Why Doctors Hate Science

[Ivor the Engineer]

<snip>

Because I think I'm having the effect I intended, which was to get you to see alternative explanations...

<snip>

What you have failed to consider is that I may have already looked at the alternative explanations even before I made my first post in the thread.

Do you put as much effort into looking for alternative explanations of the data in negative homoeopathic trials?

The reasoning is straightforward:

1) Humans respond to incentives.

2) Physicians are human.

3) Physicians have the ability to induce demand.

Given (1), (2) and (3), it is reasonable to expect that physicians will respond to incentives and use their ability to induce demand. And this is what the data overwhelmingly supports. E.g.,

Perhaps the most notable evidence is the result of a random control trial which ‘converted’ Charles Phelps, one of the most trenchant critics of SID (see Phelps 1997 p254). In this, doctors at a university hospital clinic were randomised to receive income by salary or a fee for service. Patients attending the clinic were randomly assigned to doctors. The result was that fee-forservice doctors scheduled almost 30 percent more return visits than those on salary. Most of the discrepancy was attributable to a 50 percent greater scheduling of (medically doubtful) well care visits (Phelps 1997).

As far as I can see I'm the one using the logic, while you and others are trying desperately to come up with alternative and emotionally satisfying explanations for why physician SID does not occur.

 

[Skeptic Ginger]

It's described in the article:



So the idea was that by making people pay a fee from their own money to see a physician, it would reduce the number of 'frivolous' visits and hence claims on their insurance policy, reducing overall costs.

I was thinking of cost shifting, rather than cost sharing.

I'll have to revisit my previous reply.

 

[Skeptic Ginger]

More evidence that medical professionals (as a group) are excellent at gaming the system to maintain or increase their remuneration:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862

Revisiting my previous answer:

I don't want to search through 20 pages to find what I need to know. If the physicians maintain a full schedule as a busy practice would, having one group of patients decrease their number of appointments would simply result in an economic control decreasing visits instead of a limit of physician time decreasing visits. So did they control for this?

In other words, factors which influence patient utilization can be either cost, as expected in cost sharing, or it can be the amount of time available for appointments. A provider may be short changing visits because of work load and if more time were available, the provider could address more patient problems per visit. Good care would still be the motivation of doing so, not bill padding as you suggest.

Or the provider schedule could limit requested appointments. Maybe you'd like to be seen within the week but the next available appointment isn't for 3 weeks. Having some of your patient load decreased would mean patients could be seen sooner. But the provider's schedule of appointments would be just as full each day despite the decrease in patient appointments.

Again, the result of no change in billable services is not due to provider bill padding, it would be due to one's appointments just not being made as far out.

Does the study address this or did it just look at total costs without analyzing what actually changed?

 

[BillyJoe]

As far as I can see I'm the one using the logic, while you and others are trying desperately to come up with alternative and emotionally satisfying explanations for why physician SID does not occur.

I don't know what others are doing but that definitely is not what I'm doing. I'm not saying that SID does not occur. In fact, I agree that it would be surprising if it does not occur, though to what extent is impossible to say. My point was that there are alternative explanations for the results obtained in all of those studies (I haven't looked at the last one you quoted because I have been sinfgularly unsuccessful in getting you to respond to the other four), yet you chose to accept the authors' conclusion that it is support for their SID hypothesis.

I am wondering whether you have had any negative experiences with doctors that have slanted your view.
(If you have, you wouldn't be alone ;
However, let's be impartial in our evaluation.)

BillyJoe


Edited to add:
I see skeptigirl has listed some reasons which build on those I mentioned on page 1. So I'm asking you if you have really considered the alternatives as you said you have. And, if you have, why you haven't responded when these alterntives explanations have been suggested. In other words, why have you chosen to accept SID and not the aternatives mentioned here which are equally consistent with the results obtained in those studies.

 

[Dancing David]

Just to be clear - I wasn't linking to those articles to say she had a point, I was just providing what I thought might be the source for her assertions.

I totally agree that side effect profiles are a major issue in prescribing any psychotropic medication.

Prof. Yaffle, you are cool as always.

 

[Dancing David]

There are more recent studies. Most (but not all) find exactly what would be expected if SID was occurring.

Here's another paper which discusses SID:

http://www.buseco.monash.edu.au/centres/che/pubs/wp123.pdf



Direct financial reward is not the only incentive for medical professionals to engage in SID.

It has already been mentioned that physicians in the US often perform tests they know are pointless to protect themselves from being sued (though this may also be used as a rationalisation to justify extracting more money from the patient). This would be SID to avoid a possible loss of money and public image. SID may also occur for internal rather than external payoffs. E.g., associating more care with better care.

Except most doctors in US practice do not profit from lab results or tests.

I think that patients also push for tests. I have seen many parents and adults disappointed that their child or themselves did not receive an x-ray, whne the doctor thought it was most likely a strain.

