The Role of Physicians in Health Care Delivery

Ian McCarthy | Emory University

Overview

Lots of different players

  • Physicians
  • Nurses
  • Hospitals
  • Prescription drugs
  • Rehabilitation (home health, SNF, rehap hospitals)
  • Long-term care (home health, SNF)
  • Ancillary services (labs, imaging)

But physicians have an outsized role as they influence almost all areas of health care delivery

Physician training and interactions

  • Training, residency, and maybe fellowship…all influence future practice styles
  • Primary care vs specialists
  • Referrals within and across physician types

Physician organizational affiliations

  • Self-employed as part of own practice
  • Part of much larger group practice
  • Vertically integrated with hospital or insurer

Types of hospitals

  • General, acute-care, short term
  • Rehab hospitals
  • Specialty hospitals (Children’s, orthopedic, cardiac, cancer centers)
  • Long-term care hospitals
  • Inpatient versus outpatient
  • Stand-alone surgery centers
  • Stand-alone EDs

Ownership type

  • Government owned or assisted
  • Private not-for-profit
  • Private for-profit
  • Private equity

Why does all of this matter

Physicians are often the “gatekeepers” into many other facets of health care:

  • Physician is entry point into health care for most patients (even in the ED)
  • PCPs refer to specialists and ancillary services
  • Specialists refer to ancillary services, other specialists, and may select where to operate (if needed)
  • Specialists or hospitalists refer patients to follow-up care after inpatient stays
  • All types of physicians help in selecting medications

In making these decisions, physicians are influenced by many factors:

  • Patient preferences
  • Patient “need”
  • Knowledge of possible treatments and interventions
  • Skill/training in specific interventions
  • Payment for different services
  • Relationships with other physicians and institutions

Physician agency

  • Physicians more informed that patients
  • Physicians can influence what care is provided and where
  • Physician agency reflects the fact that physicians make/suggest health care decisions on behalf of the patient, so the physician is an “agent” of the patient
  • When is this decision more or less similar to what the patient would have made on their own?

Variation in Health Care Utilization

Consequences of physician agency:

  • Patients subjected to information frictions or financial incentives of physicians
  • The types of care people receive will depend on the physician
  • Potential variation in health care utilization and spending across and even within markets
  • Example, Is Health Care Shoppable?

Variation versus “Waste”?

What does this say about waste?

  • Estimates are that more than 30% of health care expenditures are “wasteful”: (The Atlantic, 2013)

  • Some clear areas of waste:

    • Payment differentials by location of treatment (policy quirks)
    • Better imaging with little benefit
    • Proton treatment (for some conditions)
    • Heart stents (for some patients)
    • Arthroscopic knee surgery

But…Many estimates of “waste” are after-the-fact. It’s actually very hard to identify waste before-hand. Report on End-of-life Spending