing overtreatment. In part, this is because they don't like any kind of govt regulation; in part, the drug-makers, device makers and others who make huge contributions to conservative and libertarian campaigns don't want to see government doing anything that would curb their profits--even if over-treatment is hazardous to our health.
BTw, for-profit drugmakers etc. contribute far more to conservative Republicans than they contribute to liberal Democrats or liberal Indpendents.
That's why people like the Oklahoma senator who Barry heard speaking at a conservative think tank keep trying to pretend that fear of malpractice is one of the main drivers of inflation. It's a factor, but not a main driver.
As I've said before, I respect the fact that fear of malpractice is causing real anxiety for many good doctors--particularly in certain specialities. As I noted above, I don't think lay juries should be deciding these cases, I think legislation like the law in Washington that calls for shared decision-making would go a long way toward solving the problem.
And finally, I think that doctors themselves need to get much tougher about reporting colleagues who are, in fact, practicing sub-optimal medicine.
Posted by: Maggie Mahar | January 31, 2008 at 10:12 AM
Barry;
I apologize for becoming slightly uncivil myself on your behalf, but I think Maggie's statement about your making false assumptions was patently untrue.
Like I once said on Paul Levy's blog; you should run for Congress. In addition to being thoughtful (wait, maybe that's a disqualification!), you have thick skin! (:
Maggie;
I'm not sure where to start with you, either. Let's start on what we can agree on - the root cause(s) of excess expenditures on health care in the United States are multifactorial. You are doing a multipart post on these causes, the first of which is "physician services", on which we are commenting here.
Barry, pcb and I, if I may speak for them also, are putting forth the thesis that malpractice and defensive medicine comprise two of the many root causes of perceived excess expenditures for physician services. Evidence for how big a role they play is difficult to measure, but, as Barry says, even a 5-9% contribution is "worth pursuing." Here is one reference (maybe the AMA didn't study it, but a lot of other people are; try googling "entrez pubmed").
http://www.ncbi.nlm.nih.gov/pubmed/8723178?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1
Your trying to minimize them as a factor is, ultimately, counterproductive - since there are MANY factors which will have to be pursued in order to reduce expenditures for physician services. I absolutely agree with you that fee for service payment is another root cause - but it's not the ONLY one, so why oversimplify a complex situation?
Second, re pap smears - even though this is off topic, I am following up because it's really important for you to understand. A layperson reading your statement could badly misinterpret and cost herself her life as a result. You have previously stated pap smears detect 100% of cervical cancers. There is no laboratory test, I repeat, no test, which detects 100% of anything in the entire population tested. In a recent post on another blog (I forget which one), someone was angry that they were charged for a pap smear and an HPV test - you replied that the HPV test was unnecessary and she should not pay for it. Please read this link from the medical literature (not "someone told me"), which says otherwise.
http://content.nejm.org/cgi/content/abstract/357/16/1579
Any female reading your 100% detection statement could go out and get ONE pap smear which is read as negative and, following your advice, figure she's home free, as you did not mention the all-important qualifier that many sequential pap smears will detect most (not all) cases of cervical cancer. Please modify your future statements to reflect the whole picture.
Finally, as to California, i could not access the Health Affairs link. However, I did not, and do not, dispute the Dartmouth's group's expertise nor that they factored in malpractice environment in their studies. I merely took exception with your, once again, overly simplistic interpretation that because all of California is covered by one state law, that all doctors in California have an equal fear of lawsuits. As pcb points out, it is FEAR of lawsuits, not actual malpractice data, that drive defensive medicine - and I would fear that more from a southern California patient than a northern California one. Enough said.
Posted by: bev M.D. | January 30, 2008 at 02:42 PM
Maggie,
I think the figure of 5%-9% of medical costs that could be saved if we had effective malpractice reform is well worth pursuing, though it will not, by itself, come anywhere close to solving the problem of rising healthcare costs.
I accept the build it and they will come evidence developed by Dartmouth Atlas that you have written about often. Medicare, as you say, has known for years that it spends far more per beneficiary in some regions than in others with no difference in outcomes. The issue is what can we do about it?
I am a believer in the power of information. Even if it is not feasible to rate individual doctors, small practices or even large practices, I think there are some things we could do. For example, suppose I live in Boise, ID, and a surgeon tells me I need back surgery. If there were a user friendly website or objective infomediary that I could access and learn that surgeons in Boise are twice as likely as surgeons elsewhere to recommend back surgery, it would be helpful to know that. What if my images and chart could be e-mailed to a surgeon at Mayo or Inter-Mountain for a second opinion review paid for by CMS or my private insurer? The reviewer would be paid the same no matter what the verdict and no matter what the patient decides to do. If doctors in high utilizing regions were challenged more often, maybe practice patterns would start to change for the better sooner rather than later.
