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Physician behavior under prospective payment schemes: Evidence from artefactual field and lab experiments

Physician behavior under prospective payment schemes: Evidence from artefactual field and lab experiments

Crucial decisions for the design of economic experiments are the choices of sub- ject pool and framing. In studies that analyze physician behavior, the most common choice is a student subject pool with medical framing. 1 Abbink and Hennig-Schmidt ( 2006 ) and Gneezy et al. ( 2011 ) emphasize that contextual framing has advantages as well as disadvantages and therefore the framing choice depends on the underlying ques- tion. In particular for studies on physician behavior, framing might induce experimental subjects to behave as they expect physicians to behave ( Ahlert et al. , 2012 ). However, neutral framings might induce varying contexts in the subjects’ mind which can affect decisions but are unobservable to the researcher. Indeed, Kesternich et al. ( 2015 ) show in an experiment with medical students that changing perceived context by inducing professional norms influences how players distribute stakes between group members. When it comes to choosing a subject pool, Harrison and List ( 2004 ) suggest that not only students but also professionals should take part in experimental studies. The res- ults from Brosig-Koch et al. ( 2015 ) show that in the experimental analysis of physician behavior the decisions of business and economics students are similar to those of med- ical doctors. We contribute to both discussions by conducting our experiment with a student sample in neutral framing and adding a student sample with medical framing as well as a sample of physicians with medical framing.
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Professional norms and physician behavior: homo oeconomicus or homo hippocraticus?

Professional norms and physician behavior: homo oeconomicus or homo hippocraticus?

severe cases, physicians did not change their behavior significantly. There is, however, also evidence that physicians do intrinsically care about the quality of the services they provide. Kolstad (2013) analyses the effects of performance assessments on physician behavior and finds that physicians are willing to forgo profits to provide better quality. The small but growing experimental literature on physician choices has mostly focused on physicians’ reactions (or those of subjects in situations resembling those faced by physicians) to the incentives they face with respect to their own income; for instance, Hennig-Schmidt et al. (2011) study the effects of different payment systems. Godager and Wiesen (2013) design a laboratory experiment in which a patient benefits from the physician’s choices which allows them to quantify the utility weights of physicians’ own payoffs and their patients’ health. They find that physicians apply a positive weight to patients’ health benefit, but that they vary substantially in their degree of altruism. In their experiment, professional norms are not varied, but all choices are made under one of our professional norm treatments, namely that the receiver of the payoff generated by prospective physicians’ choices is a charity that cares for real patients. The choice situation we study includes a third party – the payers –, and it allows us to study the effect of a professional norm on the choices of physicians.
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Hospital-level policy can affect physician behavior and reduce C-section rates

Hospital-level policy can affect physician behavior and reduce C-section rates

The past few decades have seen a considerable increase in caesarean section rates, which have now reached unprecedented levels. Concerns have been raised about the possibility of medically unnecessary procedures having negative consequences for mothers and infants (WHO, 2015). The aim of this report is to show that a properly implemented hospital-level policy may be a powerful tool for reducing the rates of unnecessary C-sections without inflicting harm on mothers or newborns. Reducing the rates of unnecessary procedures helps lower the excessive healthcare costs that present a major concern for public policy. This report analyzes the implications of a 2005 reform introduced in the Italian region of Piedmont that increased malpractice pres- sure and reduced C-section rates. Empirical evidence indicates that this reform led to a 2.3 percentage point (approximately seven percent at the mean of C-sections) reduction in the use of C-sections in treated hospitals. This suggests that physicians will also alter their behavior in response to hospital-level policies— even though such policies do not directly influence individual insurance liability.
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Physician ethics: undermined or enhanced by modes of payment?

Physician ethics: undermined or enhanced by modes of payment?

