A Harvard study found "cowboy doctors," or physicians who push medical frontiers by providing unnecessary care for patients, can account for up to 12 percent of overall Medicare expenses and 35 percent of end-of-life Medicare expenses, according to Harvard Magazine.
The study attempted to isolate physicians' beliefs by asking almost 1,550 cardiologists and primary care physicians how they would act in specific scenarios. This method eliminates the influence of patient beliefs on care and eliminates the bias in self-reporting, because some physicians may give "correct answers" rather than their actual beliefs when self-reporting.
For example, the study presents physicians with the following scenario:
"A 75-year-old man with severe (Class IV) congestive heart failure from ischemic heart disease is on maximal medications and has effective disease management counseling. His symptoms did not improve after recent angioplasty and stent placement and coronary artery bypass grafting is not an option. He is uncomfortable at rest. He is noted to have frequent, asymptomatic nonsustained VT on cardiac monitoring. He has adequate health insurance to cover tests and medications."
The physicians were then asked how often they would arrange for five care options: repeat angiography, implantable cardiac defibrillator placement, pacemaker insertion, antiarrhythmic therapy and/or palliative care.
According to the authors of the study, the patient deserves a frank conversation about their condition and end-of-life care preferences. Since one-year mortality is above 50 percent, clinical care guidelines suggest the physicians should "always/almost always" or "most of the time" discuss the palliative care option with patients.
However, the study found only 29 percent of cardiologists said they would should "always/almost always" or "most of the time" discuss palliative care with patients in this scenario. Instead, 62 percent of cardiologists said they would "always/almost always" or "most of the time" recommend an implantable cardiac defibrillator and 45 percent would "most of the time" recommend a pacemaker.
"I think some doctors are saying: 'I just can't accept that this patient is dying and there's absolutely nothing I can do. I've got to do something,'" David Cutler, PhD, an author of the study, told Harvard Magazine.
In fact, the study suggested many of the physicians recommending the unnecessary services were not doing it for the extra money, according to the report. The study found the financial and organizational factors only accounted for about 4 to 14 percent of physicians' choices.
The study did find, however, that male physicians and older physicians were slightly more likely to be cowboys, as were physicians in solo or two-person practices.
The authors suggest physicians may be more incentivized by financial penalties rather than financial rewards, according to the report. It also notes physician beliefs play an equally important role in courses of action in patient care and that we need a better understanding of physicians' beliefs and how to shape them.
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