I was seeing a specialist (not heart related) every six months for the last several years. Since every checkup was fine (following a procedure in 2004), I asked if I could safely cut back to a once a year checkup. He said that I could and I have. Maybe most people will still follow their doctor's recommendations no matter what, but in the Internet age, patients need to learn to be more proactive, and making more information easily available to them from objective, unbiased sources could instill the confidence they need to ask questions and not just accept medical advice on blind faith.
Posted by: Barry Carol | January 29, 2008 at 06:04 PM
Barry--
You wrote: "Anyway, during his talk [Tom Coburn] cited a study, which I was not able to find, by the AMA done in the mid-1990's that pegs the cost of defensive medicine (based on today's healthcare prices) at about $180 billion per year or about 8% - 9% of healthcare costs"
It's possible that you couldn't find the study because it doesn't exist. Politicians routinely cite studies that someone told them about that they have never seen--
On the other hand, it may exist. But given the AMA's attitude toward the plaintiff's bar, I'd take their numbers with a grain of salt.
In truth, only a mind-reader could know how much defensive medicine costs. You would have to go into the mind of the doctor, untangle the 3 or 4 motives driving any treatment decision, and then figure out how much weight to give to fear of malpractice.
Even proponents of tort reform claim that malpractice reforms that directly reduce provider liability pressure lead to reductions of just 5 to 9 percent in medical expenditures without substantial effects on mortality or medical complications." )This is from Kessler, Daniel and Mark McClellan. "Do Doctors Practice Defense Medicine?," Quarterly Journal of Economics, 1996, v111(2,May), 353-390
Even if you believe those numbers (and they have been disputed) this doesn't begin to explain why Medicare spends twice as much per patient (after adjusting for age, race, differences in local prices, and underlying health of the population) in some places than in others. Supply does.
Finally, you might want to keep in mind that Sen. Tom Coburn is something of an extremist. He has said that he believes that gynecologists who perform abortions should receive the death penalty and also objects to legal abortion in cases of rape. He has justified his position by noting that his great-grandmother was raped by a sheriff.
I can understand people having concerns about abortion, but . . .
Last year, Coburn threatened to block two bills honoring the 100th birthday of Rachel Carson. Coburn,calling Carson's work "junk science", proclaiming that Silent Spring, "was the catalyst in the deadly worldwide stigmatization against insecticides, especially DDT."
Finally, this may provide a clue as to why he doesn't like malpractice suits:
In 1990 he sterilized a 20-year-old woman without her written consent.
Coburn explained that he performed the sterilization during an emergency surgery to treat a life-threatening ectopic pregnancy, removing her intact fallopian tube as well as the one damaged by the surgery.
The woman sued Coburn, alleging that he did not have consent to sterilize her, while Coburn claimed he had her oral consent.
Although the lawsuit was ultimately dismissed with no finding of liability on Coburn's part, I find it pretty extraordinary that a doctor would sterilize a 20-year-old without getting her written permission . . .
He also has charged that Oklahoma's high schools are filled with lesbians . . .and he launched a protest to try to stop NBC from airing "Schindler's List . ."
I don't know Barry, all in all, "wacko" is the word that comes to mind.
Posted by: Maggie Mahar | January 29, 2008 at 01:24 PM
Bev M.D.
You wrote: "We all know the type of people who live in southern California are totally different from those who live in northern California, duh."
I don't even know how to respond. Let me suggest you read the reserach on
overtreatment in California hospitals here http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.526/DC1
You can also read about how the supply of specialists and hospital beds drives overtreatment nationwide here http://dartmed.dartmouth.edu/spring07/html/atlas.php
The idea that, over the course of three decades of research, it never occurred to Dr. Wennberg or his researchers to consider whether fear of malpractice might also be a factor is, if you think about it, highly improbable.
In fact if you read their research you will find that they have considered this possibility. But as the point out, even proponents of tort reform (and caps on awards) claim that "malpractice reforms that directly reduce provider liability pressure lead to reductions of just 5 to 9 percent in medical expenditures without substantial effects on mortality or medical complications." )This is from Kessler, Daniel and Mark McClellan. "Do Doctors Practice Defense Medicine?," Quarterly Journal of Economics, 1996, v111(2,May), 353-390 So this doesn't begin to explain why Medicare spends twice as much per patient (after adjusting for age, race, differences in local prices, and underlying health of the population) in some places than in others.
In addition, whatever stereotypes you may have in mind about the "type of people" who live in "Southern California, Miami or Manhattan," the reserach shows that overtreatment is also commonplace in towns like Lubbock, Texas and Hattiesburg, Missippi--where there are twice as many hospital beds per 1000 residents as in many other cities.