INTRODUCTION In the medical literature, the view prevails that any change away from fee-for-service (FFS) jeopardizes medical ethics (Begley (1987), Gervais et al. (1999), American Academy of Dermatology (2000)). Redwin (2011, 53-74) even interprets the French codes of conduct as saying that e.g. sharing fees within a group practice is to be considered unethical. The objective of this contribution is to test the hypothesis that departing from FFS needs to be seen as a threat to medical ethics. It first develops two theoretical models of physician behavior building on pioneering work by Ellis and McGuire (1986) as well as Pauly and Redisch (1973). Ellis and McGuire depict the behavior of a physician in independent practice, while Pauly and Redisch analyze a provider who shares resources such as in a hospital or a group practice. In keeping with Ellis and McGuire, ethical orientation is reflected by a parameter α, which indicates the contribution of patient well-being to physician utility relative to his or her self-interest.
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Physician performance pay: Evidence from a laboratory experiment

Physician performance pay: Evidence from a laboratory experiment

non-optimal service provision is significantly affected by the severity of illness. The aggregate effect of performance pay on the physicians’ quality in our behavioral data relates to recent experimental studies on physician behavior under non-linear performance pay. In Keser et al.’s (2014) chosen effort experiment, which closely relates to Hennig-Schmidt et al. (2011), performance pay tied to the share of patients treated optimally leads to some increase in the physicians’ quality, compared to a fee-for-service system. Lagarde and Blaauw (2015), who employ a real-effort experiment with a bonus and fine condition, report that performance pay enhances performance in the medically framed data entry task. In a hospital frame, Cox et al. (forthcoming) find that utilizing performance pay mechanisms incentivizes cost-effective reductions in hospital readmissions.
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Financial incentives and physician prescription behavior: Evidence from dispensing regulations

Financial incentives and physician prescription behavior: Evidence from dispensing regulations

Although it is very likely that changes in reimbursement schemes lead to both a vol- ume and a substitution response, the relative importance of these two responses has not yet been addressed in the literature. Disentangling the volume and substitution response is important as a change in volume is likely to affect health outcomes in a different way compared to a change in the composition of services provided. Consequently, quantify- ing these two types of responses is relevant for shaping policies to improve efficiency in health care provision. More broadly, isolating these two behavioral channels contributes to a better understanding of physician behavior in the presence of monetary incentives. Therefore, our objective is to empirically investigate the relative importance of the volume and substitution response. To our knowledge, we are the first to disentangle these two behavioral channels in the context of physician agency.
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Comparison of German Pre-Hospital Physician Practice to Paramedic Protocols
and Paramedic Practice

Comparison of German Pre-Hospital Physician Practice to Paramedic Protocols and Paramedic Practice

ALS units in New Haven served a population that was younger and had more female patients. EMS utilization at the ALS level in New Haven was higher than in Berlin in the time period studied for a similarly sized population (3224 dispatches vs. 1106). This may be due to a less developed primary care system in particular in urban areas, and the lack of on-call primary care physicians seeing patients outside of regular office hours. There has been a tendency in Germany to activate the pre-hospital physician for acute medical conditions that do not meet the seven traditional criteria for the disposition of this valuable resource (chest pain, loss of consciousness, respiratory distress, bleeding, major trauma and shock). The need for integrated dispatch and specialized training of primary care physicians on call in acute-care and emergency medicine has been recognized in Germany[21]. In addition, the less affluent demographics of the New Haven study area may result in the EMS system being used for transportation purposes as opposed to only for acute medical emergencies. However,
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Knowledge and behavior

Knowledge and behavior

While the investigation of the dyadic relationship between one particular piece of knowledge and the behaviour deriving from it in various situations concentrates on the statement of k[r]

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Medical insurance and free choice of physician shape patient overtreatment: A laboratory experiment

Medical insurance and free choice of physician shape patient overtreatment: A laboratory experiment

