Michael Zubkoff

Professional uncertainty and the problem of supplier-induced demand

This paper discusses the puzzling problem of large differences in per capita use of certain common surgical procedures among neighboring populations, which by all available measures are quite similar in need for and access to services. The evidence reviewed here supports the hypothesis that variations occur to a large extent because of differences among physicians in their evaluation of patients (diagnosis) or in their belief in the value of the procedures for meeting patient needs (therapy). This hypothesis, which we call the professional uncertainty hypothesis, is germane to current controversies concerning the nature and extent of supplier influence on the demand for medical services. It is also important because of its implications for health regulatory policy. Our plan is to (1) review the relevance of the hypotheses for the supplier-induced demand controversy; (2) review the epidemiologic evidence on the nature and causes of variation; (3) examine patterns of use of common surgical procedures to illustrate the importance of supplier influence on utilization; and (4) consider some of the implications of the professional uncertainty hypotheses for public policy.

Assessment of function in routine clinical practice: description of the COOP Chart method and preliminary findings.

The COOP Project, a primary care research network, has begun development of a Chart method to screen function quickly. The COOP Charts, analogous to Snellen Charts, were pretested in two practices on adult patients (N = 117) to test feasibility, clinical utility, and validity. Patients completed questionnaires containing validated health status scales and sociodemographic variables. Practice staff filled out forms indicating COOP Chart scores and clinical data. We held debriefing interviews with staff who administered the Charts. The results indicate the Charts take 1-2 minutes to administer, are easy to use, and produce important clinical data. The patterns of correlations between the Charts and validity indicator variables provide evidence for both convergent and discriminant validity. We conclude that new measures are needed to assess function in a busy office practice and that the COOP Chart system represents one promising strategy.

Measuring resource use in economic evaluations: determining the social costs of mental illness.

Concern over costs associated with mental disorders has led to an increase in the number of economic evaluations of treatment interventions; unfortunately, methods for measuring resource use have not kept pace with this concern. Although it is well-known that a significant proportion of the costs associated with mental illness are for resources other than treatment, program evaluators and researchers often count only treatment costs in cost-effectiveness comparisons. Further, existing methods for measuring resource use are plagued by faulty assumptions about resource use, poor validity and reliability, and difficulties quantifying resource use. The authors discuss these problems and suggest five ways of improving measurement of nontreatment resources: clarifying assumptions, using multiple data sources, flexible data collection strategies, methods for improving the accuracy of recall, and an episodic approach to measurement.

Health, Society, and the Physician: Problem-based Learning of the Social Sciences and Humanities: Eight Years of Experience

We describe a required course for fourth-year medical students focusing on the application of the social sciences and the humanities to critical decisions in the practice of medicine. During 160 hours (70 with faculty contact) in a 7-week period, active, patient-centered, problem-based learning takes place in small collaborating groups, is facilitated by trained tutors, and uses computerized access to library materials plus reference files and resource persons. Major issues identified in the cases are clarified in complementary lectures and symposia. Formative evaluation is ongoing within tutorial groups. Summative evaluation is determined by the individual students performance in a final complex management problem using a simulated patient. Evaluation of the course, and the basis for its ongoing revision, are provided by participating students and faculty, whose evaluations of the course have been favorable in 80% to 90% of cases.

Economic impact of a primary care career: a harsh reality for medical students and the nation.

Purpose The ranks of U.S. medical students choosing careers in primary care (PC) are declining even as the demand for new PC physicians is increasing. Although the decision to choose a career in PC is multifactorial, financial security in the setting of rising medical student debt is often cited as a reason to pursue other medical specialties. The authors sought to quantify the financial factors associated with a career in PC. Method The authors used economic modeling, which employs a variety of factors, to develop a net income and expense model. They attempted to account for the variability of factors by looking at best, worst, and average expense scenarios. They used published retrospective data from the Bureau of Labor Statistics, the 2007 Physician Compensation Survey, the National Association of Realtors, the College Board, and U.S. News and World Report regarding medical student debt, physician reimbursement, retirement planning, college savings, and cost-of-living expenses to develop their models. Results PC salaries, in contrast to other subspecialties, result in an initial budgetary deficit and decreased discretionary spending. This gap closes as PC physician income rises in the first few years of practice. Only under scenarios of optimal low cost assumptions or no debt do a PC physicians initial earnings exceed predicted expenses. Conclusions PC physicians, in the first three to five years following residency, will have expenses that exceed earnings. This reality greatly increases the financial disincentive for pursuing a career in PC compared with other fields of medicine.

Public Choice in Health: Problems, Politics, and Perspectives on Formulating National Health Policy

Development of health policy goals necessitates a choice among normative premises--an accommodation of conflicting values. Any debate that does not identify underlying assumptions or link policy prescriptions to a theoretical perspective is destined to degenerate into uncommunicative and unproductive rhetorical posturing. A sensible approach toward formulating national health policy requires that competing values be identified and discussed explicitly. This article will examine the effect that selection of different theoretical perspectives can have on the identification of problems and on the formulation of prescriptive policies in the health field. It will also focus on the different values that are promoted by different policy perspectives and consider alternative models for implementing value choices.

Perspectives on Government Policy in the Health Sector

Health expenditures and prices have accelerated markedly in recent years, both in absolute and relative terms. The pressures for some form of governmental intervention have generated widespread debate about national health policy. Determinants of health are complex, and policy development must follow the identification of issues and review of theoretical policy analysis. Formation of a theoretical basis will have a significant impact on substantive policy outcomes. Unfortunately, past and current proposals and policies have given insufficient attention to the traditional public finance criteria for government intervention; as a result, the importance of market forces has frequently been overlooked. Before wholesale rejection of the market as a means of promoting rationality, government should examine alternatives that foster increased efectiveness of the market mechanism. Even within this context, however, some forms of regulation will be necessary; also, traditional public finance norms would allow certain kinds of expanded government intervention. Market-perfecting policy instruments would result in different kinds of government programs, and much of future policy will be shaped by political decisions about substantive health policy issues.