4
As chapter 3 showed, the American public believes “doctors know best” when it comes to the use of medical evidence and the allocation of resources within the health care system. But what do doctors think about these issues? In the second half of this chapter, we report the results of a national survey of physicians. What actions would doctors like their medical societies to take when high-quality studies challenge the efficacy of treatments in their practice areas? Do doctors support bringing colleagues who deviate from evidence-based protocols to the attention of disciplinary boards? How well informed are doctors about indicators of wasteful spending, such as regional variation in the Medicare program? These issues are key to explore not only because doctors are opinion leaders on health care reform, as the previous chapter showed, but also because medical societies are frequently at the center of controversies over the use of medical evidence. Consider the debate over prostate cancer screening.
In 2008, the United States Preventive Services Task Force (USPSTF), an independent panel of experts in evidence-based medicine, recommended that healthy men ages 75 and older should no longer receive a prostate-specific antigen (PSA) blood test to screen for prostate cancer because the harms of routine screening and treatment outweigh any potential benefits.1 The PSA test produces many false positive results, and most of the prostate cancers discovered through tests are so slow growing that they are unlikely ever to become harmful, especially in older patients. Autopsy studies show that three-fourths of men over age 85 have prostate cancers, most of them clinically unimportant.2 Prostate cancer is commonly treated through radiation or radical prostatectomies, which may cause pain and lead to serious complications such as urinary incontinence and impotence, with little or no survival benefit.3
Many urologists did not heed the call to stop routinely screening men 75 and older for prostate cancer. Although the American Cancer Society and American Urology Association (AUA) discouraged prostate cancer testing in men whose life expectancy was a decade or less, a study conducted four years after the USPSTF recommendation found that 43 percent of men ages 75 or over were being screened.4 Some experts believed that the 2008 USPSTF recommendation did not go far enough to curb unnecessary screening. Professor Richard Ablin, research professor of immunobiology and pathology at the University of Arizona College of Medicine, who discovered PSA in 1970, wrote an op-ed in the New York Times on March 9, 2010:
The test’s popularity has led to a hugely expensive public health disaster…. The test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer—the one that will kill you and the one that won’t…I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.
Ablin stated that the test was still being used because it was being pushed by drug companies and advocacy groups. “Shamefully, the American Urological Association still recommends screening, while the National Cancer Institute is vague on the issue, stating that the evidence is unclear,” he said.5
In 2012, the USPSTF updated its 2008 guidance. Based on five wellcontrolled clinical trials,6 the task force now recommended against routine prostate screening for men of all age groups. The taskforce concluded that the unreliability of PSA test results, coupled with the test’s inability to distinguish clinically insignificant from aggressive tumors, meant that a substantial number of men would be overdiagnosed and overtreated for prostate cancer.
Many urologists rejected this recommendation and continued to defend PSA testing. “The AUA is outraged and believes that the Task Force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease,” the association stated.7 The group said that it was “inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African American men.”8 Prominent physicians also spoke out against the recommendation. Dr. Peter Schlegel, chairman of urology at New York–Presbyterian/Weill Cornell Medical Center in New York City, stated, “Death rates from prostate cancer have dropped dramatically in the U.S. despite an aging population, which suggests evaluation and early treatment of prostate cancer is valuable in saving lives.” Referencing high-risk patients, such as African Americans, who face a higher prostate cancer risk, Schlegel added, “There will be more people who die of prostate cancer because of the application of these study results.”9 This concern was a valid one, but many of the statements of the medical community failed to acknowledge the potential harms of excess screening or confront the trade-offs for public health in a scientifically responsible way.
Yet the mounting scientific evidence against routine screening put the urologists’ association on the defensive. In 2013, the AUA issued new guidance of its own, stating that the association no longer recommended routine screening for men 40 to 54 years of age who are at average risk of developing prostate cancer, and also no longer recommended the test be administered to men 70 and older. The AUA’s updated position indicated that men 55 to 69 should discuss the benefits and harms of PSA testing with their doctors. Some prostate experts said that the AUA “risked losing credibility” if it did not change its position, and that the new guidelines might preserve testing by favoring more moderate use.10 In 2017, the USPSTF issued a draft recommendation (based on new evidence published since 2012) that moved its stance closer to the position of physicians. The draft maintained the recommendation against the PSA screening for men age 70 years and older, but recommended that “clinicians inform men ages 55 to 69 years about the potential benefits and harms of PSA based screening for prostate cancer.”11
Did the 2012 USPSTF guidance against routine PSA screening for men of all ages shift practice? Yes, but not in the way many experts hoped. A 2015 Journal of Clinical Oncology study found that screening rates among 40 to 49 year old men did not significantly change between 2010 and 2013, but that rates did decline significantly among men over age 50.12 However, a large fraction (about one-third) of men over 75 continued to undergo screening despite the recommendation against it.13 A previous study, using claims-based measures of screening rates rather than patient self-reports, also found that 40 percent of men ages 75 and over continued to receive PSA tests.14 “While we weren’t surprised to see a decline in screening, we were disappointed to see the way these declines have occurred,” said Michael W. Drazer of the University of Chicago Medical Center. “Instead of observing large declines among older, less healthy men who are the highest risk for overdiagnosis and overtreatment, the steepest declines in screening were observed among younger, healthier men.”15
The PSA screening case is illustrative of several important patterns in the politics of health policy making in the United States. First, a scientific consensus that a treatment or test is not associated with better outcomes for certain patient groups may lead to public controversies in which medical societies and leading physicians take center stage. The PSA case is hardly unique on this score. There have been similar controversies over breast cancer screening and other diagnostic tests and medical interventions.16 The American public watches these controversies unfold with considerable interest. Compared to Europeans, Americans seem to have higher expectations for medicine and are more likely to consider themselves very knowledgeable about new medical technologies.17 Second, the positions of medical societies in these controversies reflect not only the state of medical evidence, but also a desire to preserve professional authority. When evidence emerges that common interventions are less useful than advertised, doctors and medical societies often defend current practices, at least for a time. Multiple factors— cultural, psychological, and organizational, as well as financial—explain why doctors’ groups often adopt this posture.18 The key point for our purposes is that rather than assuming a proactive, public leadership role to promote evidence-based care and the elimination of low-value services, many physicians strongly defend tests and treatments that evidence suggests have clear trade-offs for patients.
