Physicians’ use of medical technology: an analysis of the introduction and subsequent failure of drug-eluting stents

Using data on cardiac patients in Florida hospitals from 2003 to 2007, we analyse the adoption and deadoption of a major new medical technology, drug-eluting stents (DESs). The Food and Drug Administration approved DESs in April 2003 and physicians rapidly adopted the new technology. In March 2006, a presentation was made at the American Cardiology Conference which showed that patients receiving DES in real-world settings suffered higher rates of mortality and myocardial infarction than those receiving stents without drugs. We examine the utilization of DES from April 2003 to the end of 2007. Using a hospital fixed-effects model, we find that board-certified and top-trained physicians were initially quicker to adopt DES. Over time, this effect dissipated and top-trained physicians were less likely to use DES by the time new clinical trials indicated they could be problematic. After the news, board-certified and top-ranked physicians were less likely to change their behaviour. Physicians’ own experience also contributes to the use of technology and the effects are stronger for non-board-certified physicians. We conclude that even within hospitals, physician training and experience play an important role in explaining differences in rates of technology use.     

Joining a capitated IPA: should you, or shouldn't you?

The "bygone" doctor practiced in the good old days under a relatively uncomplicated, clearly defined system. Physicians could afford to be independent. To survive in practice today, say the authors of "Renegotiating Health Care: Resolving Conflict to Build Collaboration," physicians must adapt to change or the health-care market will pass them by. Today's "evolving" doctor is a partner, contributing to and deriving benefit through collaborative patient-care networks, physician practice organizations, and medical services organizations. Historical rivalries have been forgotten as hospitals, insurers, and physicians seek and achieve innovative alliances. Still, resistance to these plans runs strong. The following story typifies one dilemma that faces physicians today. It concerns a hypothetical group practice that must decide whether to form a capitated individual practice association.     

OBESITY AND MORAL HAZARD IN DEMAND FOR VISITS TO PHYSICIANS

In this article, we use count data regression with sample selection to analyze the effects and degree of moral hazard in demand for visits to physicians among groups of individuals with similar body mass index (BMI). Our results suggest that the effect of moral hazard on the demand for visits to doctors is increasing in BMI for men and for overweight and obese women. Moral hazard is highest among overweight men. (JEL I11, C25)     

THE ASSOCIATION BETWEEN PHYSICIAN SUPPLY AND THE MIX OF GENERALIST AND SPECIALIST SERVICES USED

Variations in physician supply, and the impact on a patient's use of physicians, remains a concern. This article asks how the supply of physicians is associated with both the number of visits and the dollar value of services received from general practitioners and specialists. Ontario respondents in the Canadian Community Health Survey 2000/2001 are linked to their Ontario Health Insurance Program claims for 3 years (1999–2002). A geographic weighting method is employed to account for physician supply in surrounding jurisdictions. The results are consistent with the conclusion patients substitute one physician type for another when physician supply is constrained. (JEL I10, I12, C29, C39, C52)     

Inflation, Welfare, and Public Goods

In this article we study the welfare effects of monetary policy in a simple overlapping generation economy in which agents voluntarily contribute to a public good. Inflation has two effects at equilibrium: it increases voluntary contributions and it misallocates private consumption across time. We show that the aggregate effect is welfare-improving for "not too large" inflation rates. Moreover, there exists an optimal inflation rate.     

Implications of nurse-physician relations: report of a successful intervention

Given the evidence linking medical errors to ineffective communication, strategies for improving communication among health care professionals must be implemented. The purpose of this article was to examine the effect of a collaborative intervention on improving communication patterns between nurses and physicians on two study units. The intervention consisted of two nurses and two physicians (per unit) meeting together (8 hours total) to collaboratively develop a solution to communication issues on their respective units. Physicians scored significantly higher on reports of openness of communication within groups, openness between groups, accuracy between groups, and collaboration between groups. Collaboration reported among nurses and physicians improved for both professions, with significance reached for physicians (p = 0.031). Strategies must be identified to break down the barriers set by the current culture, and that expedite the development of a team-centered culture supporting collaborative relations among health care professionals.     

Health IT adoption,productivity and quality in primary care

Within the last decade, there has been a growing push towards the use of electronic medical records and health information technology (IT) within primary care physician practices. Despite financial subsidies, smaller practices remain reluctant to adopt these information systems. Using a nationally representative survey of physicians, this study explores the relationship between physician, practice and area attributes and the adoption of health IT systems. Controlling for these attributes, the analysis subsequently studies the relationship between health IT, physician productivity and perceived quality of care. It finds that smaller practices and physicians with lower incomes are less likely to adopt health IT systems and that adoption varies with the type of medical conditions the practice typically treats. With regards to productivity, health IT adopters are more likely to see fewer patients and spend a larger amount of time on each visit with marginal increases in time on administrative tasks and no differences in perceived ability to deliver quality health care.     

