• Quick note - the problem with Youtube videos not embedding on the forum appears to have been fixed, thanks to ZiprHead. If you do still see problems let me know.

Why Doctors Hate Science

Ivor the Engineer said:
Physicians as a group are no worse or better than any other professional group at attempting to game the system in their favour. The primary difference is in the opportunity physicians have to do it compared to other professionals.
Click to expand...

More assertion of opinion, great Ivor, why don't you admit it. You can't substantiate this claim either.
 
paximperium said:
And that somehow equates to me not enjoying my job or caring about what my patient's want?

<snip>
Click to expand...

*Sigh*

No, it doesn't.

Repeatedly repeating this claim does not magically make it true.
Click to expand...

How is CYA not supplier induced demand? I.e. do patients regularly come in and ask to be tested and/or treated for everything their physician can think of because they happen to be particularly litigious?
 
Dancing David said:
More assertion of opinion, great Ivor, why don't you admit it. You can't substantiate this claim either.
Click to expand...

You are of course free to ignore the obvious conclusions of the evidence KellyB and I have presented and choose to believe a more warm and fuzzy interpretation.
 
I think the clarification needed here is the impetus, or causative factor behind this so called PID. In the case of CYA, I guess technically it is Physician induced, and it is increasing "demand".

However, I think the jist of the topic, and what most here are taking from it, is that PID is a money/profit driven increase in physician services brought on by the providers themselves. Covering your ass is not, for the most part, profit/income driven, but rather is their because medicine is gray, not black and white, and despite all that we know, there are Zebra exceptions to every stable full of horses, so we do at times order tests on the off chance that if we do not, we may miss the zebra.

TAM:)
 
You know, lots of vets do work on a fee-per-service basis. And there definitely are some who will over-investigate and over-prescribe for financial reasons. And instruct their salaried assistants to do likewise. Some of them (probably most of them) try to excuse it as CYA, but that's justification, no more.

But you know what? Most vets aren't like that.

I'm fairly sure the medical profession is similar.

Rolfe.
 
Ivor,

Last night I ended-up taking an 89-year-old patient to the OR emergently for an infected wrist that need to be debrided.

Prior to taking him, when I did an physical exam in the Emergency Department, I noticed a Grade III/VI systolic ejection murmur at his right sternal border. I looked through his medical records, and there was no mention of a murmur as recently as this past December.

I spoke to the Orthopedic surgeon and informed him that I wanted to get an echocardiogram, something that hadn't been done on this patient since 1997, before we went to the operating room.

I had to call the cardiologist at home and have him come into the ED and do a limited echo. The patient had a body habitus that wasn't amenable to a great study, but in it I could see that he had good coaptation of his aortic valve despite a moderate to severe degree of annular calcification. We weren't able to quantify the degree of stenosis, but he didn't have a significant degree of ventricular hypertrophy or wall motion abnormality - despite an EKG that demonstrated Q-waves consistent with a prior MI in the inferior leads. Likewise, we were able to see that he didn't have any vegetations on any of his valves indicative of infective endocarditis.

Long story short?

I took this guy to the OR, induced general anesthesia, and he ultimately did fine. So, in a sense, it could be said ex post facto that this test was an additional charge to this patient, an 89-year-old, for a relatively minor procedure. He (or his insurance) is going to get a bill for a STAT echocardiogram in the ED. I didn't produce any additional income for myself, but I certainly added some money to the coffers of the Cardiology department.

So, did I "game the system"? If you think so, please explain to me what I did wrong and what I should've done instead. And, while you're doing that, imagine that this was your father or grandfather laying in that hospital bed.

Thanks!

~Dr. Imago
 
Dr. Imago,

From your description is sounds like you detected what may have been a sign of a condition which could have caused serious complications during the operation, so it seems reasonable that you investigated it further before proceeding.

Is your claim that a salaried physician would not have investigated the heart murmur further?
 
First off, I am a salaried physician. I get no additional "performance" incentive.

Secondly, many physicians may have taken that patient to the operating room without the echo. They might have blocked that arm. They might have done it under local. They might have done a whole host of other anesthetic techniques to avoid the complication.

The patient wanted to be "out" for the procedure. I heard a murmur. I insisted, having had one of my colleagues kill a patient a few weeks ago after inducing anesthesia on a patient with critical aortic stenosis, on the echocardiogram.