We explore the beliefs that help sustain these patterns through a national survey of physicians. The survey suggests that many doctors lack familiarity with key features of current debates over the quality and efficiency of health care delivery. For example, when asked about the existence and causes of regional variation in Medicare spending—one of the major pieces of evidence adduced to support the claim that there is vast inefficiency in health care utilization—only one in five physicians indicated that they were very or somewhat familiar with the existence of this research finding. When asked about the causes of geographic variation, doctors emphasized systemic factors such as the malpractice environment but were skeptical of the importance of physician practice style, a pattern of beliefs that is in contrast with recent research emphasizing the role of physician practice style and beliefs in driving variation in Medicare spending. In sum, although the tradition of professional autonomy places the physician at the center of the U.S. health care system, our survey evidence suggests that physicians do not recognize the important role their own beliefs (and potential misconceptions) about what constitutes good medical practice play in contributing to the problems of overutilization and inefficiency. We also find that doctors generally want their medical societies to forcefully defend treatments challenged by research. At the same time, the survey uncovers notable differences among the views of physicians based on both their medical specialization and partisan affiliation. We find that, even after controlling for other factors, doctors who identify with the Republican Party place a somewhat higher priority on protecting clinical autonomy (and a somewhat lower priority on discouraging clinical interventions with minor or no benefits) than do doctors who identify with the Democratic Party. We cannot say if this partisan split is new or long-standing, but it helps explain why the medical profession has not been a unified voice for efforts to promote evidence-based practices.
Before detailing our survey results, we first provide a brief overview of the role of the U.S. medical profession in the American state, and the challenge this role poses for democratic accountability.
The Dilemma of Professional Self-Regulation
Health care is characterized by uncertainty and asymmetric information. Medical knowledge is specialized and complicated. The typical doctor knows much more than the average patient does about what care he or she needs, and the patient cannot test the “product” before consuming it. As a result of this information asymmetry and the desirability of delegation, society establishes a social institution—the medical profession—based on trust. Professional ethics require doctors to serve as reliable “agents” and put the interests of patients above their own self-interests.19
Yet while the social function of the medical profession is to harness expertise on behalf of the public welfare, professional authority is constituted by state power.20 Governments endow “legitimate” healers—doctors—with cultural status, legal privileges, and the right to prescribe and deliver medical services to patients without supervision. Legitimation occurs through the standardization and subsidization of medical education licensure.21 As Mark Peterson points out, medical knowledge is power—and this power is applied not only in the clinical work that doctors perform, but in the profession’s efforts through lobbying and civil society activities to exert “influence over the entire social structure that defines and regulates the environment in which that work is accomplished.”22 In short, professions are “political entities” that possess “the power to distract, encourage, limit, and inform public recognition of and deliberation over social problems.”23
John E. Wennberg observes that the acceptance of the agency model as rational from both the patient’s and society’s point of view rests on strong assumptions. First, the model assumes “that clinical decision making is grounded in medical science; physicians have evidence-based knowledge to diagnose illness accurately and estimate the risks and benefits for the treatments they prescribe.”24 The second assumption is that physicians choose the treatments that individual patients would prefer, if individual patients were to possess the same information as physicians and understand their “true” wants and needs. The third assumption is that professional ethics ensures that doctors will recommend what is best for their patients, even though doctors typically benefit financially from higher utilization of services. A fourth assumption is that “egregious behavior by the few unethical physicians who induce patient demand for self-serving motives is detected and controlled through utilization review and other methods the profession adopts to discipline ‘outlier’ behavior.”25 The agency model was also assumed to be rational from society’s point of view:
A doctor-patient relationship that works in the way I have just described ensures that the supply of medical resources, including physicians, will not influence demand in a way that is wasteful…. Thus, the physician serves as guarantor of the efficient allocation of society’s resources: if capacity exceeds that required to produce effective and valued services, capacity in excess will go unused.26
Unfortunately, all these assumptions have been shaken by health services research. There is widespread regional variation in the utilization of services and spending in the Medicare program that is unrelated to illness rates.27 Physician beliefs and behavior are major drivers of this variation. To be sure, most physicians have ethical motivations. Without denying the vast influence of the medical products industry,28 we strongly agree with Wennberg that most doctors are not “cynically rubbing their hands together every time a patient walks in the door, thinking of ways to deliver more care, and thus make more money.”29 Still, most patients delegate decision-making authority to their doctors. Medical education, peer-reviewed research, guideline development, and professional meetings and information sharing are all intended to ensure that patients receive appropriate treatments, but these mechanisms do not always function effectively.
Wennberg develops a typology of three categories of care: effective care, preference-sensitive care, and supply-sensitive care.30 The category of medicine labeled effective care, which Wennberg suggests accounts for no more than 15 percent of total Medicare spending, refers to treatments that are known to work better than alternatives and for which the benefits are greater than the side effects. Delegation does not pose a major risk to the patient because services are backed by reasonably strong medical evidence. The main problem in this category of medicine is underuse of necessary care.31 Preference-sensitive care (approximately 25 percent of Medicare spending) consists of services for which evidence does not point to a single best intervention (there are multiple ways of treating a condition, each of which has different outcomes) or evidence is missing altogether. Finally, supply-sensitive care, which accounts for roughly 60 percent of Medicare spending, refers to services where the supply of a specific resource (e.g., the number of hospital beds per capita in a given region) has a major influence on utilization rates.
Professional self-regulation should ensure that doctors recommend the best treatments for patients, but it sometimes disappoints. In his important book Unaccountable, Marty Makary describes physicians who overlook malpractice by their colleagues and the failure of the medical profession to play a leadership role in curbing rampant medical errors.32 A key problem concerns the failure of the medical profession to collect and use the information needed to learn from mistakes and improve performance. Makary and his colleagues at Johns Hopkins examined clinical registries that collect data on patient outcomes. Such registries are crucial for comparing the efficacy of treatments and evaluate the quality of care. The study found that 84 percent (98 of 117) of recognized U.S. medical specialties had no national clinical registries, and the registries that did exist were generally of poor quality and lacked the information needed to render them useful for physicians, patients, and policy makers.33 Of course, the fact that studies like this are increasingly common and that physicians are much more willing to be honest about the performance failures of the medical profession demonstrates how much has changed since the 1950s when there were strong norms against airing the profession’s dirty laundry in public.34 Increasingly, there are leaders who are trying to bring data, transparency, science, and accountability to the medical profession. Yet while significant progress has been made in surfacing the harms from the medical profession’s lack of internal accountability mechanisms, financial ties to the medical products industry, and general complacency, a tremendous amount remains to be done.