In both towns, patients are far more likely to land in the hospital, seeing 10 or more specialists during the final six months of life.( Yet outcomes are no better. Often they are worse.)
I suppose one could speculate that the "type of people" who live in Lubbock and Hattiesburg are more litigious than the average American and that's why they receive more aggressive treatment.
But I find it hard to imagine that two-fold differences in Medicare spending can be explained by regional character flaws--particularly when overtreatment pops up in places like Hattiesburg and Louisiana--cultural milieus that bear little resemblance to either Miami or Manhattan
You suggest that I am spreading misinformatio on Pap smears.
The truth is that while Pap smears can produce a false negative, if a woman goes for an exam each year, the disease will almost certainly be caught in time.
How do I know this?
This is what the doctor who was the lead researcher on Gardasil, Merck's vaccine against cervical cancer told me when I interviewed him.
As he explained, in Scandanavian countries where they have Organized Screening and virtually everyone gets a Pap Smear (at no cost) "they probably wouldn't need Gardasil" (the vaccine against viruses that cause 70 percent of cervical cancers.)
The point that I have made is not that Pap smears are perfect, but that they are so good that in the U.S. they have turned cervical cancer into what the NIH calls a "rare disease" and in Scandanavian countries where almost all women are screened they have been even more successful.
Therefore, it's not at all clear why we are spending a fortune on a vaccine that guards against only 70% of the viruses that cause the cancer. We might better take 1/5 of that money and use if for a campaign to make sure all women and girls get regular gynecological exams and pap smears.
Posted by: Maggie Mahar | January 29, 2008 at 12:45 PM
Barry and Maggie,
Barry: I'm not sure what the best reforms would be. If damage caps end up discouraging lawyers from seeing malpractice as a chance to win the lottery (John Edwards style) then maybe fewer cases would be filed and those that were filed would be the reasonable ones. It would take a long time to see any benefit in the actual practice of defensive medicine though. Why? Well, from a doctor's standpoint, the trial is the fear, not so much the money. (Insurance usually covers that part.) As Maggie notes, it's the time, shattered confidence, damage to professional pride, percieived (and often real) loss of reputation, having to answer "yes" to the "have you ever been sued" question on all the forms. That's the real fear, and why we practice defensively. On health courts:
Maggie,
Bottom line, I agree with your last paragraph. If practicing docs felt that other practicing docs were going to judge their decisions, right or wrong, they might practice less defensively and rely on "reasonable judgment" more often. Facing a John Edwards type, his smile and slick presentation, is a scary proposition.
If the medical facts are going to be put through the spin cycle and then judged by laypersons, most of whom have limited understanding of medical science and clinical decision making, docs are going to do whatever it takes to avoid the courtroom. Since that's the current system, those fears lead to pervasive defensive medicine.
Posted by: pcb | January 29, 2008 at 11:25 AM
pcb--
I'm famliar with the prostate cancer case.
It's in the law journals because it is such an outlier-- under virtually identical circumstances plaintiffs never have won cases like these.
But because it is so unusual, it got a lot of attention--and fueled physicians' anxiety about lawsuits.
There is an absolute consensus in the law journals that shared decision-making would protect a doctor in a case like this.
For political reasons, President Bush and other conservatives have done their best to exaggerate the likelihood of a doctor being sued.
In fact only 1 of 8 victims of avoidable medical injury sue, and only 1 of 15—about 7 percent—receive any compensation.
Moreover, in our present system, in order to win restitution, a harmed patient must prove not just that a doctor or hospital erred, but that the error was caused by neglect or incompetence so severe it amounts to a breach of the doctor's or hospital's legal duty of care.
In other countries, where there is a "no fault" system, the plaintiff only has to prove that an error was made--he does not have to claim "fault."
People like President Bush like to talk about a "malpractice crisis" much as they liked talking about how Iraq had "weapons of mass destuctions."
Their political arguments are based on fear because they have no evidence.
Here are the facts:
malpractice claims and awards are not rising. Total medical malpractice payouts dropped 6.9 percent from 2001 to 2002 according to a National Practitioner Data Bank (NPDB) analysis by Public Citizen.
· Jury verdicts in medical malpractice cases are stagnant, even according to Jury Verdict Research data, which tends to over-inflate award trends.
Verdict and Settlement Study Released: No Change in Median Medical Malpractice Jury Award
Most malpractice is caused by a small number of doctors who are never sanctioned. Just 5 percent of doctors (1 out of 20) that are responsible for 54 percent of malpractice payouts.
This is all on http://makethemaccountable.com/myth/RisingCostOfMedicalMalpracticeInsurance.htm-- a website devoted to making politicians and media accountable to ordinary citizens.