My assertion is that a lot of studies attempt to quantify the inscrutible. There is and always will be an individual practice variability. We all have our own forms of cognitive bias in a given clinical situation. To expect that we will all follow the same rules, and that somehow that is or should be predicated on whether or not someone gets an additional charge, is ridiculous.

I literally know hundreds of physicians professionally and personally. The ones that order unnecessary tests (and they are extremely rare) usually do so because they are nervous-nellies, not because they think they will get more money from an insurer. I'm a bit disappointed in you with your focus on physicians, when it is the private insurance business that is the real demon here. (Just look at what the top executives at Aetna make every year, in salary, bonuses, and stock options... I assure it is more than what 99.9% of physicians in the U.S. make).

So, I ordered what may have been by some considered to be an unnecessary test for the procedure undertaken. And, the results of that study didn't alter my anesthetic plan, although they could have.

I had no way of knowing that before I took that patient to the operating room and, if I'd killed him because of something I'd missed and could've prevented, I wouldn't have been able to live with myself.

This is the part of what we do that critics, like yourself, who believe we're out there trying to scam the public don't see. What's worse, is that you don't really have any solutions to what you perceive to be the problem either. You just like to cherry-pick studies that, in your own way, confirm your already preconceived notions and own form of cognitive bias.

~Dr. Imago
 
Last edited:
When forming an opinion about national policies with regards to healthcare, I don't think it serves either patients or providers to deny that physicians are not immune to forming biases, consciously or not, based on compensation and incentives.
Third party payers know physician behavior can be influenced by both positive and negative financial incentives. That is the whole basis of P4P and the "never events" list.
And this matters for us all.

What do American MD's here think about this:

http://www.cms.hhs.gov/apps/media/p...ge=&showAll=&pYear=&year=&desc=&cboOrder=date

CMS is proposing to expand the list of conditions that need to be reported if present when a patient is first admitted and is seeking public comment on whether they should be added to the list in the final rule to be announced later this year. The list in the proposed rule includes:



Surgical site infections following certain elective procedures
Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
Extreme blood sugar derangement
Iatrogenic pneumothorax (collapse of the lung)
Delirium
Ventilator-associated pneumonia
Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
Staphylococcus aureus septicemia (bloodstream infection)
Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)


Beginning October 1, 2008, Medicare will no longer pay the hospital at a higher rate for the original eight conditions or any conditions added to the list in the final rule, if they were acquired during the hospital stay.
Click to expand...

Could there not be unintended negative consequences (in addition to positive effects) of third party refusal to pay for some of those if, in fact, physicians respond to financial incentives?
 
While this guy is a libertarian, I think the potential problems he sees are real.

http://covertrationingblog.com/general-rationing-issues/never-events-never-mind

If you guys are right, and physicians are uniquely immune among the human species to positive and negative financial incentives influencing behaviors, then it doesn't matter.
But if you are wrong, and reimbursements can have an effect upon your decision making process, then an awareness of this will serve us all well.
 
Last edited:
Dr. Imago said:
First off, I am a salaried physician. I get no additional "performance" incentive.
Click to expand...

Then I don't see the significance of your anecdote.

<snip>

My assertion is that a lot of studies attempt to quantify the inscrutible. There is and always will be an individual practice variability. We all have our own forms of cognitive bias in a given clinical situation. To expect that we will all follow the same rules, and that somehow that is or should be predicated on whether or not someone gets an additional charge, is ridiculous.
Click to expand...

I don't believe the difference in behaviour between salaried and fee-for-service physicians can reasonably be explained by individual practice variability.

I literally know hundreds of physicians professionally and personally. The ones that order unnecessary tests (and they are extremely rare) usually do so because they are nervous-nellies, not because they think they will get more money from an insurer. I'm a bit disappointed in you with your focus on physicians, when it is the private insurance business that is the real demon here. (Just look at what the top executives at Aetna make every year, in salary, bonuses, and stock options... I assure it is more than what 99.9% of physicians in the U.S. make).
Click to expand...

Believe me, I've tried. I was derided and insulted in those threads as well.:)

So, I ordered what may have been by some considered to be an unnecessary test for the procedure undertaken. And, the results of that study didn't alter my anesthetic plan, although they could have.