The Diffuse American Medical Authority Regime
The United States is by no means alone in having doctors who seek to protect their professional authority and clinical autonomy. Yet the broader context in which American doctors practice and organize themselves is distinctive because of the nation’s political development, cultural values, and institutional arrangements.35 While physician services are increasingly financed from public sources as a result of the growth of Medicare, Medicaid, and tax preferences for employer-provided health insurance, public control over providers has “not matched the shift in dollars.”36
A recent survey of physicians in Canada, Norway, and the United States found that U.S. doctors report much higher perceptions of clinical autonomy than their counterparts in the other two countries (though somewhat lower job satisfaction). Specifically, a much larger proportion of U.S. physicians compared to Canadian or Norwegian physicians strongly agreed with the statement, “I have the freedom to make clinical decisions that meet my patients’ needs”(United States, 55 percent; Canada, 10 percent; Norway, 12 percent).37 While the United States is not an outlier in the use of expensive technologies in every practice area, the overall environment of American medical care broadly permits doctors (many of whom are self-employed) to practice as they see fit. “The policies of both private and public insurers have traditionally offered a more welcoming and costunconscious approach to the provision of new healthcare technologies in the United States,” observe health economists Alan Garber and Jonathan Skinner. “Almost uniquely among wealthy nations, the United States typically does not consider effectiveness relative to its costs or to the costs of alternative treatments.”38
History helps explain these cross-national differences. The absence of centralized budgetary or regulatory control of the U.S. medical profession reflects in part the timing of the growth of public health insurance programs. The U.S. medical profession developed well before government efforts to control health care spending. As Deborah Stone observes, “In the United States, professional organization has generally preceded state involvement in health care, though government intervention has often been an impetus to organizational activity of the medical profession.”39
The story of the U.S. medical profession’s rise to sovereignty has been told by Paul Starr in his Pulitzer Prize–winning book The Social Transformation of American Medicine. Three points bear emphasis. First, historical forces—not just the rate of scientific progress—explain why the U.S. medical profession’s claims to therapeutic authority, social privileges, and economic power were consolidated during the Progressive Era. Whereas the Jacksonian Democrats and Populists of the 1800s viewed expertise with skepticism and resisted the claims of the professions (viewing them as the means to maintain artificial privileges), progressive reformers viewed knowledge as the basis of legitimate power in the modern state. Progressives sought a rationally governed society. They believed that scientific knowledge was complex and inaccessible to the average citizen, and they held up professional authority as a “model of public disinterestedness.”40 In the political domain, Progressives believed that the public leadership of communities of scientific experts could protect citizens from the rough edges of capitalism, enlighten public opinion, and build a consensus for reform.41 Progressives therefore were supportive of the medical profession’s efforts to promote its autonomy.42 “[O]nce they were institutionalized, standardized programs of [medical] education and [state] licensing [boards]” served as gatekeeping mechanisms, allowing medical societies to contest medical “quackery” and mobilize opposition to competitors like the patent medicine industry.43 As James A. Morone argues, “Physicians were well constituted to meet the Progressive regulatory ideal of relying on skilled professionals to protect the public from abusive practices.”44
Second, the growing cultural authority of the U.S. medical profession during the Progressive Era reflected a general increase in the public’s confidence in science, but it did not “stem specifically from the development of effective therapeutic agents, which were still few in number.”45 To be sure, nineteenth-century physicians could point to major advances in public health, immunology, and surgery, but in other areas, doctors made recommendations on the basis of little or no evidence. As Starr writes, “cultural authority need not be based on competence. Ambiguity may suffice.”46 This point still resonates; the therapeutic authority of doctors does not appear to have a one-to-one relationship with the quality of medical knowledge in specific specialty areas.
Third, while physicians exercise authority in every health care system, the U.S. medical profession’s situation is distinctive because of the weakness of the central American state. In many European nations, national governments and social institutions have a long history of regulating “public health functions such as sanitation, vaccination, and quarantine.”47 This subsequently provided the institutional foundation for centralized oversight over the medical profession’s therapeutic decisions. In contrast, medical authority in the United States has traditionally been diffuse. As Daniel Carpenter observes, in Australia, Japan, and Western Europe, licensure, examination and testing, and professional entry processes are regulated at the national level, but in the United States these matters are subnational affairs,48 much as they are for other professions like lawyers and clinical psychologists. In a comparative historical study of the medical profession in the United States and France through the 1980s, David Wilsford showed that French medical societies are poorly financed, inadequately staffed, and internally divided. The centralized bureaucratic French state was generally able to withstand the pressures of the doctors’ groups. By contrast, in the United States centralized state authority was weaker, the financing of medicine was more fragmented, and organized medicine was able to guard its professional autonomy in the name of promoting quality.49
In a series of articles, University of Pennsylvania Law School dean Theodore Ruger analyzes the deep historical and constitutional roots of the diffuse authority structure in American medicine. Since the founding of the nation and up to the present, Ruger argues, the main thrust of U.S. medical practices has been “relentlessly centrifugal: therapeutic authority was devolved to and resided in the most granular level of medical interaction.”50 As he writes:
Central to the individualistic diffusion of medical authority in the United States were three basic devolutions of power generated by a coalescence of constitutional federalism, weak state licensure regimes, and professional eclecticism and resistance to standardization. The first decentralization was a product of constitutional federalism, as regulatory power over medicine was understood to rest with the states, where it largely remains today. To the extent that states regulated medicine at all (and in the nineteenth century, most repealed their licensure laws under popular pressure), they in turn delegated authority to the profession itself in the form of licensure boards. Finally, the medical boards effected a third devolution to individual practitioners through their inability or unwillingness to actively monitor or standardize the actual practice of medicine.51
In short, America’s medical authority regime has traditionally delegated most authority over the utilization of medical services to individual physicians and their patients. This approach allows physicians to practice according to their (specialized) training and beliefs, but it also produces troubling results from the perspective of both patient outcomes and system rationality and costs, including wide variations in treatment utilization, and spending and outcomes without apparent logic. To be sure, these problems are not unique to the United States.52 Compared to its counterparts in other nations, however, the U.S. medical profession is more specialized and fragmented—by one count, there are 37 primary specialties and 92 subspecialties.53 Doctors in the United States also practice within the context of an overall medical system in which health care is treated as a market good, many doctors still own their own practices, and there are few supply-side constraints to limit overutilization of low-value services, such as controls on high-tech medical capital equipment.