But the fact that ideologues misrepresent the dangers of malpractice does not mean that the fear is not real. Moreover, way too many "nuisance cases" are brought, adn even if the plaintiff does not win, the whole process is very time-consuming and exhausting for the physician.
For that reason, I'd like to see panels of health care professionals deciding these cases.
Posted by: Maggie Mahar | January 29, 2008 at 10:59 AM
Maggie,
Thanks very much for your response to my last comment.
Today, I attended a luncheon sponsored by the Manhattan Institute for Senator Tom Coburn, Republican from Oklahoma. I didn't even know that he is a physician by training (internal medicine and pediatrics) and he has proposed a healthcare reform plan that, as you would imagine, relies on the formation of a national insurance market, high risk pools, and replaces the current tax preference for employer provided health insurance with a tax credit.
Anyway, during his talk he cited a study, which I was not able to find, by the AMA done in the mid-1990's that pegs the cost of defensive medicine (based on today's healthcare prices) at about $180 billion per year or about 8% - 9% of healthcare costs. The AMA's figure also includes the current cost of malpractice insurance. He further commented that he thought as much as half of that amount could eventually be saved through sensible malpractice reform, most notably, health courts. I suspect that these figures would have an upward bias as both the objective and the sponsor of the study would encourage doctors to provide high estimates for their defensive medicine costs. Even if we take these figures at face value, they are not going to save the system. I think health courts are worth pursuing, however, both because they would improve the way we resolve medical disputes and it would neutralize defensive medicine as an issue in the healthcare reform debate. At the very least, it is a strategy that can be pursued at the state level without federal level action.
Posted by: Barry Carol | January 28, 2008 at 07:39 PM
Barry, Bev M.D. and pcb--
Barry--
I'm glad you didn't take offense. I didn't think you would. I often spend quite a bit of time responding to your comments (doing research, sending you links) because your comments are generally very intelligent and thoughtful.
Admittedly, I was annoyed when you suggested that the DArtmouth researchers had never considered the malpractice angle.
Dr. Jack Wennberg, who started this research has spent more than three decades on it, working up hill the whole time. And if you think about it, over the course of that time, it's insulting to suggest that the malpractice angle wouldn't have occured to him and his team. If it had, they would have used it. They're not particularly political.
So in many ways, when I responded, I was defending the expertise of Wennberg, et.al., and the time, commitment and absolute integrity that they have brought to their research.
As for the role of defensive medicine in healthcare inflation, I agree that, in conversation with other doctors, many doctors would say that they are doing more tests and procedures because they are worried about lawsuits.
What they wouldn't say--even to most of their peers--is that they are pumping up volume in order to make up for the fact that their costs are rising while fees are not.
I don't even fault primary care docs for doing more tests, seeing more patients per hour in order to break even. They really are having a hard time financially.
But I think you and I agree that the fact we pay for volume (fee-for-service) is a major problem in our system.
Bev MD and pcb- just came home from work, must eat dinner - but I'll catch up with you tomorrow
Posted by: maggie mahar | January 28, 2008 at 06:01 PM
Bev – Thanks very much for the kind words. This topic, by its nature, can get a little heated at times. I try to never take it personally. I respect Maggie's knowledge base, healthcare industry contacts and research skills. We are at different places on the philosophical spectrum, however. I've learned a lot and continue to which is why I enjoy commenting here. Moreover, in contrast to sites like Daily Kos and even Ezra Klein, where you often find liberal ideologues who don't even know much about the subject trying to shout down opponents with foul language, the generally civil tone here is very much appreciated, at least by me.
I want to make a comment about the research Maggie cited that suggests that defensive medicine is not an especially important factor in rising healthcare costs and invite comments. Suppose a team of researchers goes around and asks a representative group of doctors practicing both in office and hospital settings what percentage of the healthcare utilization (at cost) that they ordered or performed in, say, the last month was defensive or CYA medicine. The chances are that most docs would say little or none of it was. It was almost all necessary and in the best interest of their patients. Now suppose a doctor, at the end of the day in the doctors' lounge, asks another doctor with whom he is friendly and may even socialize with the same question. How much of that utilization would you not have ordered if the patient were a family member and you were paying the bill out of your own pocket? The chances are that the answer would be very different and much higher. One of the key reasons why estimating the cost of defensive medicine is so difficult is that doctors are not likely to answer questions about it truthfully to anyone other than other doctors with whom they are friendly. Yet, as both Bev and pcb say, defensive medicine is embedded in the medical culture and is likely to be most intense in the highest risk surgical specialties and in the cities and states with the most litigious populations and environment.