31 public health is comparable, but overall expenditures are lower with competition. On the other hand, insurance reduces inequality amongst the group of patients. We conclude that competition in the guise of free choice of physician has unambiguously beneficial effects in our setting. Informed competition increases the level of public health and decreases overtreatment at the same time. Even though the increased level of public health leads to higher total expenditures, the total expenditures are not as high as they could be – because competition provides incentives to keep overtreatment reasonably low. Of course, extrapolation to health care policies in the field is difficult. Here are three reasons. First, competition is not the only mechanism that can reduce overtreatment, and quite possibly it is not the best that can be thought of. For instance, Brosig-Koch et al. (2014) find that overprovision is significantly lower in a mixed-fee-for-service remuneration system (where the fee-for-service component is complemented by a lump-sum component) compared to a pure fee-for-service system. One would need a comparative evaluation of competition and mixed- fee-for-remuneration or other potential measures to be on safer ground for policy advice. Second, there are distinct differences between the anonymous interactions in an abstract laboratory setting and the interactions of patients and physicians in the field where personal interaction often plays a role. We think it would be interesting for follow-up research to investigate the effects of the institutions studied here in controlled environments that are richer in context. Third, professional norms are also likely to play an important role for the degree to which physicians engage in opportunistic behavior. Kesternich et al. (2015) for instance show (in a controlled laboratory-like internet experiment) that medical students are more likely to sacrifice parts of their own income for a patient’s benefit if they are primed for professional norms (in the context of the Hippocratic Oath).
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Immigrant Examination Behavior

Immigrant Examination Behavior

Table 4 depicts our main model, which estimates whether there are differences in the percentage of passed exams immigrants and natives retake out of the exams they had an opportunity to retake. Overall, immigrants retake a higher percentage of their passed exams than natives. Columns 1 through 3 include the entire sample because the pre-college exam scores are not included. We find a positive relationship between immigrant status and the percentage of exams that a student retakes (column 1), with this relationship being stronger for more recent immigrants (columns 2, 4 and 6). The coefficient on Older Immigrant, which represents immigrants that immigrated before 1986, is around -0.045, depicting that older immigrants are less likely to retake exams than newer immigrants. As mentioned earlier, these individuals are more likely to have been in Israel more time before the beginning of their studies than the other immigrants. This may point, to a degree, to the idea that the more time immigrants are in the host country, the more their behavior assimilates to that of natives. The inclusion of pre-college exam scores (columns 4 and 6) only increases the point estimate on Immigrant. As noted earlier, the inclusion of these variables decreases the sample size substantially, by dropping most of the observations from before 2004. There are more Psychometry scores for the years prior to 2004, so these specifications are going to include more immigrants from older cohorts than the specifications with Bagrut scores. It is important to note that the changing coefficient on
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Organizational boundaries of medical practice: The case of physician ownership of ancillary services

Organizational boundaries of medical practice: The case of physician ownership of ancillary services

One example of the benefits of better PT-physician communication is order clarification. There is some evi- dence that physicians typically provide non-specific and sometimes unclear referral diagnoses to PTs; according to one study, only 32% of physician referrals were judged to contain critical information regarding anatomy and pathology [59]. Orthopaedic surgeons and PTs prac- ticing together have the potential to reduce these ineffi- ciencies in knowledge transfer and face few impediments to doing so. In addition, physicians tend to underestimate pain and overestimate functioning [60], which suggests potential benefits from improved post- treatment communication between patients and physi- cians; in-office PTs offer a conduit for this type of infor- mation feedback.
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Physician decision making on new technologies and the role of coverage with evidence development

Physician decision making on new technologies and the role of coverage with evidence development

additional data on effectiveness and safety [22]. The reform of 2016 focusses on new diagnostic and therapeutic methods whose technical application is based essentially on a medical device of high risk class (in short: ‘high-risk medical device’). ‘High-risk medical devices’ according to the SGB V are (1) medical devices of risk class IIb or III in line with the Directive 93/42/EEC or active implantable medical devices in line with the Directive 90/385/EEC 1 whose (2) application possess a highly invasive character. ‘New diagnostic and therapeutic methods’ thereby are defined as medical procedures with a new theoretical and scientific concept. The term ‘method’ includes procedures in terms of a ‘physician-led treatment concept’ characterised by a certain degree of complexity. It is thus distinct from other medical devices, such as medical instruments or appliances, that are used for one-step procedures [24]. The underlying new theoretical and scientific concept has to differentiate the method from others [24]; i.e., according to §137h SGB V, the new method’s mode of action or its field of application needs to differ substantially from systematic approaches already introduced in inpatient care. One example for a method that has been considered for assessment so far is the Coronary Lithoplasty for the treatment of Coronary Heart Disease (CHD). It is set apart from, e.g., the Rotablation, that is utilised in the treatment of CHD using another mode of action for coronary plaque ablation [25].
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Effects of increased drug copayments on the demand for drugs and physician visits in Germany