National efforts to regulate health care have built around the constraints posed by traditions of strong professional autonomy. Even when Congress has enacted national legislation to expand insurance coverage, as in the adoption of Medicare over the opposition of organized medicine, there has been pressure to reassure doctors that the government was not a threat to their professional autonomy.54 The result is that government health insurance programs have largely respected preexisting patterns of therapeutic authority. Despite growing concerns about whether the roughly 18 percent of GDP spent on health care55 delivers good value for money, federal officials often lack the tools to promote quality, safety, efficiency, or cost control in either Medicare or the health care sector as a whole.56 The health care sector thus reflects and encapsulates some of the most challenging features of public administration in the United States. As political scientist Terry Moe argues, “American public bureaucracy is not designed to be effective. The bureaucracy arises out of politics, and its design reflects the interests, strategies, and compromises of those who exercise political power.”57 Moe’s statement applies with special force to the CMS, which lacks the capacity to routinely defund low-value treatments or even to root out fraud and abuse despite growing concerns about Medicare’s cost growth.58
Nicholas Bagley, a health law professor at the University of Michigan, summarizes Medicare’s administrative pathologies:
Here’s the crux of the dilemma. Only physicians have the opportunity, knowledge, and legitimacy to make clinically sensitive judgments about what medical care beneficiaries need and, by extension, what Medicare should finance. And so Congress, in the Medicare statute, put physicians at the center of the program. They judge whether treatments are medically necessary and thus eligible for reimbursement. They must certify the need for institutional care or Medicare pays nothing to hospitals, hospices, or skilled nursing facilities. And they diagnose the medical conditions that establish how much Medicare pays for institutional care. Physicians are Medicare’s bureaucrats at the bedside. Taken together, their decisions constitute Medicare policy …
However understandable [when Medicare was created in 1965], Congress’s design choice has hamstrung subsequent efforts to assert control over the physicians that actually have the administration of the program in hand.59
Bagley carefully reviewed the implementation of the four most ambitious efforts to reform Medicare since 1965: peer review organizations, the shift from retrospective to prospective payment, Medicare managed care, and limitations on the coverage of new technology. He finds that while these changes (especially prospective payment) may have slowed the rate of cost escalation, they have done relatively little to make the thousands of private physicians paid by the program—“Medicare’s bureaucrats at the bedside”— attentive to government’s programmatic health care goals. Further, Bagley argues that while the ACA aimed to reshape the delivery system to reduce costs and improve quality through a transition to “bundled payments” and other changes, “the ACA reforms are inattentive to the structural features of Medicare that have frustrated the development of organized systems of care that have the incentives, bureaucratic wherewithal, and legitimacy to reshape physician practice patterns to accommodate federal priorities.”60
To be sure, there have been countervailing developments. For example, CMS has sometimes conditioned reimbursement of a new device on the collection of additional evidence about its effectiveness after the device is on the market.61 Private insurers are increasingly requiring drug companies to supply data on the clinical performance of their new products and using these data when deciding which products to include on formularies that, in turn, shape doctors’ treatment decisions. Physicians increasingly are receiving capitated payments or being paid based on outcomes or quality. And key health institutions like Kaiser Permanente are at the vanguard of efforts to rationalize health care delivery. These developments could potentially reconfigure American medicine over time.62 For now, though, they represent islands of rationality and efficiency in the overall U.S. health care system.
THE FALL OF THE HOUSE OF MEDICINE?
There is no doubt that physicians enjoy less power (and lower job satisfaction) today than their counterparts did during the “golden age” of American medicine during the postwar era.63 Yet the prevailing view that the professional and clinical autonomy of the U.S. medical profession has crumbled over the past several decades cuts too deeply. Starr persuasively traced the loss of legitimacy and influence after the 1960s to the corporatization of medicine, growing concerns about costs, and the rise of countervailing powers, including insurance companies and social movements questioning all sources of traditional authority.64 Yet as noted in chapter 3, while public trust in the leaders of medicine has indeed fallen in an absolute sense, Americans still believe that doctors have high ethical standards and remain confident in their own physician. Moreover, the public has much more faith in doctors to recommend the “right thing” when it comes to health reform than other groups. The high degree of trust that Americans have in their own doctors colors the way medical societies are perceived. Much of political power is a function of relative trust, and relative to the other institutional actors with whom the medical profession competes for influence, doctor groups have maintained a fairly high level of prestige and trust. Medical societies remain powerful vested interests that are often forces for stability who seek to protect their institutions and resist threatening reforms.65
Physicians and medical societies in the United States continue to exercise vast influence in policy venues and settings characterized by low visibility and high technical complexity. A canonical example is in the calculation of physician fee schedules under the Medicare program. As Miriam J. Laugesen observes in her important book Fixing Medical Prices, the Centers for Medicare and Medicaid Services (CMS) heavily relies on the recommendations of the American Medical Association’s Relative Value Scale Update Committee (RUC). Little known to the general public, the RUC has an enormous influence on Medicare financing decisions. Between 1994 and 2010, CMS agreed with 87.4 percent of the committee’s recommendations on how much physician time and effort is associated with various physicians’ services.66 There is evidence that the RUC’s estimates of the time involved in many procedures are often exaggerated, sometimes by as much as 100 percent, according to a Washington Post investigation.67 To determine how long a procedure takes, the committee relies on surveys of doctors conducted by the medical societies representing specialists and primary care physicians. The doctors who fill out the surveys are told that the reason for the survey is to set their Medicare pay. “What started as an advisory group has taken on a life of its own,” said Tom Scully, who administered Medicare under George W. Bush. “The idea that $100 billion in federal spending is based on fixed prices that go through an industry trade association in a process that is not open to the public is pretty wild.”68 The RUC’s influence over health policy making is vast; studies show that changes in Medicare’s relative value units influence private insurers. When Medicare raises the price of a service by $1, private insurers raise prices by $1.30 on average.69
The biggest recent threat to doctors’ clinical autonomy occurred with the rise of “managed care” in the 1980s.70 Directors of managed care insurance plans argued that they, not doctors, were the key to scientific progress and patient welfare.71 “Armed with treatment protocols and guidelines predicated on the results of clinical trials, outcomes research, quality measures, and patient satisfaction surveys, they have moved to supplant physicians as the primary arbiters of what works and does not work in medical practice.”72 For a time, doctors and patients had to seek permission to use expensive treatments—a textbook definition of explicit rationing.73 Robert Blendon and his colleagues report that 53 percent of U.S. physicians in 1991 indicated that “external review of clinical decisions for the purpose of controlling health care costs” was a serious problem, compared to 28 percent of Canadian physicians and 43 percent of West German physicians.74 But managed care restriction generated a furious backlash. “The transition to managed care was rapid and stunning. But the demise was even more rapid and even more stunning…. The managed care backlash was typified by the 1997 movie As Good as It Gets, in which the Helen Hunt character unleashed a flurry of expletives about managed care, and audiences across the country cheered loudly.”75 Political attacks, along with an outpouring of anti–managed care regulatory initiatives at the state level, succeeded in diluting strong utilization management controls and increasing physicians’ clinical autonomy.76 As David Mechanic observes, while “some managed care strategies are being reintroduced and new ones tried. American doctors and patients want to remain in the driver’s seat, and their wishes are likely to affect the range of realistic future options.”77 While the role of doctors in the United States has evolved over time, the main story line is continuity, not change. As medical historian Rosemary A. Stevens wrote in 2001,
Despite the gloom and doom expressed over managed care from the early 1990s to the present, doctors have not lost their normative roles in American society. They embody a huge reservoir of goodwill, inherited from the past. This is derived in various parts: from long respect of the doctor as healer; from the ideology of medicine as a public service and the doctor as hero; from the huge advances of scientific medicine in the 20th century, continuing through promises for the future; from claims for scientific objectivity; from the symbolic value of medicine as culturally suited to other American values (such as ingenuity, technology, and international superiority); and, not least, from the sheer visibility of national medical organizations, even in the absence of a unified governmental health policy.78
National Survey of Physicians on Medical Evidence Issues
Because of these long-standing institutional and cultural features of our national approach to health policy, the future of U.S. health policy will be shaped to a significant extent by the preferences and beliefs of our nation’s doctors. It is important to understand how individual physicians think about issues that affect the overall efficiency and performance of the U.S. health care system, such as regional variation in Medicare, the role of medical societies, and professional self-regulation. To explore these issues, we conducted a national survey of 750 U.S. physicians between August 21, 2015, and September 24, 2015.79 Each survey was accompanied by a letter of introduction and included $20 as a (small) compensation for the physician’s time.80 We received 12 returned envelopes owing to bad addresses and 374 total responses, for a response rate of 50.7 percent (374/738).81
We separate the results of our survey of doctors into six subsections. We first discuss doctors’ political interest and civic engagement. We then examine doctors’ views on how the United States compares to Western European nations when it comes to a variety of health outcomes. Next, we examine doctors’ beliefs about the causes of regional variation in Medicare spending. We also report doctors’ views of the appropriate role of medical societies in representing physicians’ interests and in responding to research challenging the effectiveness of treatments. Last, we discuss the “practice style” of doctors and how it impacts physicians’ beliefs about patient care.