Posted by: Barry Carol | January 28, 2008 at 05:58 AM
OK, Maggie, if you're going to go after my buddy Barry Carol ("you constantly throw out ideas based on false assumptions"), I'm coming off the sidelines. Be careful thinking that you possess all the facts yourself. Your information on pap smears detecting 100% of cervical cancers is just plain wrong, for instance. I've seen you make this assertion in several places. The pap smear has both high false negative and false positive rates and is now being supplanted by better procedures. Look up the medical references before you spread misinformation yourself.
I agree with pcb and Barry about defensive medicine and malpractice. Anyone who practices sees it every day in every way. Your example about California is irrelevant - just because the state law is the same does NOT mean the "malpractice environment" is the same. We all know the type of people who live in southern California are totally different from those who live in northern California, duh! Likelihood to sue is the operative characteristic here, not state law.
Barry was kind enough to ignore your slight, but I find him one of the more thoughtful commentators on this blog. I do think you should make your own interpretations more thoughtful and less media-like black and white.
Posted by: bev M.D. | January 28, 2008 at 05:13 AM
pcb,
Great comments on defensive medicine.
The prostate cancer case discussed in the link you cited clearly illustrates the need for clear liability protection codified in law for doctors who follow established evidence based standards. It would also inspire more confidence, I think, if malpractice cases were heard by special health courts presided over by knowledgeable judges with the medical panels Maggie described as opposed to by juries who cannot understand the science, the evidence and are easily swayed by sympathy for the plaintiff and the skill of lawyers.
I think malpractice reform will have to evolve state by state. It is highly unlikely that a legislative change like this would ever see the light of day at the federal level under a Democratic president or a Democratic congress (especially in the senate). Democrats love trial lawyers and take a lot of their money. I won't hold my breath waiting for a Democratic president to stand up to them on this issue.
By the way, I would be interested in your comments as to what malpractice litigation reforms you would like to see and, if achieved, how long it might take before doctors practiced materially less defensive medicine as a result of the changes becoming the law of the land.
Posted by: Barry Carol | January 28, 2008 at 02:15 AM
sorry, that should have read "and not ONLY when it comes to ordering PSAs"
Posted by: pcb | January 27, 2008 at 04:23 PM
maggie,
I too like shared decision making in medicine. I'd like your thoughts on this case, well publicized and exactly the sort of thing that drives up costs:
http://depts.washington.edu/gim/calendar/hmcjc_abstracts/JCJul04Article1.pdf
It would be hard to overstate how reading this sort of thing affects overtreatment, and not when it comes to ordering PSAs, shared decision making or not.
Posted by: pcb | January 27, 2008 at 04:21 PM
pcb--
I don't mean to suggest that fear of malpractice isn't a problem and isn't part of the mix leading to overtreatment.
It's just that people tend to focus in on one problem and decide that it's the villain. We could declare an end to malpractice suits tomorrow, and we'd still have overtreatment in this country because a) so many people make so much money on overtreatment (drug-makers, device makers, hopsitals that are operating on very thin margins and are desperate for revenues as well as some doctors) and b) because Americans have been taught to believe that "more" is always better.
But you are right that unrealisrtic expectations, a sense of entitlement and poor understanding of probabilty theory all contribute to malpractice suits. The public needs to be educated so that people understand the uncertainty us inherent in medicine. And that a bad outcome doesn't mean you've won the Lotto.
There is a way to do this--through "shared decision-making" which I have written about on this blog http://www.healthbeatblog.org/2007/10/shared-decision.html and for Dartmouth Medicine Magazine: http://www.healthbeatblog.org/2007/10/shared-decision.html.
The state of Washington recently passed a law which says that if a doctor takes a patient through shared decision-making (there is a whole protcol and international guidelines for this) so that the patient truly understands the risks, the benefits and the odds of the procedure ahead, it will be much, much more difficult for the patient to sue the doctor after the procedure.
This seems to me an excellent idea. And other states are likely to follow suit.
I personally also would like to see malpractice cases decided by judges who specialize in medical cases or panels of doctors, nurses, and well-informed patient advocates.
The cases are just too
complicated and lay juries are just too emotional.
Settlements have been expanding in Canada, the U.K. and Australia for a while, but overtreatment isn't rising for a simple reason: their health care systems have global budgets and other constraints that put a lid on volume.
For example, in Canada certain surgeons can only do so many operations a year--based on how many surgeries citizens in that province have needed in past years, adjusted for various factors, with room for some increase, but nothing like the increases in volume that you see here.
Global budgets for regions also limit volume at hospitals.
In this country, we need similar constraints on growth. At the conference I attended last week, I interviewed Don Berwick, head of the Insitute for Healthcare Improvement.