Effects of increased drug copayments on the demand for drugs and physician visits in Germany

Methods: A survey of 695 non-exempted adult pharmacy customers who suffered from acute or chronic health conditions in the previous 12 months was conducted. Logistic regression was per- formed to analyse the effect of different income levels on the demand for drugs and physician visits. Results: Of the respondents, 19.9% reported reduced physician visits, 22.6% reported reduced pre- scription drug purchases, 44.9% reported increased use of over-the-counter products and 46.3% re- ported increased use of non-drugs such as household remedies. A total of 11.2% waived more than one visit to the physician. Almost all of those respondents who reduced their purchases of prescrip- tion packages waived 1 to 5 packages (82.5%). There was distinctly less change in purchasing pat- terns among persons with chronic diseases. Logistic regression confirmed that lower income house- holds were more likely to change demand patterns than households in other income brackets. Conclusion: Increased copayments had little effect on drugs and physician visits of adult pharmacy customers, especially among those with chronic conditions. Negative effects on low income house- holds were observed.
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Simulated conversations for assessing professional conversation competence in teacher-parent and physician-patient conversations

Simulated conversations for assessing professional conversation competence in teacher-parent and physician-patient conversations

Assessing the outcomes of such training and providing feedback to learn- ers requires reliable and valid measures of PCC. For this purpose, a specifi c chal- lenge is to create performance-oriented assessment methods that measure partic- ipants’ communicative behavior in authentic task situations (Braun, Athanassiou, & Pollerhof, 2016; cf. Blömeke, Gustafson & Shavelson, 2015; Shavelson, 2013). Simulated conversations (SC), as established in medical education, are a promising method for this purpose (e.g., Lane & Rollnick, 2007; for more information on sim- ulated patients, see Association of Standardized Patient Educators, 2017; Barrows & Abrahamson, 1964). In SC, examinees lead a simulated professional conversation about a pre-defi ned authentic case scenario with actors trained to portray a stan- dardized role. For example, a patient seeking medical advice on diff erent treatment options. Beyond medical training, SC have started to expand into other profession- al domains, such as teacher education (Dotger, Harris, & Hansel, 2008; Gerich & Schmitz, 2016). However, while medical research maintains substantial evidence for the psychometric quality of SC (e.g., Cleland, Abe, & Rethans, 2009; Newble, 2004), such research is lacking in teacher education.
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Physician incentives in managed care organizations: Medical practice norms and the quality of care

Physician incentives in managed care organizations: Medical practice norms and the quality of care

affected minimally. These differences reflect the structure of incentive contracts offered by the HMO, which were designed to reduce incentive pressures on physicians treating the most vulnerable patients. This second lesson raises an important economic question: in the environ- ment of rising health care costs in which this HMO was competing for new members, why did it write incentive contracts that so dramatically limited cost-cutting incentives for the most costly patients? A plausible answer is that at the same time this HMO was cutting prices to build market share, it was also trying to position itself as the high-quality care provider in the mar- ket. Stop-loss provisions were a way to assure high-quality care and still apply cost-containment pressures on elective medical services. This expla- nation may be correct, but it is also incomplete. Physician incentive con- tracts were not advertised, and even if these contracts had become common knowledge, they were so complex that only the most sophisticated buyers would have been able to understand the significance of the stop-loss provi- sions. In addition, the general impression at the HMO was that purchasers were much more responsive to premium levels and the number of physi- cians in its network than to assertions regarding quality. If the HMO was marketing itself as a high-quality provider and paying customers did not perceive quality (or the quality-preserving contractual provisions), to whom was it sending the message about quality?
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The digital transformation of physician-patient consultations : identifying problems and approaches to improve adherence

The digital transformation of physician-patient consultations : identifying problems and approaches to improve adherence

