Physician Practice Style and Healthcare Costs: Evidence from Emergency Departments

Abstract

We examine the variation across emergency department (ED) physicians in their resource use and health outcomes, and the relationship between ED resource use and future healthcare costs and outcomes. Our data record the initial treating hospital, ED physician, ED billed expenditures, and all interactions with the provincial health system within the subsequent 90 days for EDs in Montreal, Canada. Physicians in Montreal rotate across shifts between simple and difficult cases, implying a quasi-random assignment of patients to physicians conditional on the choice of ED. We consider three medical conditions that present frequently in the ED and for which mistreatment can result in dramatic consequences: angina, appendicitis, and transient ischemic attacks. To control for variation across physicians in their diagnostic acumen, for each condition, our sample consists of patients with a broader set of symptoms and signs that could be indicative of the condition. We regress measures of healthcare costs on indicators for the hospital and ED physician separately by condition. We then evaluate the correlations between different measures of skill and resource use. We find strong positive correlations of physician resource use and skills across the three conditions. However, physicians with costly practice styles are often associated with worse outcomes, in terms of more ED revisits and more hospitalizations. One exception is that for patients in the angina sample, ED physicians with more spending have fewer hospitalizations. Comparisons of physician effects for the base and broader sets of conditions show that both diagnosis and disposition skills are important.

Association of Clinical Characteristics With Variation in Emergency Physician Preferences for Patients

“…If patients who are sicker (or less sick) are preferentially seen by different clinicians, this practice would challenge the assumption that patients are randomly assigned to clinicians (eg, in emergency departments [EDs]). [10][11][12][13] In this study, by contrast, we examined a setting in which physician-patient matching was frequent and easy to identify. We used a comprehensive electronic health record (EHR) data set with detailed information on physician behaviors for more than 300 000 patient encounters at a large ED of an academic hospital, including what physicians observed about patients before signing up to see them, the exact times and shift orders in which patients were seen, and detailed financial charges.…”

The economic consequences of practice style variation in providing medical interventions: A systematic review of the literature

“…In fact, what has been considered as a pivotal point in the variation of health services is the decision to prescribe and provide diagnostic and medical services that are directly related to the practice of physicians. [ 30 31 ] This part of the variation is also known as “unwarranted variation.” Physicians, as agents of patients, play unavoidable roles in delivering healthcare services and its frequency for the patients (clients). Some studies acknowledge that doctors prescribe and provide different services to patients with the same health need even after control role of environmental and structural factors.…”

Saving lives by tying hands: the unexpected effects of constraining health care providers

“…Moreover, while healthmaximizing ED personnel will internalize the costs of waiting to the extent that they impact patient outcomes, this will be imperfect in the presence of uncertainty and may not account for patient well-being beyond health outcomes. Theoretical ambiguities such as this have motivated a growing number of empirical studies of hospital production in the ED setting (Chan, 2016(Chan, , 2017Gowrisankaran et al, 2017;Silver, 2016).…”

“…We contribute to two literatures. First, there is a growing literature that has begun documenting features of hospital production relevant for incentive setting (Chan, 2016(Chan, , 2017Gowrisankaran et al, 2017;Silver, 2016). Chan (2016) and Chan (2017), for example, study how ED physicians respond to team environments and work schedules, while Silver (2016) studies peer effects in the ED.…”

“…Chan (2016) and Chan (2017), for example, study how ED physicians respond to team environments and work schedules, while Silver (2016) studies peer effects in the ED. Gowrisankaran et al (2017) also study the ED and estimate different measures of physician skill. Adjacent to these studies, a medical literature has documented robust correlations between mortality rates and measures of ED crowding and wait times (Hoot and Aronsky, 2008).…”