Monday, July 08, 2013

Surgeons and perverse incentives

There is a lot of criticism that surgeons do too many unnecessary operations and that all this overtreatment increases the cost of healthcare . Even worse, all this surgery doesn't help to improve patient outcomes – and can actually result in harm.

While there is truth in this criticism, we also need to understand that society itself is partly responsible for the sad state of affairs. After all, if you teach and train surgeons how to do surgery , and then you pay them to perform surgery, it’s very irrational to expect them not to do surgery ! After all surgeons are homo economicus as well and will maximize their personal benefits .

It’s not that they are greedy or unethical. They have a particular worldview , and often suffer from tunnel vision . All they are taught is how to operate and when you have a hammer in your hands, you see nails all over the places ! Unfortunately, very few surgeons are taught when not to operate !

It's possible to wax eloquent about the importance of medical ethics and why and how doctors need to be professionals , who should not operate when not required. However, we can talk till we are blue in the face , but we know that the reality will not change. Just like financial advisors will push a particular product , because they are paid to do so , doctors also are likely to respond in exactly the same manner! It's unfair to hold them to a superhuman standard , because this is extremely unrealistic and smacks of wishful thinking.

However, there is a solution – we need to develop  clever ways in which we could incentivize surgeons not to do surgery ! There was a  time in the US not too long ago, when repeat cesarean sections were the norm because obstetricians would get paid much more doing a cesarean section , rather than allowing vaginal birth ( VBACs). It’s only when insurance company started to refuse to pay for repeat cesarean sections that the VBAC rate decreased from virtually zero percent in private hospitals to up to 50 percent - which is what the optimal number should be !

We need an entrepreneur who can come up with a clever solution which will help to ensure that surgeons do not benefit by doing unnecessary surgery. One solution is to slap penalties for doing unnecessary surgery , but this is something which is very hard to implement in real life . Clinical decisions are rarely made by following a cookbook protocol slavishly - we need to come up with more ingenious methods .

One of the best methods would be empowering patients with information , so they can discuss non-surgical treatment options with their surgeon ! We need to align incentives for both patients and surgeons – and find ways to pay surgeons for not operating ! Retired surgeons, who are no longer active in the OR can provide lots of useful insights !

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