Unnecessary Tests and Procedures In the Health Care System: What Physicians Say About The Problem, the Causes, and the Solutions: Results from a National Survey of Physicians

ABIM Foundation, May 1, 2014

Nearly three-quarters (73 percent) of physicians say the frequency of unnecessary tests and procedures in the health care system is a very (29 percent) or somewhat (44 percent) serious problem. ….

The top reasons physicians say they order unnecessary tests and procedures are concern about malpractice issues (52 percent say a major reason), just to be safe (36 percent), and wanting more information for reassurance (30 percent). …

The second-tier influences are patients’ insistence (28 percent) and wanting to keep patients happy (23 percent). Third-tier reasons include other factors such as … the fee-for-service system (5 percent)…. [p 5]

http://www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Ch…

****

Phasing out fee-for-service payment

By William Frist and Steven Schroeder
New England Journal of Medicine, 2013; 368:2029-2032

The fee-for-service mechanism of paying physicians is the major driver of higher health care costs in the United States [citation omitted] ….. The long-range solution is [to] shift from a payment system based on a fee-for-service model to one based on value through mechanisms such as bundled payment, capitation, and increased financial risk sharing.

http://www.nejm.org/doi/full/10.1056/NEJMsb1302322

There is an enormous gap between the opinions of the health policy elite in this country and those of the public, including physicians. The health policy elite find this gap too boring to analyze. They know why this gap exists. The problem is not them, it’s the hoi polloi and the doctors. Patients are bewitched by “technology” and think “more is better,” and doctors’ minds are warped by the incentives of the fee-for-service system. It does not occur to health policy experts that there might be something very wrong with their culture. The idea that there is even a “culture” within the health policy establishment would strike the establishment as at best uninteresting and at worst silly. That this culture might be dysfunctional is unthinkable. In their view, the only “culture” that needs analysis is that of the medical profession and of the unwashed masses.

Although the gap between public and expert opinion was documented by the early 1990s, the health policy community has shown no interest in understanding its cause. For the health policy elite, there is nothing to explain: The public is wrong and they are right. Pollster Daniel Yankelovich articulated the establishment point of view in a 1995 paper on the muddled debate about the Clintons’ Health Security Act. “The nation’s leadership and the public are carrying out a bizarre dialogue of the deaf,” Yankelovich wrote. “The nation’s elites have little trouble conversing with one another, but when it comes to engaging the public, there is an astonishing lack of dialogue.” [p. 8]

http://content.healthaffairs.org/content/14/1/7.full.pdf+html?sid=fa42b8…

The problem, said Yankelovich, is the public does not agree with the experts’ diagnosis of the health care crisis. Virtually the entire health policy establishment thinks US expenditures are high because the volume of health care is excessive. But the public disagrees. As Yankelovich put it, “[M]ost Americans attribute the rising costs of health care to waste, fraud, greed, and inefficiency, [and] they assume that whatever is wrong can be fixed by cracking down on these expressions of venality….” [p. 14] The public, Yankelovich concluded, is “on a collision course with the majority of experts”. [p. 14] Yankelovich’s explanation for this standoff was “lack of realism” and “wishful thinking” by the masses. The elite couldn’t possibly be wrong.

The health policy cognoscenti treat the gap between physician and expert opinion with the same incuriosity and arrogance. The latest evidence of how drastically physician opinion departs from that of the establishment appeared in a poll published by the ABIM Foundation (created by the American Board of Internal Medicine) on May 1. The poll found that only 5 percent of physicians believe the fee-for-service payment method is a major cause of overuse of medical care. The three most common explanations doctors offered were variations on the same theme: Reducing uncertainty. Other polls report similar resultshttp://www.unitedhealthgroup.com/~/media/UHG/PDF/2012/UNH-Working-Paper-…(see p. 8) http://jama.jamanetwork.com/article.aspx?articleid=1719740 (see Table 3).

The health policy elite emphatically disagrees. “The fee-for-service model is like asking a butcher how much steak you should eat,” Jonathan Gruber, a prominent advisor to the Obama administration, “explained” to NPR.

http://www.npr.org/templates/story/story.php?storyId=106859968

According to former Senator William Frist and Steven Schroeder (see article quoted above), the “fee-for-service mechanism is the major driver of higher health care costs.”

How do we explain this divergence of opinion? I propose a modest hypothesis: That the health policy community is as deeply influenced by incentives peculiar to their profession as physicians are by incentives peculiar to their profession. I propose that researchers both inside and outside the health policy community begin their analysis of my hypothesis by documenting the pattern I have outlined above – the experts’ habit of issuing pronouncements on the allegedly irresponsible behavior of doctors as the chief cause of the health care crisis – and comparing that pattern with analogous patterns in physician explanations. Investigators would then examine the evidence behind the different world views.

Let me offer an illustration.  The paper from the New England Journal of Medicine quoted above – “Phasing out fee-for-service payment” – contained one of those extremely rare instances in which proponents of the FFS-is-to-blame diagnosis tried to document their claim. The authors, Frist and Schroeder, cited one and only one paper – a paper published in 2011 by Laugeson and Glied entitled, “Higher fees paid to US physicians drive higher spending for physician services compared to other countries.”http://content.healthaffairs.org/content/30/9/1647.abstract The paper didn’t merely fail to support Frist and Schroeder’s claim, it contradicted it. It demonstrated that volume of services (in other words, overuse) could not explain why expenditures on physicians are so much higher in the US than in other countries that also rely primarily on the FFS method, and that higher physician fees in the US explained the difference. To paraphrase Gerard Anderson et al. http://content.healthaffairs.org/content/22/3/89.full.pdf+html, it’s the prices stupid, not FFS.

Researchers investigating my hypothesis might ask, What incentives are Frist and Schroeder exposed to that would incline them to make such a sloppy mistake? Do proponents of the FFS-is-to-blame mantra and managed care in general make more money, publish more often, advance faster within the ranks of politics and academia, have greater access to the media, or have more luck raising money from foundations than, say, single-payer advocates or observers who are less passionate about their criticism of doctors and patients?

I’m not proposing to exempt doctors and patients from similar scrutiny. I’m proposing that the scrutiny, at long last, become even-handed. I have little doubt even-handed scrutiny would either force the health policy illuminati to honor the rules of scientific discourse and stop promoting diagnoses and solutions with little or no evidence, or it would lower the credibility of the illuminati in the eyes of the public and the media. In either event, the decks would be cleared for a real debate about single payer. Then the most profound gap between the public (including physicians) and the experts would become more visible: By large majorities the public supports single-payer.http://www.pnhp.org/sites/default/files/docs/2011/Kip-Sullivan-Two-third…