But I know your bias. In the US most doctors work for a practice that farms out the labs and tests. My doctor does not stand to profit for running labs, nor my poutine tests. She tests based upon my conditions, age, lipid profile, etc...

I also forgot! Canada caps imcome at some level , personal profit and income are limited to $250,000 a year or something like that. There are also caps on industrial production and the like. I talked to number of bussiness owners in Windsor ONT about this. How do you know that it is not income caps that caus ethe effect you are discussing?

 

[fls]

I also forgot! Canada caps imcome at some level , personal profit and income are limited to $250,000 a year or something like that. There are also caps on industrial production and the like. I talked to number of bussiness owners in Windsor ONT about this. How do you know that it is not income caps that caus ethe effect you are discussing?

WTF?!

What on earth are you talking about?

Linda

 

[Ivor the Engineer]

<snip>

Does the study address this or did it just look at total costs without analyzing what actually changed?

On page 12:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862

PHYSICIAN-INITIATED AMBULATORY CHARACTERISTICS

The regression results for the first equation estimating physician initiated characteristics of ambulatory treatment find a negative effect of cost sharing on visit fees (AVGFEE) for the miners (COST + CXI = -.01988). However, the statistically significant (p < .01) and positive parameter for cost sharing (COST) indicates that visit fees for nonminers have increased following UMWA cost sharing.
The next equation analyzes a measure of utilization-average services per visit (AVGSVC) -that is also controlled by the physician. Again, a negative coefficient is associated with the interaction variable. Miners, in relation to nonminers, are getting fewer services per visit following cost sharing. However, there is no effect on services per visit for nonminers following cost sharing. Thus, in this study, the positive effect of cost sharing on utilization seems applicable to ambulatory fees, but not to ambulatory "intensity" as measured by number of services.

 

[Ivor the Engineer]

I don't know what others are doing but that definitely is not what I'm doing. I'm not saying that SID does not occur. In fact, I agree that it would be surprising if it does not occur, though to what extent is impossible to say. My point was that there are alternative explanations for the results obtained in all of those studies (I haven't looked at the last one you quoted because I have been sinfgularly unsuccessful in getting you to respond to the other four), yet you chose to accept the authors' conclusion that it is support for their SID hypothesis.

I've been singularly unsuccessful in getting anyone to read the evidence without spoon feeding it to them.

I am wondering whether you have had any negative experiences with doctors that have slanted your view.
(If you have, you wouldn't be alone ;
However, let's be impartial in our evaluation.)

BillyJoe

None that are relevant to the issue of SID. Quite the opposite in fact.

BTW, whatever SID physicians engage in, it is probably nothing compared to dentists. My current dentist and hygienist are always trying to sell me stuff at inflated prices.

Edited to add:
I see skeptigirl has listed some reasons which build on those I mentioned on page 1. So I'm asking you if you have really considered the alternatives as you said you have. And, if you have, why you haven't responded when these alterntives explanations have been suggested. In other words, why have you chosen to accept SID and not the aternatives mentioned here which are equally consistent with the results obtained in those studies.

Because the SID hypothesis is consistent with what we know about human behaviour, while the alternative explanations have to be stretched to breaking point to explain the observed variation in demand.

 

[blutoski]

I also forgot! Canada caps imcome at some level , personal profit and income are limited to $250,000 a year or something like that. There are also caps on industrial production and the like. I talked to number of bussiness owners in Windsor ONT about this. How do you know that it is not income caps that caus ethe effect you are discussing?

Because it's not true.

I think this is part of the problem: Americans seem to actually believe this stuff, even the ones with enough education and intelligence who I think should be grounded in enough common sense to know better.

The fear is based on incredible, widespread, consumer misinformation. I'm not sure how to get around that. I suspect part of it is also jingoism: some people in any country enter cognitive dissonance when exposed to evidence that other countries could be doing better in even a trivial way.

 

[Ivor the Engineer]

You've only got yourselves to blame; there's way too much red on your flag.

 

[blutoski]

You've only got yourselves to blame; there's way too much red on your flag.

Interesting enough, one of the proposed flags had blue bars and a red maple leaf, but people thought red-white-and-blue looked "too french."

 

[paximperium]

Except most doctors in US practice do not profit from lab results or tests.

It is illegal to refer patients for tests that a physician has a financial stake or to self refer a patient to anyone that the physician has a financial interest in.
http://www.cms.hhs.gov/physicianselfreferral/

This does not prevent mutual referrals ie. back scratching(I'll refer a lung patient to you if you'll refer a heart patient to me.) which I believe is fine as long as it is not abused.

 

[Tomblvd]

I couldn't have penned better, more succinct answers myself than the first two replies below the article...





~Dr. Imago

You quoted a statement that has taken on the status of urban legend, so I'll take the opportunity to address it:

The Institute of Medicine report and other articles state that between 44,000 and 195,000 preventable deaths occur at the hands of healthcare professionals in this country every year.