I had no way of knowing that before I took that patient to the operating room and, if I'd killed him because of something I'd missed and could've prevented, I wouldn't have been able to live with myself.

This is the part of what we do that critics, like yourself, who believe we're out there trying to scam the public don't see. What's worse, is that you don't really have any solutions to what you perceive to be the problem either.
Click to expand...

Two obvious solutions to the perverse incentives created by fee-for-service are salary and capitation, though these lead to different incentives which may be considered undesirable. I think, however, that these problems are easier to mitigate than those created by fee-for-service.

You just like to cherry-pick studies that, in your own way, confirm your already preconceived notions and own form of cognitive bias.

~Dr. Imago
Click to expand...

I believe people respond to incentives. Is this an irrational belief?
 
kellyb said:
If you guys are right, and physicians are uniquely immune among the human species to positive and negative financial incentives influencing behavious, then it doesn't matter.
Click to expand...

I don't think anyone is saying that physicians are uniquely immune. I think what is being pointed out is that there is very little opportunity for a change in behaviour to change financial renumeration, there are many other influences on behaviour, and attempting to indicate excess services is confounded by quite reasonable variations in need and practice.

But if you are wrong, and reimbursments can have an effect upon your decision making process, then an awareness of this will serve us all well.
Click to expand...

I suspect you are way behind the curve on the issue of 'awareness'. This has been of interest to physicians for a lot longer than whenever it managed to hit the popular press.

Linda
 
I don't think anyone is saying that physicians are uniquely immune. I think what is being pointed out is that there is very little opportunity for a change in behaviour to change financial renumeration, there are many other influences on behaviour, and attempting to indicate excess services is confounded by quite reasonable variations in need and practice.
Click to expand...

Well, the randomized trial demonstrated that the effect of fee-for-service increasing visits is real. But the effect is small, and not particularly expensive, it appears. It's not something that bothers me or something I think is a key element in our skyrocketing healthcare costs.

I suspect you are way behind the curve on the issue of 'awareness'. This has been of interest to physicians for a lot longer than whenever it managed to hit the popular press.

Linda
Click to expand...

Then why are the MDs on this thread trying to say that they're not influenced by reimbursements at all? Is it because everyone here is on salary, so the potential isn't even there? Or is the argument that only negative incentives can have an effect?
 
fls said:
I don't think anyone is saying that physicians are uniquely immune. I think what is being pointed out is that there is very little opportunity for a change in behaviour to change financial renumeration, there are many other influences on behaviour, and attempting to indicate excess services is confounded by quite reasonable variations in need and practice.

<snip>
Click to expand...

No, it is not.

Originally posted by KellyB:

http://pediatrics.aappublications.org/cgi/content/abstract/80/3/344

We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P < .01) and saw their patients more often (2.70 visits v 2.21 visits, P < .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P < .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended ommended visits and scheduled visits in excess of those recommendations.
Click to expand...
 
kellyb said:
Then why are the MDs on this thread trying to say that they're not influenced by reimbursements at all? Is it because everyone here is on salary, so the potential isn't even there? Or is the argument that only negative incentives can have an effect?
Click to expand...

Are you suggesting that they are only saying this because they were unaware of the issue until people like you brought it to their attention?

Linda
 
kellyb said:
Well, the randomized trial demonstrated that the effect of fee-for-service increasing visits is real. But the effect is small, and not particularly expensive, it appears. It's not something that bothers me or something I think is a key element in our skyrocketing healthcare costs.

<snip>
Click to expand...

Is 43% more visits per well patient small?
 
fls said:
Are you suggesting that they are only saying this because they were unaware of the issue until people like you brought it to their attention?

Linda
Click to expand...

Can you not see how it would appear that MDs in this thread are in denial about the fact that physicians respond to financial incentives?
Back on page one Yuri asked:


If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri
Click to expand...

And the concensus was "Absolutely not, you heathen!"
 
Rolfe said:
You know, lots of vets do work on a fee-per-service basis. And there definitely are some who will over-investigate and over-prescribe for financial reasons. And instruct their salaried assistants to do likewise. Some of them (probably most of them) try to excuse it as CYA, but that's justification, no more.

But you know what? Most vets aren't like that.
Click to expand...


The Today programme on ITV (8 to 8.30) just spent half an hour saying exactly that.

Rolfe.
 
You must log in or register to reply here.

Back
Top Bottom