Among other things, he talked about how we need to encourage hospitals Not to fill all of their beds. "We need to cut the link between profit and volume" he said, and suggested that rather than pay hospitals for quantity of patients they admit, we might pay them for not using all of those beds. (Rather like paying farmers not to plant.) In Mass. they have are talkign about paying utility companies for conservation efforts that lead their customers to use less energy. Rather than paying utilities only for the number of kilowatts sold, they are paid negowatts--- whenever they sell fewer kilowatts.
Posted by: maggie mahar | January 27, 2008 at 03:15 PM
maggie,
If the number and award size of malpractice cases is increasing in Europe, and more physicians' reputations and confidence are affected as a consequence, it's just a matter of time before defensive medicine starts to proliferate overseas.
While I agree that the reasons for overtreatment are many, to minimize defensive medicine in the US healthcare system just doesn't pass the sniff test for those of us practicing medicine on a daily basis.
CYA medicine is widespread and pervasive, it is hammered into young physicians during their training by the majority of our mentors, among both staff and supervising residents. (It dominates decision making in the ED, ask some ED docs and the radiologists who have to read their CT/MRI scans.)
I do not pretend to have a solution to this problem. (I think societal expectations/entitlement, poor understanding of probability theory, and a litigious culture are the main players.) But to downplay it as a significant driver of costs in our country doesn't fly with what is actually happening in the trenches.
Posted by: pcb | January 27, 2008 at 12:51 PM
Barry--
You constantly throw out ideas based on false assumptions --and this kind of "I'll bet that" off-the-top-of-your head thinking can lead to the spread of misinformation.
Over the course of nearly 3 decades of research, the doctors at Dartmouth also considered whether difference in the malpractice environment explained overtreatment. Those many years of painstaking reserach show that the answer is NO.
Just one example: There is far more overtreatment in Southern California than in Northern California. Yet the same state law regarding malpractice applies in both halves of the state.
And that's just one of many examples.
In addition, the size of malpractice awards and settlements is increasing much faster in the U.K. Canada and Australia than in the U.S., giving their doctors good reason to practice "defensive medicine" but we don't see the problem of overtreatment in these countries.
Conservatives have made a crusade out of exaggerating the cost of defensive medicine as part of their compaign against plaintiffs' attorneys. They don't like plantiffs' attorneys because they protect all of us by bringing suits against corporations that knowingly produce dangerous products--whether those products are cars that explode into a ball of fire when back-ended, drugs that cause heart attacks and strokes, or abestos insulation.
Corporations (and the conservatives who support them) believe they should have a right to continue to market a dangerous product--even when they know its dangerous--and settle with the relatives of the deceased as needs be. This, corporations think, is part of the cost of doing business.
But to be sued for wrong-doing, to have to pay hundreds of millions in fines, to be publicly exposed! Thus, they would like to crush the plaintiffs' bar. And one way to do that is to suggest that the fear of malpractice is what drives the high cost of medicine in this country.
In fact all of the settlements and court awards combined equal less than 1/2 of one percent of the nation's health care bill. As to how many tests and procedures doctors do because they fear a lawsuit--there is no way to measure that.
What we do know is that whenever a doctor decices to order a test or treatment, he probbably has a number of reasons-- a gut instinct that tells him he should go one step further, genuine concern about the patient who he has known for a long time, perhaps a fear that if he misses something he might be sued, probably a much greater fear that if he makes a mistake, he might seriously hurt the patient, and perhaps, somewhere in the back of his mind, the knowledge that, since his fees aren't rising and his costs are, he needs to make up the difference on volume.
As for the quality of healthcare in the U.K.. anecdotes really don't tell us much. Medical research does. And that research shows that affluent Caucasions in the U.S. are only as healthy as low-income Caucasians in the U.K. (Meanwhile affluent caucasians in the U.K. are much healthier than affluent white Americans.) No one can explain why--we're more obsese, but they smoke more. Drinking is about the same in two countries.
The only reasonable explanation is difference in the quality of care. When preventive care is free at the point of service, people don't postpone it.
By the way, I recently ran into Brian Klepper at a conference where he told me about the clinics that he is involved with. There are no co-pays are deductibles--and the results have been excellent.
Since Brian is working with employers and large corporations, this suggests that it is "politically possible" for Americans to grasp the
importance of making sure that money is not a barrier to care.