PARTICIPATION AND INTEREST IN POLITICS
It is well known that doctors’ interest groups such as the AMA and medical societies play an active role in politics, but individual doctors are also influential actors in health care within their social networks and local communities. How engaged are individual physicians in politics?
A study published in the Journal of General Internal Medicine that analyzed data from the 1996 and 2002 elections found that physicians vote at rates that are 9 percent lower than the general population and 22 percent lower than lawyers, controlling for socioeconomic variables known to influence voting rates.82 Yet casting a ballot is not the only or likely the most effective avenue of civic engagement for physicians. Most doctors are much wealthier than the average American and can easily afford to give political donations to candidates and causes they believe in. Bonica, Rosenthal, and Rothman, for example, report that physician campaign contributions increased from $20 million to $189 million between the early 1990s and the 2010s.83
In our survey, we asked doctors about their general interest in politics and whether they contact government officials. In terms of political interest, 84 percent of doctors in our sample report following what’s going on in government and public affairs at least some of the time (45 percent most of the time; 39 percent some of the time). In comparison, a 2014 Pew report found that 77 percent of the general public reported following what’s going on in government and public affairs to the same degree (48 percent most of the time; 29 percent some of the time).84 Although not a large difference, this suggests that even if doctors do vote at somewhat lower rates than the general population, they are at least as, if not more, attentive to governmental affairs than the general public.
Similarly, our sample of doctors reported having contacted government officials somewhat more than the general public. Thirty-one percent of doctors in our sample reported having initiated direct contact with their members of Congress (either a congressional representative or senator) in the past twelve months.85 In the same Pew report cited above, 28 percent of the general public reported contacting an “elected official” in the last two years.86 So, again, doctors appear to be at least, if not more, politically active than the general population. In addition, we also asked our sample of physicians whether they had contacted a White House official, an executive department official, or an official at a regulatory agency. Although fewer doctors reported making such contacts, 14 percent did report contacting an official at a regulatory agency, 5 percent an executive department official, and 2.5 percent a White House official. Although we do not have comparable figures for such contacts among the general population, these findings suggest that a nontrivial number of individual doctors, not just interest groups such as the AMA and medical societies, are willing to contact those executive agencies (such as those falling under the purview of the Department of Health and Human Services) involved in rule making that may directly affect their practice/autonomy. In sum, many doctors report being politically engaged. Doctors are geographically dispersed across the country, and it is likely that at some point or another virtually all members of Congress hear from doctors in their districts.
THE UNITED STATES COMPARED TO WESTERN EUROPEAN NATIONS
It is widely believed among health services researchers that U.S. health outcomes are not consistently superior to the health outcomes to those of other rich Western societies, despite our substantially higher level of spending.87 But what do doctors know about our relative spending levels and what do they think about the relative quality of care? We asked doctors a factual question about whether the level of health care spending in the United States differs from other Western democracies. More than 90 percent of doctors correctly indicated that health care spending as a percentage of GDP is higher in the United States compared to Western European nations, such as France or Germany. Only 7.6 percent of all respondents indicated that the United States was on par with these other nations or spent less as a percentage of GDP. Many doctors expressed concerns about what the United States achieves for its high level of health care spending. A majority of doctors indicated they believe that “the quality of health care” received by the average patient in the United States is “worse” (21 percent) or “the same” (43 percent) as the health care received by the average patient in Western European nations. However, only 36 percent of doctors in our sample stated that the quality of health care in the United States is “better.”88
REGIONAL VARIATION IN MEDICARE SPENDING AND UTILIZATION
One reason to believe there is wide scope to improve the efficiency and quality of U.S. health care comes from the Dartmouth Atlas of Health Care, which documents a more than twofold variation in per capita Medicare spending in different regions of the country.89 Atul Gawande distilled the lessons from this body of research in a famous 2009 New Yorker article, “The Cost Conundrum,” describing medical practices in high-spending McAllen, Texas.90 The essay went viral and became required reading in the Obama White House.91
We were interested in gauging whether physicians were aware of the regional variation controversy and what they thought might be responsible for the variation. Before describing the results of the physician survey, we briefly review some of the key findings about the regional variation controversy.
Most of the variation in Medicare spending is due to utilization, meaning the amount of care given to patients. Regional variation in Medicare spending is often said to be “unwarranted” because it does not show a consistent relationship between Medicare patients’ use of services on the one hand, and quality or health outcomes on the other.92 It is important to note that prices do not explain most of the variation in Medicare spending. All providers face the same Medicare reimbursement schedule, adjusted across regions for cost of living, graduate medical education, or low-income subsidies. (As we noted earlier, the situation is quite different in insurance markets under age 65, in which the prices of procedures do vary tremendously across regions. As a result, total per capita regional spending in the under-65 markets is not closely associated with per capita Medicare spending in those markets, even though there is a strong correlation between utilization patterns in Medicare and commercial insurance plans.)93
If not prices, then what does drive geographic variation in Medicare utilization? Controlling for patients’ age, sex, income, race, and health attenuates differences in the amount of services patients receive across areas, but a lot of unexplained variation remains.94 Additionally, most research suggests that patient preferences for life-prolonging treatments and other services have a relatively small influence on regional variations in Medicare spending.95 The threat of malpractice is also often mentioned as a cause, but “defensive medicine has yet to be shown to be an explanation for regional variation in spending and utilization.”96
On the other hand, supply-side factors are clearly a key driver of geographic variation.97 These include the number of physicians, specialists, and hospitals beds in an area, as well as doctors’ beliefs about appropriate practice style.98 Practice style, which we discuss in more detail at the end of this chapter, can contribute to overtreatment in two ways. First, doctors may use unsupported or discredited treatments, such as the arthroscopic knee surgeries discussed in chapter 2. Here, the physical benefits for all patients who receive the treatments are small or nonexistent. The second and likely much more common situation arises when doctors who have an aggressive practice style use treatments in low-value settings, giving the treatments to patients beyond the appropriate target population based on evidence.99
A fascinating recent study found that physician beliefs about treatments (unsupported by clinical evidence) can explain as much as 35 percent of end-of-life Medicare expenditures and 12 percent of Medicare expenditures overall.100 The authors created vignettes of specific patient scenarios and asked samples of cardiologists and primary care physicians what they would do in each situation; for example, whether to provide intensive care to a heart patient beyond the indications of evidence-based guidelines or attempt to make the patient more comfortable by administering palliative care. Based on these surveys, the authors were able to classify the physicians as either “cowboys” or “comforters” and found that their respective concentrations in a region closely tracked the level of end-of-life spending in that area. The authors also conducted surveys of Medicare enrollees to check if patient preferences were driving the results and determined they were not. The effects of the geographic variation in the practice styles elicited by the vignettes are substantial. The study suggests that physician beliefs about the appropriate care for patients accounts for more than half of the variation in end-of-life spending across areas, as well the frequency with which physicians recommend their patients for routine office visits.