Research in the field of medical informatics studies the use of existing technologies in physician–patient communication. Among others, it focuses on how physicians employ shared displays of various forms (wall screens, tablets, desktop monitors) to show electronic medical records to patients or to gather the necessary information in a collaborative way [2, 11, 21, 25, 28]. While the studies do not provide a conclusive answer as to whether computers improve the physician–patient interaction or not [2, 11, 28], they make clear that the use of technology is growing – reading or filling out medical records amounts to 25% of consultation time and covers over 40 specific activities [21]. Physicians also record their consultations in an audio or video format to make the documentation processes less interruptive for the communication with the patients, although this practice remains controversial [29]. Technologies expected to enter the consultations are double checks / clinical diagnosis decision support systems in which AI supports the physician with the interpretation of proper symptoms and treatment choice, but how they will impact the interaction with the patient remains unclear [33]. Also, the popularity of mHealth, mobile health applications which support self-monitoring and self-management by patients, may contribute to the extended presence of computers in consultations and may support adherence [1, 19]. Overall, the impact of
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Learning from failure in healthcare: Dynamic panel evidence of a physician shock effect

Learning from failure in healthcare: Dynamic panel evidence of a physician shock effect

4 relate to income, patient break-ups because of low performance and/or adverse events (Rizzo, 2003; Hareli, 2007). However, failure may not only stimulate learning, it could also result in more failures. This result, typically found in the organizational literature, occurs when for example failed (business) projects negatively influence a team (Shepherd, 2013). Psychologically, personal goal failure may lead to negative affective states and may therefore translate into negative subsequent outcomes (Jones, 2013). Also, physician inertia may contribute to continued failure. A failure to respond to adverse outcomes may stem from habit formation and from the reluctance to adjust treatment practice because of sizeable search and learning costs (Janakiraman, 2008). Whereas the idea of learning from failure for physicians is related to research on physician inertia in pharmaceutical prescriptions, we apply the idea of previous experience and inertia to a more interventional setting.
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Influence of management behavior on the skilled labor migrations' unsafe behavior

Influence of management behavior on the skilled labor migrations' unsafe behavior

Keywords: unsafe behavior, management behavior, skilled labor migrations, SEM 1. Introduction With individual project construction’s subcontracting to other construction team, skilled labor migrations (SLMs) is becoming the most important construction factor in the engineering construction (EC). Due to the highly risky working place, low level of education, poor technical quality, safety consciousness and poor self-defense capability, casualties continue to occur (Chen, Yu, Zheng & Chen, 2014). According to the accident investigation, the unsafe behavior of SLMs is the most important accident reason in EC (Chen, Yu & Wu, 2014). Thus, SLMs’ unsafe behavior management has been recognized as the fundamental way for the prevention and conformity of EC (Cao & Xu, 2010).
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Incentives and Prosocial Behavior

Incentives and Prosocial Behavior

— Publicity and disclosure. The prominence and memorability of contributions strengthen the signaling motive and thus generally encourage prosocial behavior. When individuals are heterogeneous in their image concerns, however, a greater prominence also acts like an increase in the noise-to signal-ratio: good actions become suspected of being motivated by appearances, which limits the effectiveness of policies based on “image rewards” such as praise and shame. The same concern can lead individuals to refrain from overtly disclosing their good deeds and from turning down any rewards that are offered. Sponsors may respond to contributors’ desire to appear intrinsically rather than extrinsically motivated by publicly announcing low rewards, but then find it profitable to offer higher ones in private, creating a commitment problem.
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Gender Differences in Smoking Behavior

Gender Differences in Smoking Behavior

From a policy perspective it is of interest whether these gender differences in smoking prevalence could mainly be explained by differences in core economic characteristics or whether they are mainly due to behavioral differences. This knowledge would help, for example, to design anti-smoking policies, such as media campaigns, in a more efficient way by addressing specific target groups. The psychological literature concludes that gender differences in tobacco consumption are mainly due to different behavior, having its roots in traditional sex roles. Waldron (1991), for example, identifies three main reasons for gender differences in smoking behavior: (i) general characteristics of traditional sex roles lead to social pressure against female smoking, (ii) traditional sex role norms cause differences in personal characteristics leading to more or less acceptance of smoking (e.g. rebelliousness among males is more accepted than among women and causes higher smoking rates), (iii) sex roles influence the assessment of costs and utility of smoking (e.g. a thin women’s beauty ideal makes weight control more important for women and therefore increases the benefits of
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