Posted by: maggie mahar | January 27, 2008 at 09:47 AM
Maggie,
While there may well be a near unanimous consensus in the UK that healthcare should be paid for through taxes and free to the individual at the point of service. I seriously doubt that such an approach could ever survive the U.S. political process, at least in the foreseeable future. As I understand it, the UK system also vests PCP's with a critical gatekeeper role in accessing specialists. I'm told that it is difficult, if not impossible, to see a specialist without going through a PCP first to get authorization. Didn't we try that approach with HMO's in the 1990's, and didn't it have a bad ending? Presumably, making healthcare free at the point of service also requires a robust system to control utilization. While I'm absolutely convinced that good preventive care extends lives, I'm not at all convinced that it saves money for the healthcare system. I don't need to look any further than my own experience with heart disease for evidence. Catching it in time led to bypass surgery, a lifetime of medical therapy, and a stent six years after the bypass. If it wasn't caught in time, perhaps I would have died of a heart attack years ago. While that obviously wouldn't be so great for me, it would have been a lot cheaper for the healthcare system!
The UK, as a society, also determined that it is willing to spend much less of its GDP on healthcare than other OECD countries, including those in the rest of Western Europe as well as Canada. The NHS uses QALY metrics to both ration care and decide which drugs, devices, procedures, and other services it will pay for. While I personally think that is a sound approach, it would be an extremely tough sell in the U.S.
Finally, with respect to the large regional differences in practice patterns in the U.S., you and others have consistently said that it is, in large part, due to regional differences in the supply of specialists and hospital beds. I wonder to what extent it may also be due to differences in the malpractice litigation environment. I'll bet that the perceived need among doctors to practice defensive medicine is a lot lower in Minneapolis and Salt Lake City than it is in New York, Los Angeles, Miami, Philadelphia, and Washington D.C.
Posted by: Barry Carol | January 27, 2008 at 03:50 AM
pcb,Barry, Bev M.D. j.d., dr.matt,
thanks for your comments.,
Bev. M.D.--as always, thanks for the links.
Pcb & Barry-- I agree with pcb about the difficulty of evaluating physician's performance. We're not ready to do it well, particularly in an economy (and a health care system) where there are such disparities in the overall health of rich and poor.
At this conference, Dr. Don Berwick, head of IHI, and one of the most respected people in American Medicine (regularly elected the most important person in American Medicine) said that he often asks his medical students what would be the most important test they could do to judge the overall health and likely life expectancy of a new patient.
He receives answers like "check their cholesterol," "check blood sugar," "weigh them."
No, the correct answer is "look at the color of their skin."
I interviewed Berwick before he gave his speech (I'll be posting about our conversation and his speech) but one thing I asked him was about the debate we've been having here. At this point, are we in a good position to rate the quality of care that docotrs are offering?
He said "no, because what you're rating is 'the cream of crap.' Our system is so broken," he said, "that even top performers are trapped in a system where they cannot perform optimally."
The system in the U.K. on the other hand, is much better he pointed out, because there is a nearly unanimous consensus on two points: everyone has a right to health care, and it should be absolutely free at the point of delivery. That's not the time to pay. (Instead, you pay through taxes.) But when you are sick, whether or not you get care (or go for care) should not depend on whether or not you can afford it.
He added that, in the U.K. it would make no difference which political party is in power. This is what the vast majority of people in the U.K. believe.
Money should have absoultely nothing to do with health care.
dr. matt-- I agree with you that $95 billion is a significant amount of money (even if a small percentage of the whole)--and more importantly, I don't think we're getting much value for that $95 billion. Moreover, in many cases private insuerers are obstructing the delivery of good care.
That said, I'm trying to make the point that the private insurers are just a
small part of the problem of wasting health care doillars. The biggest waste comes when you look at some of the other slices of the pie: drug-makers, device-makers, hospitals and doctors who try to pump up volume, selling us more care than we need in a dangerous way while too often ignoring people who most need care.
Too many people would like to tell themselves that if we just got rid of the insurers, we could on with our current health care system and somehow magically raise quality while finding the money we need to provide care for the uninsured.
That just isn't true. Seeing the waste in the insurer's slice of the pie is the easy part.
What Don Berwick has to say--that's the hard part.
Have any of you read his book "Escape Fire"? I highly recommend it. Many of you would like it. It's brilliantly written--he's a compelling speaker and it's a collection of his speeches.
In particular, his speech about what happened when his wife was seriously ill and they went from one elite hospital to another seeking good care is an eye-opener.
You can get the book on Amazon.
j.d.-- the point is that it really doesn't matter whether private insurers' overhead is 1 1/2% higher than govt overhead, 2% higher, or 3% higher.
I don't mean to be copping out of the argument, but you're losing sight of the forest for the trees.
Posted by: maggie mahar | January 26, 2008 at 08:29 AM
Maggie,
I am sorry to belabor the point on your numbers but there is a "perspective" problem that I have with them. When speaking of the overall efficiency of medicare vs private insurance, the overhead percentage should be calculated as a percentage of the total that entity paid out, not total paid out over all. Making the overhead of pvt insurance 13.6% vs medicare 5%. If we are shopping around for say, a pump that fills resevoirs, they all lose water, we dont evaluate how well a pump does by dividing it's losses by the work of all the pumps, just the work of the pump you are evaluating.