Evidence that regional variation is explained in large measure by physician-specific effects is found in a recent study that followed Medicare enrollees who moved from one part of the country to another. The study concluded that 50–60 percent of the geographic variation in health care utilization is due to place-specific factors, such as doctors’ incentives and beliefs, physical and human capital, and hospital market structure. The remainder is due to fixed characteristics of patients that they carry with them when they move, such as preferences and health status. Patient characteristics matter more for outcomes such as emergency room visits than for outcomes such as diagnostic and imaging tests, where the physician is the main decision maker.101
Research on regional variation in Medicare received wide media attention during the Obama administration, even showing up in the pages of magazines like the New Yorker widely read by educated professionals. How familiar are physicians with the literature on geographic variation, and what factors do they believe cause it? Do physicians’ beliefs accurately reflect the state of the academic literature? Although there has been some survey work concerning physician views of and support for CER,102 the extent to which physicians understand the underlying problems of waste, inefficiency, unwarranted variation, and over- or underutilization that helped justify an increased federal role in CER remains largely unexplored.
First, we asked physicians if they have heard anything about health services research on the regional (or geographic) variation in health care spending within the United States. The typical doctor appears unfamiliar with these important features of medical spending. Just under half of the physicians in our survey (48.5 percent) reported that they had “heard anything about” this research; 51.5 percent said they had not. Moreover, of the doctors who reported that they had heard anything about these studies, less than half reported that they were “very familiar” (4.5 percent) or “somewhat familiar” (40.5 percent) with this research; in other words, given that half the sample stated they had not heard anything about these studies, doctors who were very or somewhat familiar with this research represent only one-fifth of the entire sample (80 out of 368 total responses to this measure). And, of course, this is a self-reported measure where we might expect a “social desirability” bias toward overreporting of knowledge.103
There were statistically significant differences in knowledge of regional variation across groups. The results of a regression analysis in which we predicted reported familiarity with the studies on regional variation with a series of demographic and other characteristics of the doctors are included in the appendix to this chapter (table A4.1).104 Reporting a high level of interest in politics (p<.01), having had residency training at a VA (p<.05), and being in practice longer (p<.05) are associated with greater familiarity with these studies.105
Next, we provided respondents with some factual information about regional variation in Medicare spending and asked what might be causing this situation. In particular, we investigated what doctors believe are the major factors that explain the observed variation. We asked the following question to all the doctors, regardless of how familiar with the research they reported they were:
According to a recent Institute of Medicine (IOM) study, there is large and persistent regional variation in health care spending across the United States. We will now ask you some questions about regional variation in the Medicare program. How much do you think each of the following factors contributes to regional variation in Medicare spending?
Doctors indicated to what degree—“none,” “little,” “some,” or “a lot”—each of eight statements contributed to regional variation in Medicare spending (see figure 4.1). All eight factors were thought to contribute “a lot” or at least “some” to regional variation in Medicare spending by at least 65 percent of doctors. However, there were important differences in the factors viewed as most important, and this pattern of emphasis did not always follow the evidence that has accumulated in the health services literature. Many doctors see malpractice suits as the most important driver of variation in the Medicare program. Fifty-five percent of doctors said differences in the threat of malpractice litigation across regions contributed “a lot” to variation with an additional 36 percent saying such threats contribute “some” to explaining regional variation in Medicare spending (leaving only 9 percent saying “a little” or “none”). No other factor was cited by more than half of doctors as contributing “a lot” to variation. In comparison, only 35 percent of doctors said they believe that overuse of services of low or unproven value contribute “a lot” to variation (with 48 percent saying “some” and 16 percent “a little” or “none”). In contrast with recent work focusing on the importance of doctors’ beliefs to regional variation in Medicare spending, just 18 percent of doctors said that physicians’ beliefs in the value of certain treatments contribute “a lot” to variation (with 54 percent saying “some” and 27 percent saying “a little” or “none.”). In sum, doctors’ views of the causes of regional variation in Medicare spending are somewhat informed yet off the mark in key respects. Doctors appear to overemphasize systemic factors beyond physician control (for example, the malpractice environment) while underweighting factors that in principle are subject to the control of physicians and their professional organizations (such as physician beliefs and practice styles). To the extent that regional variation is driven by variation in physician practice style and decisions to provide care not based on evidence, a reform movement within the medical profession to educate doctors about how their own clinical decisions are contributing to the problem could make a difference.
FIGURE 4.1. Doctors’ beliefs about what factors contribute to regional variation in Medicare spending. Note: Responses to question: “According to a recent Institute of Medicine (IOM) study, there is large and persistent regional variation in health care spending across the United States. We will now ask you some questions about regional variation in the Medicare program. How much do you think each of the following factors contributes to regional variation in Medicare spending?” (N=366). Source: Fall 2015 survey of physicians.
There were notable differences in the factors different types of doctors believe to be causes of variation (see regression analysis in table A4.2). Controlling for other factors, doctors who identify as Republicans are less likely than doctors who identity as Democrats to say that physician beliefs’ in the value of certain treatments and the underuse of services of high or proven value contribute to regional variation in Medicare spending (p<.05). A recent study in the Proceedings of the National Academy of Sciences demonstrates that physicians’ political worldviews are correlated with their professional decisions on certain politically salient issues.106 For example, doctors who identify with the Democratic Party are more likely to urge patients against storing firearms in the home, while Republican physicians are more likely to counsel patients on the mental health risks of abortion and to urge patients to cut down on marijuana use. Our survey results show that Democratic and Republican doctors also possess somewhat different understandings of how the medical system works.
Besides partisan differences, we found that medical specialists are less likely than primary care doctors to say that differences in the amount of care demanded by patients with the same condition contributes a lot to variation (p<.05), whereas surgical specialists are less likely than primary care doctors to say that the health status and medical needs of Medicare patients contributes a lot to variation (p<.05). Finally, years of practice is positively associated with a belief that how much Medicare pays physicians contributes a lot to variation (p<.05).107
WHOM DO DOCTORS TRUST?