The main article debunking the number is here:

http://www.devicelink.com/mddi/archive/01/11/007.html

money graph:

"Much less attention was paid to a subsequent article, published in the Journal of the American Medical Association (JAMA) last July 25, which called into question the conclusions of the IOM report. According to authors Rodney Hayward and Timothy Hofer, the results of their study suggest that "these statistics are probably unreliable and have substantially different implications than have been implied in the media." Hayward has suggested that the number of deaths due to error is probably closer to between 5000 and 15,000 annually."

 

[paximperium]

You quoted a statement that has taken on the status of urban legend, so I'll take the opportunity to address it:

The Institute of Medicine report and other articles state that between 44,000 and 195,000 preventable deaths occur at the hands of healthcare professionals in this country every year.

The main article debunking the number is here:

http://www.devicelink.com/mddi/archive/01/11/007.html

money graph:

"Much less attention was paid to a subsequent article, published in the Journal of the American Medical Association (JAMA) last July 25, which called into question the conclusions of the IOM report. According to authors Rodney Hayward and Timothy Hofer, the results of their study suggest that "these statistics are probably unreliable and have substantially different implications than have been implied in the media." Hayward has suggested that the number of deaths due to error is probably closer to between 5000 and 15,000 annually."

That was the issue with how that report was reported. It was nonsense. It basically included a multitude medical related deaths including deaths from surgery or deaths from massive heart attack after cardiac stenting, not medial errors.

It was basically a nice report about the number of deaths of patients who die after any medical intervention...great whoop.

 

[blutoski]

That was the issue with how that report was reported. It was nonsense. It basically included a multitude medical related deaths including deaths from surgery or deaths from massive heart attack after cardiac stenting, not medial errors.

It was basically a nice report about the number of deaths of patients who die after any medical intervention...great whoop.

For the sake of lurkers, I'd like to emphasize that iatrogenic morbidity and mortality is taken very seriously. Even the low numbers of 5-15k/yr is the focus of study to create strategies to ultimately eliminate all avoidable situations.

 

[Skeptic Ginger]

On page 12:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1069862

From my copy this is on page 38:

for the UMWA beneficiaries, these time intervals were increased...

for the other patients in the practive, follow-up visits were recommended at more frequent time intervals

You cannot deduce from this data that the physicians only increased visit frequency to pad their bills. You cannot rule out increased followup visits because more physician time was available.

As for the increased hospital stays, that one is questionable. Third party payers in this country have been using DRGs to determine reimbursement for hospital stays since well before 1992. That means everyone is reimbursed, not by length of stay, but by diagnosis. Patients staying more days in the hospital do not result in more income for the provider, rather they result in less income. The study didn't address this as far as I could see if they only looked at patient hospital days.

It's possible all the providers needed was feedback about the frequency of follow up visits and outcomes. They could easily believe closer observation during followup was preferable but they had to consider availability of their time to meet all the patients' needs.

It's possible this particular "large multispecialty group practice" was the exception. They may have had corporate managers pressuring them to increase appointments.

The conclusion drawn by you is premised on the belief 'physician controlled' equals greed as the only possible motivation. That is a false premise.

I could generate a lot more business in my practice simply by telling employers that I recommended all their blood exposed employees have 6wk, 3mo, and 6mo follow up lab work. I don't do that because it is unnecessary if the person who is the source of the blood tests negative (with a few exceptions). I would say such recommendations are more usual than not and where they are not usual, the most common reason is provider belief such follow up tests are necessary.

 

[T.A.M.]

Some provinces do place Caps on physician income, this is (from memory after reading it years ago - I have never made so much as to have my fees capped), IIRC, how it works.


You have a cap of lets say $350,000 per year.

The payer (Provincial Health Care Plan) will then reduce the amount you can receive per billing by a percentage. This means that every $1 you make above the $350,000, you will only see a certain percentage of it. That leads to a second cap, and after that cap, every $1 you bill, you will see even less of it.

eg.

MD Bills the health care plan for $500,000 this year. He is in a province that has a 1st cap of $350,000, and a 2nd cap of $450,000. The first cap reduced billing payout by 33%, and the second cap reduces it by 50%.

So The doc gets $350,000 + $67,000 + $25,000 = $442,000 total instead of $500,000

Or at least, this the way I think it works.

TAM

 

[Miss_Kitt]

I do wish I was worshiped as a god but the nurses keep me in line.

Pax -- Are you coming to TAM? I can at least throw rose petals at your feet...

 

[paximperium]

For the sake of lurkers, I'd like to emphasize that iatrogenic morbidity and mortality is taken very seriously. Even the low numbers of 5-15k/yr is the focus of study to create strategies to ultimately eliminate all avoidable situations.

Sorry for the flippant tone but yeah, while 5000-15000 isn't that great a number compared to the millions treated each year, this number does not include the errors that don't kill people which is probably in the tens or thousands if not in the hundreds of thousands.

We will never be able to totally get rid of medical errors but I believe we can decrease to a few hundred a year if we properly take precautions.