The bottom line, even though 95 billion would be eaten up quickly, we need to evaluate and remove all and any inefficiencies possible, and if you look at private insurance, it should be one of the first to go in it's current form.
Posted by: drmatt | January 25, 2008 at 10:39 AM
pcb and Barry:
Here are the references on the subject to which you refer. I hope the table of allowable exclusions for patients transmits, as well as the two articles, from the New England Journal.
http://content.nejm.org/cgi/content/full/355/4/375
http://content.nejm.org/cgi/content/full/355/4/375/T2
http://content.nejm.org/cgi/content/full/357/2/181
Posted by: bev M.D. | January 23, 2008 at 08:35 PM
pcb,
Your comment about the UK doctors being able to exclude patients from the data as inappropriate is important and something I, of course, was not aware of. Even using that methodology, I think, would be a lot better than nothing in the eyes of the non-physician public (including myself). It would also be useful, though, if each practice disclosed the total size of the patient population that its metrics are based on as well as how many additional patients were excluded for various reasons and what the most common reasons are. Might we be on the way toward some common ground here?
Posted by: Barry Carol | January 23, 2008 at 07:05 PM
Barry,
I do know this: the UK P4P let doctors opt out patients if they (the doctor) felt the patient "wasn't appropriate" for the measurement. For whatever reason, as far as I know. (correct me if anyone knows better on this point).
Bottom line, this is a HUGE concession to the concerns I have about ratings. If I can decide that a patient isn't appropriate for the data, using my judgment, I'm more willing to accept the data as an accurate measure of quality. I've not heard this opting out to be a part of any P4P program this side of the pond, at least none that I'm familiar with.
Posted by: pcb | January 23, 2008 at 05:54 PM
pcb,
I wonder how you (and Maggie) view the UK's NHS' effort a year or so back to offer incentive bonus compensation to PCP's based on no fewer than 147 separate metrics with points assigned to each adding up to a maximum possible score of 1,050 points. I have no idea what the metrics were or what the impact on the health of the population or the utilization of healthcare services turned out to be. I do know that the docs performed better than the NHS expected and, therefore, it had to award more bonus compensation than it budgeted for. Apparently, the program could not have been implemented without widespread use of interoperable electronic medical records to gather and analyze the data. The sheer number of metrics is mind numbing to me, but the NHS obviously thought it was worth doing.
Posted by: Barry Carol | January 23, 2008 at 02:30 PM
Barry,
I've noticed there seems to be two camps on the doctor ratings issue:
1. The "we need to do something, even if it doesn't totally make sense (yet)" camp.
2. The "we can't do something until what we do makes sense" camp.
Count me in the latter group, mainly for the serious unintended consequences I mentioned in my previous reply. There are limitations, and there are fatal limitations.
Addressing other points:
The P4P and ratings system I'm familiar with have absolutely no risk adjustment or socioeconomic adjustment. None. I cannot extrapolate, but I haven't heard of much of that going on elsewhere either. (keep in mind my experience is with primary care ratings) That's probably due to a couple reasons. One, it takes time and money to make it a decent adjustment, and no one wants to spend. Two, there is a lot of doubt that this sort of adjusting, even the expensive type, does what it's suppossed to do in the first place.
On to other things…
Each time a patient walks into the doctor's office, it's a completely unique situation. Not only are the medical details unique, but also the values and preferences of the patient (not to mention economic issues.) The job of the physician is to take all the info and render a verdict as to what is in the patient's best interest. Much like a judge renders a verdict in a legal case. The reason we have judges rather than algorithmic rules for legal judgment is the details provide important information regarding a proper outcome. I see physician decisions similarly.
Additionally, the doctor patient relationship is often essential to proper physician judgment, and that relationship (and the decisions that flow from that relationship) is difficult to measure.
So then how do we rate physicians? Well, how do we rate judges? I don't know, do we have a good system for objective measurement of a good judge? Intuitively, looking for outliers on verdicts seems reasonable. But that only addresses the outliers, which by definition are few. How would we rate the rest?
One thought: The least distorted way to rate a physician would be a case by case evaluation/audit by an independent medically trained panel, sort of like an court of appeals would assess a previous judge's opinions in the legal world. Then the details on cases (where the devil always hides) can properly be taken into consideration. There are still issues with such a system (how much to weigh cost consideration vs. “best care available”, bedside manner, interaction with staff, etc.), but it’s better than what’s being done now.
Posted by: pcb | January 23, 2008 at 08:35 AM