Suppose one wishes to influence the opinions of doctors or provide evidence that might shape their beliefs. Who should ideally be selected as messenger? Chapter 3 showed that the American public places more trust in doctors compared to other groups, but who do doctors trust to provide accurate, factual information about the U.S. health care system? Do doctors have greater faith in the medical profession or other groups?
FIGURE 4.2. Doctors’ reported trust in various groups. Note: Responses to question: “How much would you trust the following groups to provide accurate, factual information about the U.S. health care system?” Unreported percentage is for those who responded “very little.” (N=373). Source: Fall 2015 survey of physicians.
The groups we asked about are listed in figure 4.2, where we also report the percentage of respondents who stated they would trust that group “a great deal,” “quite a lot,” or “some.” Doctors reported the highest level of trust in leaders of their own professional society, university researchers, and editors of leading medical journals—a majority of doctors reported either a great deal or quite a lot of trust in these three entities. Doctors expressed the least amount of trust in newspapers and the Centers for Medicare and Medicaid Services (CMS), two entities that less than 25 percent of doctors reported at least “quite a lot” of trust in. In between these most and least trusted entities were several others that received middling levels of trust from doctors. Notably, deans of leading medical schools are not ranked particularly high, and both the American Medical Association and the Institute of Medicine are viewed as less trustworthy than leaders of doctors’ own professional societies. The lower level of trust that doctors have in the AMA than in their own societies’ leaders is consistent with the declining proportion of physicians who are members of the AMA since the 1950s. The secular decline in AMA membership reflects many factors, including growing allegiance among physicians to specialty groups. In addition, AMA membership took a hit following the organization’s endorsement of the ACA.108
PRIORITIES OF MEDICAL SOCIETIES
Given that doctors trust their own professional societies more than other actors, what role should they ideally play both in general and with respect to controversies over medical evidence. What do they see as the association’s priorities? We first asked doctors the following:
Medical societies have to set priorities. How important do you think each of the following goals should be to the American College of Cardiology, the American Academy of Orthopedic Surgeons, and other medical societies representing different specialties?
Doctors expressed strong support for five priorities of medical societies (see figure 4.3): “disseminating best practices through guidelines and professional education,” “protecting the clinical autonomy of physicians in the society’s area of specialization,” “finding ways to cut health care costs by discouraging the use of clinical interventions with minor or no benefit to patients,” “pointing out where physicians in the society’s area of specialization are not following best medical practices,” and “advocating for the economic interests of physicians who practice in the medical society’s area of specialization.” Sixty-five percent or more of doctors thought each of these five goals was at least a very important priority for medical societies. The belief of many doctors that advocating for the economic interests of physicians should be a priority of medical societies is notable for the frank admission that medical societies are in a sense trade associations.
Doctors viewed the remaining goal we asked about—“identifying physicians in the society’s area of specialization who are not following best medical practices and bringing them to the attention of disciplinary boards”—as a much less important priority. Indeed, less than 20 percent of doctors indicated this was an extremely important goal. Thus, although many doctors felt it was important for medical societies to point out when best medical practices are not being followed (nearly 75 percent indicated it was at minimum a “very important” goal), far fewer felt medical societies should be in the business of policing their members. This view is perhaps not surprising in light of the failure of peer review organizations in Medicare, which are supposed to sanction providers that abuse Medicare, but in practice have been “paper tigers” and have done little to control costs or improve quality: “Physicians are loath to second-guess their colleagues’ work.”109 Coupled with the high level of support doctors had for protecting clinical autonomy, we observe evidence that doctors believe professional societies should protect the interests and autonomy of doctors.
FIGURE 4.3. Doctors’ rating of importance of various goals to medical societies. Note: Responses to question: “Medical societies have to set priorities. How important do you think each of the following goals should be to the American College of Cardiology, the American Academy of Orthopedic Surgeons, and other medical societies representing different specialties?” Unreported percentage is for those who responded “not that important” or “moderately important.” (N=373). Source: Fall 2015 survey of physicians.
We observe some interesting patterns when we examine the relationship between what a physician believes causes regional variation in Medicare spending (reported in figure 4.1) and his or her view about the role that medical societies should play.110 In particular, doctors who are more likely to think that overuse of services (p<.05), underuse of services (p<.10), and availability of expensive medical technology (p<.05) in some regions are to blame for geographic variation are more likely to think it is important for medical societies to bring physicians not following best practices to the attention of disciplinary boards. However, respondents who think physicians’ beliefs in the value of certain treatments (p<.05) and the health status of Medicare patients (p<.05) are responsible for variation desire more protection of clinical autonomy. In other words, the more doctors view variation in Medicare spending across regions as the product of the professional judgment of physicians or the health status of patients, the more likely they are to believe it should be a priority for medical societies to safeguard doctor’s clinical autonomy in the society’s area of specialization.
As noted, recent research demonstrates that Democratic and Republican physicians tend to counsel patients about topics such as abortion and gun safety in line with their own political beliefs.111 Our survey finds that there are also significant partisan differences on what actions they want their medical societies to prioritize. In particular, doctors who self-identified as Republican rated advocating for economic interests and protecting clinical autonomy as more important priorities for medical societies than doctors who self-identified as Democrats (p<.05). In addition, self-identified Republican physicians rated finding ways to cut health care costs by discouraging clinical interventions with minor or no benefit to patients as less important medical society priorities than did Democrats (p<.05).112 Beyond partisan identification, the survey also revealed that doctors whose specialty is primary care rated advocating for economic interests and protecting clinical autonomy as more important than doctors whose specialty is surgical care (p<.05). In short, there are important divisions along both partisan and specialization lines about the role that medical societies should play in representing the medical profession’s interests in the health care system. (See table A4.4 for details.)
RESPONSE OF MEDICAL SOCIETIES TO RESEARCH CALLING INTO QUESTION THE EFFECTIVENESS OF TREATMENTS
Beyond views about the overall priorities of medical societies, we were especially interested in how doctors think medical societies should respond to new medical evidence about treatment effects. We asked respondents to consider the following scenario:
FIGURE 4.4. Doctors’ opinions on what medical societies should do when a medical study calls into question a common treatment in practice area. Note: Responses to question: “Suppose a leading medical journal publishes a new study (widely covered in the mainstream media) that calls into question a treatment that is commonly used in your practice area. The evidence suggests that the treatment might not be as effective as previously thought. Indicate below the extent to which you would support or oppose each of the following responses by the medical society in your practice area” (N=372). Source: Fall 2015 survey of physicians.
Suppose a leading medical journal publishes a new study (widely covered in the mainstream media) that calls into question a treatment that is commonly used in your practice area. The evidence suggests that the treatment might not be as effective as previously thought.
