Monday, June 9, 2008
Ezra Klein takes on the question of why doctors may be over-prescribing drugs. He writes,
. . . . Doctors make money from prescribing treatments. If, as in England, they made money by not prescribing treatments (i.e, through capitation pay, where they're paid X amount per patient, rather than per treatment), they would prescribe more carefully. You could even set up those salaries such that doctors made approximately what they do now (so they don't rebel), but they kept more of it as profit if they didn't spend so much on treatments. Over time, that would radically slow the growth in health spending. So too would increasing the supply of doctors and increasing the responsibilities of nurse practitioners, both of which the doctor's guilds oppose.
But there's more than just guild greed at work. Methods of rationing, like capitation, are a hard sell to voters who want to believe they'll get not only every treatment they could plausibly benefit from, but quite a few they couldn't plausibly benefit from. In general, patients have a Samuel Gompers attitude towards medical treatment: They want more. Doctors don't make much money when they prescribe unnecessary antibiotics for colds. They do it because patients want antibiotics -- they feel better knowing something has been done. And doctors want them to feel better. . . . This isn't a guild protecting itself so much as human nature pointing in a possibly harmful, and definitely pricey, direction. Doctors take an oath to heal, they don't take an oath to cut health spending.
Additionally, doctors prescribe a lot of useless treatments because, in the aggregate, they don't know what works. It's a bit shocking and a bit scary to realize how little evidence we actually have on treatment effectiveness. Recent years, for instance, have cast a lot of doubt on both angioplasties and cardiac bypass surgery. Lumbar back surgeries are widely thought to be bunk in health policy circles, but lots of doctors still think they work (after all, it's surgery, it must work!). . . .
If you reworked all the incentives for doctors tomorrow, they wouldn't overprescribe as much, but they might not get any better at prescribing care that's actually of high quality. That sort of transformation requires a whole lot of evidence, which means funding a whole lot of comparative effectiveness research. Currently, that's not happening, and so a lot of the data comes from medical device manufacturers, pharmaceutical companies, and so forth. . . . If we spent a couple hundred million a year testing treatments, we'd make it back tenfold in cuts to total health spending.