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‘Cowboy’ Doctors Could Be A Half-A-Trillion-Dollar American Problem

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When Dartmouth economics professor Jonathan Skinner was speaking recently at the University of Texas about the “cowboy doctor” problem, an audience member objected: “You have a problem with cowboys?”

Well, actually, we all have a problem with cowboys — when they’re doctors. Including the Texans. New research written up in a National Bureau of Economic Research paper finds that “cowboy” doctors — who deviate from professional guidelines, often providing more aggressive care than is recommended — are responsible for a surprisingly big portion of America’s skyrocketing health costs. The paper concludes that “36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence.”

Whoa, Nelly. That means cowboy doctors are a half-a-trillion-dollar problem. But mightn’t they also be good? Wouldn’t many of us want a go-for-broke maverick when we’re in dire medical straits? I asked Prof. Skinner, who’s also a researcher at the Dartmouth Atlas of Health Care, to elaborate. Our conversation, lightly edited:

So how would you define a cowboy doctor?

Cowboys go it alone. They have developed their own rules and they don’t necessarily adapt those rules to what the clinical evidence would suggest. So if you actually talked to what we term a ‘cowboy doctor,’ he or she would say, ‘I get good results with this procedure for this type of patient.’ That’s why we found it so interesting: they go beyond what the professional guidelines recommend. And it’s not as if they were out there before the professional guidelines got there. Sometimes pioneers are doing things that the guidelines haven’t figured out yet. But we found no suggestion that subsequent guidelines were consistent with what these physicians were actually doing.

So is it stubbornness, then?

I don’t know if it’s stubbornness but it’s individuality. It’s the individual craftsman versus the member of a team. And you could say, ‘Well, but these are the pioneers.’ But they’re less likely to be board-certified; there’s no evidence that what they’re doing is leading to better outcomes. So we conclude that this is a characteristic of a profession that’s torn between the artisan, the single Marcus Welby who knows everything, versus the idea of doctors who adapt to clinical evidence and who may drop procedures that have been shown not to be effective.

This graph shows 64  hospital referral regions, with the size of the blob proportional to the number of doctors surveyed. It shows  that in regions with a larger share of “cowboys,”  risk-adjusted end-of-life Medicare spending is higher.(Courtesy Jonathan Skinner)

This graph shows 64 hospital referral regions, with the size of the blob proportional to the number of doctors surveyed. It shows that in regions with a larger share of “cowboys,” risk-adjusted end-of-life Medicare spending is higher. (Courtesy)

Yes, the extent of the variation in medical practice is striking. But I was most struck in your paper by how big a piece of the health-cost problem this could be. Can you quantify that?

We were surprised, too. What we show is that the opinions of these physicians — in particular, opinions that are outside of the clinical guidelines — explain as much as 17 percent of total variation in health care spending, which is, roughly speaking, 3 percent of GDP.

Wow. What is that in billions?

The association we found suggests it’s almost half a trillion dollars.

Can you give me a concrete example of how a cowboy doctor could drive up costs? Continue reading

Top 10 Reasons Doctors Over-Order

Just recently out of medical school (and the Kennedy School of Government as well) Dr. Neel Shah has a particularly keen eye for medical culture and its tendency to overlook what things cost. He founded the Boston-based non-profit Costs of Care last year to try to change that culture. We wrote about the group’s essay contest yesterday; for today, we asked Shah, currently a resident in obstetrics and gynecology at Brigham and Women’s Hospital, for his top 10 reasons that doctors might over-order tests or treatments. What do you think? Would you add or subtract anything from this list?

  1. How we’re taught: Doctors are taught to consider whether a procedure is safe and whether it’s likely to work. We’re almost never taught to consider cost — it’s considered taboo.
  2. Trying to do our best for the patient: We’re worried. Often we over-order because of our personal risk aversion.
  3. Pre-emptive ordering: For residents, who do much of the ordering of tests in hospitals, it may be more efficient to order tests now rather than later. Standard practice might be to order a relatively cheap screening test and then if it’s positive, order other expensive tests. Instead we sometimes just order everything at the same time so we don’t have to wait.
  4. Covering all bases: In medical culture, doing more is equated with being thorough. If there are five possible conditions that may explain a patient’s symptoms, and it’s probably going to be one or two of them, we might order tests for all five conditions right away.
  5. General unawareness: We just don’t know what things cost. When you talk to people and say, ‘Do you know a magnesium level is $70?’ it blows their mind.
  6. Continue reading