Thread by @AnupamBJena

It’s Time To Rethink The Anatomy Of Physician Behavior

Our @Health_Affairs blog piece where @LisaRotenstein & I argue that the fee for service payment system, while not ideal, IS NOT the main culprit driving waste in U.S. health care. Thread for why...

healthaffairs.org/do/10.1377/hbl…

Dartmouth studies show large variation in FFS Medicare across patients that are arguably similar (at least more similar than not). The fact that doctors who are all paid same way (FFS) have such different utilization suggests it’s something about doctors not the payment mechanism

Most PCP offices don’t actually get paid for the costly services that ensue from doctor decisions, like MRIs, CTs, specialist consults. If the PCPs aren’t paid for these sometimes low value services, it’s hard to argue that financial incentives drove those decisions.

A lot of factors influence how doctors may think and the decisions they make.

-Where & how they trained. Some studies suggest if you trained in a high utilization place, those practice patterns continue
-Malpractice fears. Estimates put this at 2-5 percent that may be too low

-Risk aversion and how docs deal with uncertainty. This is critical. A lot of decisions are driven by fear of the unknown, not direct financial incentives.
-Insulation from costs. Doctors don’t bear the costs of the tests they order, and often aren’t even aware.

Why does this matter?

Many efforts to fixing health care focus on fixing FFS, ‘Aligning incentives’. That’s fine and makes sense. But it also makes sense to understand more deeply what is the anatomy that drives physician decisions and to target that pathology directly.