A COMPARATIVE ANALYSIS OF HOUSEHOLD CONSUMPTION FINANCED BY INDIVIDUAL AND COLLECTIVE RESOURCES, IN FRANCE AND ITALY (1959, 1965, 1969)

In this article the authors anticipate some results of a study carried out in France and in Italy, in the framework of a wider research project aiming at analysing in some depth and at comparing the recent trends and patterns of total household consumption in some capitalist and socialist countries. ¹
The accounting scheme used to arrive at a comprehensive definition of household consumption, inclusive of the "non-market" divisible services produced by public administrations, and to identify the share of this new aggregate which is financed by collective resources, isoutlined in the first section. In the second section, the article shows the growing relative importance of publicly-supported consumption, but it also shows that during the sixties, the overall cost of divisible public services and of social benefits provided in kind or in cash was, in both countries, almost entirely auto-financed by the household sector, via social security contributions and taxes levied on that sector's income and consumption. In the third section, comparative analysis of the recent structural evolution of the "market" and the "non-market" shares of total household consumption points out the similarities and dissimilarities between the patterns and forms of private and public spending in the two countries.
The results of this analysis seem to support the thesis that unless a better integration of social policies with economic growth policies is achieved, it will not be possible to implement rational choices between the "market" and the "non-market" ways of satisfying specific population needs. The authors' conclusion is that under present circumstances, public civil expenditures will continue to rise, both in France and in Italy, more rapidly than total national resources and it will become difficult to balance total receipts and total outlays of the public sector.     

CHILD SUPPORT, ROUTINE INCOME WITHHOLDING, AND POST-DIVORCE INCOME

Policymakers are proposing child support reform as a way of reducing "welfare dependency" and countering the "feminization of poverty" while increasing the well-being of children living in single-parent households. The federal government and some states have begun to change laws regarding establishment of child support awards and collection of payments. The 1988 Family Support Act mandates routine income withholding of child support payments—i.e., collecting child support directly from the payer's paycheck. This article assesses the effects on post-divorce income by using data from a demonstration of routine withholding in ten Wisconsin counties. Unfortunately, these data conclude that routine income withholding has little effect on post-divorce income, at least in the year following divorce. The authors suggest three requirements for substantially increasing post-divorce income, as well as child support: (i) More family court cases must establish awards, (ii) The amount of those awards must be greater. (Hi) The collection rate for those who have awards must improve.     

PHYSICIANS' COST SHIFTING BEHAVIOR: MEDICAID VERSUS OTHER PATIENTS

Much of the debate about rising health care costs in the United States centers on the notion of "cost shifting." Cost shifting is loosely defined as charging one set of patients a higher price to offset losses on another set of patients. One aspect of the cost shifting debate that the empirical work has ignored is whether or not doctors—as opposed to hospitals—practice cost shifting. The analysis here investigates this question using the Physicians' Practice Costs and Income Survey, 1983–1985 (PPCIS, expanded version)
Using variation across states in Medicaid reimbursements, the analysis finds that lower Medicaid reimbursements tend to lower the fees physicians charge, contradicting the standard cost shifting story. Evidence also suggests that lower Medicaid reimbursements tend to cause physicians to treat fewer Medicaid patients. These results are consistent with profit maximizing behavior for physicians and also with the hypothesis that physicians exert some monopoly power.     

The effect of information technology on IT-facilitated coordination,IT-facilitated autonomy,and decision-makings at the individual level

The effect of information technology (IT) has been a central concern to economics of IT ever since it has been viewed as an important resource to improve firm productivity. Although significant research progress has been made on the impacts of IT use at the individual level, the mechanism of how IT use increases individual performance at work has not been fully explored. In an attempt to examine the IT effects on performance, we focus on individual work productivity gained from IT use. Following the discussion of previous works, we develop a research model, describing that the ubiquitous IT transforms the way individual employers’ work in organizations, and facilitates working processes and practices that may affect the decision-making of individual performance.

As a result of testing the research model, we found not only that IT use does have a direct effect on the quality of decision-making in organizations, but that this effect is partially mediated by the extent of IT-facilitated autonomy and of IT-facilitated coordination. These findings suggest that the effects of IT use on decision-makings in an organization may be attributed, in part, to its beneficial use in coordination and tendency to foster more discretion.     

American Unionism: From Protest to Going Concern

This article is the companion to "Pragmatism(s) Plural, Part I" which argued the virtue of classical pragmatism (of C.S. Peirce and John Dewey) as a methodological and philosophical adjunct to empirical inquiry in political economy. This article briefly examines the use of "pragmatism" to refer to philosophical positions having little to do with classical pragmatism and which are generally antithetical to it. Succeeding sections indicate how W.V. Quine, Richard Rorty, Karl Popper and others are associated with distortions, misreadings, and baseless criticisms of classical pragmatism — or more often of imagined or phantom versions of classical pragmatism. These other "pragmatisms" block more effective inquiry by substituting philosophical attacks and rationales for ongoing, evidential criteria.     