We asked respondents to indicate the extent to which they would support three potential responses by the medical society in their practice area. The pattern of responses indicates doctors want their medical society to push back and defend professional autonomy when treatments are questioned. Figure 4.4 shows that the most preferred response by doctors is for medical societies “to take an active role in critiquing the quality of the study and point out any weaknesses of the study.” Almost 75 percent of respondents somewhat or strongly agreed with this posture. An additional 17 percent neither supported nor opposed this response, leaving only 9 percent in opposition (somewhat or strongly).
Many doctors also supported the idea that the medical society should “argue that individual physicians are able to evaluate the new evidence and should be permitted to continue practicing as they think best.” Sixty-one percent of physicians supported (somewhat or strongly) the medical society taking this approach. An additional 17 percent neither supported nor opposed this response, leaving 21 percent who opposed it—the vast majority of which (18 of the 21 percent) only somewhat opposed this response by the medical society.
In contrast, there was less vigorous support for having medical societies play a neutral information transmission role without taking a stance. Just a bare majority (52 percent) of doctors (somewhat or strongly) supported the medical society disseminating “the study’s results to physicians and patients, but not tak[ing] a position on the issue.” Indeed, what makes this response stand apart from the other two is that less than 20 percent of physicians strongly supported this response, making it the only response in which the opposition (somewhat and strong) was greater than those who strongly supported it (21 to 18 percent). This response also had the greatest percentage of physicians who were neutral, at 27 percent.
Although doctors overall want their medical societies to defend clinical autonomy, there are some notable differences among the views of different subgroups of doctors. The results of a regression analysis (reported in table A4.5) indicate that, compared to primary care doctors, doctors with a surgical specialty are more hesitant to support their medical societies taking an active role in critiquing the quality of the study (p<.01).113 Female doctors in our sample were less likely to support the statement that the medical society should disseminate the results but not take a position on the issue compared to their male counterparts (p<.10). Republican doctors were more likely than their Democratic counterparts to support the statement that “individual physicians are able to evaluate the new evidence and should be permitted to continue practicing as they think best” (p<.10).
PRACTICE STYLES
Finally, we asked doctors to assess their own “practice style.” We told respondents that “academic research suggests that physicians practicing in similar organizational settings often exhibit large and persistent ‘style’ differences in their tendency to prescribe certain treatments and utilize medical resources for similar patients.” We asked doctors how confident they were that they could characterize their own practice style compared to the practice styles of other doctors in their area of specialization. Most respondents lacked confidence in their knowledge of their own practice style. Only 31 percent of doctors in our sample said they were “very confident” they could identify their own practice style compared to the practice style of other doctors. An additional 52 percent were “somewhat confident,” with 17 percent reporting that they were “a little” (13 percent) or “not at all” (4 percent) confident. These findings suggest there is room for doctors to become more self-aware of their own practice styles—and how they stack up against evidence-based protocols.
Practice styles are important in part because there is growing evidence that tendencies to prescribe certain treatments and utilize certain medical resources or technology are established early on and persist, and that some practice styles can be beneficial or harmful to the welfare of patients with certain conditions.114 For example, research has documented substantial variation in the practice styles of both cardiologists115 and obstetricians.116 Even more central to the concern about overutilization, Lipitz-Snyderman and colleagues find high rates of nonrecommended care in the treatment of cancer patients.117 These findings “provide strong evidence that some physicians persistently use low-value care.”118
Our survey results show that physicians are reluctant to be evaluated according to their adherence to simple metrics. We asked the doctors which of the following two statements came closer to their own view:
It is reasonable to evaluate doctors in terms of their adherence to simple metrics, such as the fraction of their patients who receive influenza immunization or whether patients with coronary artery disease are taking appropriate medications.
Or:
Decisions about treatment should be tailored to the needs of individual patients, and this type of sensitivity to patient characteristics cannot be captured through adherence to simple rules.
Sixty-nine percent of doctors indicated the second statement came closer to their own view; in other words, less than one-third of doctors felt evaluating doctors in terms of their adherence to metrics was most appropriate. This result is not surprising, but it underscores that medical reformers face an uphill battle to convince doctors that evidence-based metrics can support the diagnostic and treatment capabilities of even skilled physicians. Consistent with the partisan differences concerning the roles of medical societies we report above, compared to Republican physicians, Democratic physicians were more likely to say that evaluating doctors in terms of their adherence to metrics was most appropriate (p<.05).
Still, there might be room for medical societies to promote greater selfawareness of practice styles among members. For example, if information about the practice styles of individual physicians were routinely collected, and if these data were used to tease out the influence of practice style on patient outcomes, it might be possible to refine treatment guidelines in order to improve health outcomes.119 Although altering physician practice styles is difficult, “providing physicians information about how their practice styles compare to their peers” has been shown to change, for the better, physician behaviors.120 Importantly, a refinement to treatment guidelines need not necessarily imply a reflexive endorsement of reduced use of invasive procedures—in some cases, a careful study might reveal that more aggressive practice styles are superior.121
Conclusion
The U.S. medical system has long emphasized the professional and clinical autonomy of physicians. Doctors possess the discretion to prescribe the treatments that patients receive, and their practice styles have a big influence on variation in utilization and spending in Medicare. In addition, doctors, who enjoy a high level of public trust, are heavily involved in health policy making both through their membership in medical societies and in their role as prominent and respected leaders of their local communities. Given that the future of U.S. health policy will be shaped to a significant degree by the preferences of doctors, we surveyed doctors to learn what they think about key medical evidence issues. Our national survey produced several key findings.
First, many doctors do not recognize the important role their own clinical decisions and practice style play in contributing to regional variation in Medicare spending. (The main exceptions are doctors who have been in practice longer, had their residency take place at a VA, or express a high level of interest in politics.) Overall, our survey uncovered little evidence that the leaders of the medical profession have done an adequate job diffusing knowledge about waste and geographic variation to rank-and-file doctors, despite the attention the topic has received from prominent policy makers and researchers.
Second, the survey suggests that many doctors want their medical society to play an “attack dog” role when evidence emerges that treatments in their practice areas may not work as well as previously believed. As the knee surgery case study (chapter 2) showed, leaders of medical societies are often quite aggressive in critiquing the results of even the most rigorous randomized controlled trials.
Finally, while our survey results overall show support for the role of medical societies as guardians of physician discretion and economic interests, our survey uncovered some notable differences in the beliefs of physicians based on their partisan identification. Republican doctors viewed advocating for economic interests and protecting clinical autonomy as more important priorities for medical societies than did Democratic doctors. Republican physicians also viewed discouraging clinical interventions with minor or no benefit to patients as less important than Democratic physicians. As the next two chapters show, partisan polarization and electoral competition has politicized efforts to promote efficiency and quality in U.S. health care. The physician survey findings reported in this chapter raise the possibility that another barrier to the creation of a technocratic consensus on the need for better use of standardized evidence is partisan polarization within the medical profession itself.