Ethnoscapes,National Territorialisation,and the Afghan War

This article pursues the question of how the territorialisation of power in the establishment of the Afghan nation-state has affected the spatial perceptions of political actors and the population at large. This question is particularly topical as spatial references are at present the driving force behind an ethnicisation of politics in Afghanistan. These perceived ethnic spaces, so-called ethnoscapes, not only compete with one another, but also contradict Afghanistan itself as a national territory. Thus since the outbreak of the Afghan war 1979 various political actors have been attempting to mobilise their constituencies over ethnic issues in order to use references to the spatial origins and expansion of their ethnic category to legitimise political claims. The principal argument of this article is that the population’s strong identification with the national territory of Afghanistan has to date prevented an ethnicisation of the masses in the Afghan conflict. Furthermore the article argues that the irreconcilability of the various perceived ethnic territories is an obstacle to the currently much-discussed establishment of ethno-federalism.     

Networks,Law, and the Paradox of Cooperation

There is a tension between libertarians' optimism about private supply of public goods and skepticism of the viability of voluntary collusion (Cowen 1992, Cowen and Sutter 1999). Playing off this asymmetry, Cowen (1992) advances the novel argument that the free market in defense services favored by anarcho-capitalists is a network industry where collusion is especially feasible. The current article dissolves Cowen's asymmetry, showing that he fails to distinguish between self-enforcing and non-self-enforcing interaction. Case study evidence on network behavior before and after antitrust supports our analysis. Furthermore, libertarians' joint beliefs on public goods and collusion are, contrary to Cowen and Sutter (1999), theoretically defensible.     

Consumer decision making,E-commerce and perceived risks

This article studies how adoption and usage behaviour of the Internet and online shopping, respectively influence the preference to use electronic commerce to purchase different types of products. We empirically model the preference for electronic commerce when consumers have to buy different types of products and thus face different types of risks (Cox and Rich, 1964 Cox, D and Rich, S. 1964. Perceived risk and consumer decision making-the case of telephone survey. Journal of Marketing Research, 1: 32–9. [Crossref], [Web of Science ®] , [Google Scholar]). Unlike previous research, we find that consumers who have previously shopped online, display stronger preferences to buy products on the Internet irrespective of the perceived level of product-specific risks of online shopping. This article provides an interesting and novel insight into how both adoption and usage of electronic commerce impact on the attitude and risk perception of buying less predictable (more risky) products on the Internet.     

Competition and market power in physician private practices

This article presents a theoretical and empirical model to examine competition in physician private practices implementing a conjectural variation framework. Our study uses the 1998 American Medical Association Physician Socioeconomic Monitoring Survey and tests for collusion and market power in physician private practices. The year 1998 is of particular interest due to charges filed in Federal court by The United States Department of Justice (DOJ) against a number of large physician practices, ruling that physicians could no longer engage in joint negotiations. The indictments by the DOJ were based on anecdotal economic and legal observations rather than the result of empirical evidence from accepted econometric modeling. Our model indicates that the behavior of physicians in medical subspecialties and surgical subspecialties is consistent with a non-cooperative Nash equilibrium.     

REPLY TO LOOMIS, WALSH, AND McKEAN

In commenting on my article "… The Opportunity Cost of the Redwood National Park" (Walker 1984), Loomis, Walsh, and McKean (1984) argue that I gave inadequate consideration to concepts of option, existence, and bequest values for wilderness areas. I am familiar with these concepts, and I believe I gave them the attention they deserve.     

The effect of physician board membership on uncompensated care provision

Previous studies indicate that nonprofit and for-profit hospitals provide comparable levels of uncompensated care, when taking into account their sizes. This evidence suggests that for-profit hospitals extract some indirect benefit when providing uncompensated care. Our article investigates how physician board membership affects uncompensated care provision. With data for hospitals in California from 1997 to 2010, we estimate a fixed-effect model where uncompensated care is a function of physician board membership, other board attributes, as well as hospital characteristics. Our results indicate that physician board membership in for-profit hospitals relates positively with uncompensated care provision. Prior evidence, such as Goldstein and Ward (2004) and Molinari et al. (1995), has shown that involving physicians in strategic decisions improves hospitals’ financial performance. Our results reinforce the notion that having physicians in leadership or strategic positions benefits for-profit hospitals. In these hospitals, physicians seem to understand the strategic component of providing uncompensated care, possibly due to their closer assessment of patients’ needs.     

Dilution costs,underinvestment, and utility regulation under asymmetric information

This article addresses the problem faced by a regulated natural monopolist who must raise outside funds to finance socially desirable projects. We demonstrate that fair rate of return utility price regulation will lead to underinvestment incentives in the presence of asymmetric information between the firm and the capital markets regarding the firm's assets and future costs. This problem is especially severe when financing choice is restricted to equity. Underinvestment can be either completely eliminated by adjusting the allowed rate of return above the fair rate or reduced by switching to debt finance.Support from the Center for the Study of Regulated Industry at Georgia State University is gratefully acknowledged. We have benefited from the comments of Victor Andrews, two anonymous reviewers, and the editor, Michael A. Crew. The usual disclaimer applies.