The formation of physician altruism

Physician Altruism and Spending, Hospital Admissions, and Emergency Department Visits

Importance

Altruism-putting the patient first-is a fundamental component of physician professionalism. Evidence is lacking about the relationship between physician altruism, care quality, and spending.

Objective

To determine whether there is a relationship between physician altruism, measures of quality, and spending, hypothesizing that altruistic physicians have better results.

Design, Setting, and Participants

This cross-sectional study that used a validated economic experiment to measure altruism was carried out between October 2018 and November 2019 using a nationwide sample of US primary care physicians and cardiologists. Altruism data were linked to 2019 Medicare claims and multivariable regressions were used to examine the relationship between altruism and quality and spending measures. Overall, 250 physicians in 43 medical practices that varied in size, location, and ownership, and 7626 Medicare fee-for-service beneficiaries attributed to the physicians were included. The analysis was conducted from April 2022 to August 2024.

Exposure

Physicians completed a widely used modified dictator-game style web-based experiment; based on their responses, they were categorized as more or less altruistic.

Main Measures

Potentially preventable hospital admissions, potentially preventable emergency department visits, and Medicare spending.

Results

In all, 1599 beneficiaries (21%) were attributed to the 45 physicians (18%) categorized as altruistic and 6027 patients were attributed to the 205 physicians not categorized as altruistic. Adjusting for patient, physician, and practice characteristics, patients of altruistic physicians had a lower likelihood of any potentially preventable admission (odds ratio [OR], 0.60; 95% CI, 0.38-0.97; P = .03) and any potentially preventable emergency department visit (OR, 0.64; CI, 0.43-0.94; P = .02). Adjusted spending was 9.26% lower (95% CI, -16.24% to -2.27%; P = .01).

Conclusions and Relevance

This cross-sectional study found that Medicare patients treated by altruistic physicians had fewer potentially preventable hospitalizations and emergency department visits and lower spending. Policymakers and leaders of hospitals, medical practices, and medical schools may want to consider creating incentives, organizational structures, and cultures that may increase, or at least do not decrease, physician altruism. Further research should seek to identify these and other modifiable factors, such as physician selection and training, that may shape physician altruism. Research could also analyze the relationship between altruism and quality and spending in additional medical practices, specialties, and countries, and use additional measures of quality and of patient experience.

Medical ethics and physician motivations

This paper provides an institutional economics framework for analyzing medical ethics. An ethical policy partitions the set of physician actions into (un)ethical subsets, with unethical actions then unavailable. Individual physicians' preferences over policies combined with a political process determine equilibrium constraints. I show that physicians' concern for colleagues' patients uniquely motivates their support for ethics which restrict behavior under strong assumptions. Without these assumptions, even identical physicians might ban actions they would otherwise select for reasons varying from protecting patients to differences in the costs of maintaining ethical policies. Interestingly, heightened altruism for colleagues' patients makes the former reasoning less credible. Novel applications for 'Provide Free Care to Physicians' and 'Duty to Treat in a Pandemic' demonstrate: (i) rising physician income can explain long-run weakening of both formal ethics in the United States; and (ii) the duty to treat can deteriorate as fewer physicians are required to improve pandemic outcomes.

Looking inside the lab: a systematic literature review of economic experiments in health service provision

Experimental economics is, nowadays, a well-established approach to investigate agents' behavior under economic incentives. In the last decade, a fast-growing number of studies have focused on the application of experimental methodology to health policy issues. The results of that stream of literature have been intriguing and strongly policy oriented. However, those findings are scattered between different health-related topics, making it difficult to grasp the overall state-of-the-art. Hence, to make the main contributions understandable at a glance, we conduct a systematic literature review of laboratory experiments on the supply of health services. Of the 1248 articles retrieved from 2011, 56 articles published in peer-review journals have met our inclusion criteria. Thus, we have described the experimental designs of each of the selected papers and we have classified them according to their main area of interest.

Career choice motivation and professionalism in medical students in China: a gender-stratified analysis

OBJECTIVE

To examine the associations between career choice motivation and professionalism among medical students based on gender in the context of COVID-19.

DESIGN

Cross-sectional study.

SETTING

The study was conducted at a medical school in China.

METHODS

A total of 1421 second-year to fourth-year medical students participated in the survey using cluster sampling. They were asked to complete questionnaires on demographic information, career choice motivation and professionalism. Linear regression models were used to analyse the relationship between career choice motivations and professionalism based on gender differences.

RESULTS

Female medical students outperformed males in professionalism (p<0.001). Third-year medical students have the lowest level of professionalism irrespective of gender. In addition, females have more intrinsic career choice motivation than males. Students motivated by personal interest had the highest level of professionalism, while those who go with the flow had the lowest. According to the linear regression analysis, the motivation advice from parents was the factor of professionalism in male medical students (p<0.05). However, the motivation go with the flow negatively influenced the professionalism of female medical students (p<0.05).

CONCLUSION

The level of professionalism differed between genders based on different career choice motivations. Career choice motivation can be used as an entry point for professionalism education among medical students. Targeted interventions should be implemented to improve professionalism, especially for male medical students and unmotivated students.

Effect of Performance-Based Nonfinancial Incentives on Data Quality in Individual Medical Records of Institutional Births: Quasi-Experimental Study

BACKGROUND

Despite the potential of routine health information systems in tackling persistent maternal deaths stemming from poor service quality at health facilities during and around childbirth, research has demonstrated their suboptimal performance, evident from the incomplete and inaccurate data unfit for practical use. There is a consensus that nonfinancial incentives can enhance health care providers' commitment toward achieving the desired health care quality. However, there is limited evidence regarding the effectiveness of nonfinancial incentives in improving the data quality of institutional birth services in Ethiopia.

OBJECTIVE

This study aimed to evaluate the effect of performance-based nonfinancial incentives on the completeness and consistency of data in the individual medical records of women who availed institutional birth services in northwest Ethiopia.

METHODS

We used a quasi-experimental design with a comparator group in the pre-post period, using a sample of 1969 women's medical records. The study was conducted in the "Wegera" and "Tach-armacheho" districts, which served as the intervention and comparator districts, respectively. The intervention comprised a multicomponent nonfinancial incentive, including smartphones, flash disks, power banks, certificates, and scholarships. Personal records of women who gave birth within 6 months before (April to September 2020) and after (February to July 2021) the intervention were included. Three distinct women's birth records were examined: the integrated card, integrated individual folder, and delivery register. The completeness of the data was determined by examining the presence of data elements, whereas the consistency check involved evaluating the agreement of data elements among women's birth records. The average treatment effect on the treated (ATET), with 95% CIs, was computed using a difference-in-differences model.

RESULTS

In the intervention district, data completeness in women's personal records was nearly 4 times higher (ATET 3.8, 95% CI 2.2-5.5; P=.02), and consistency was approximately 12 times more likely (ATET 11.6, 95% CI 4.18-19; P=.03) than in the comparator district.

CONCLUSIONS

This study indicates that performance-based nonfinancial incentives enhance data quality in the personal records of institutional births. Health care planners can adapt these incentives to improve the data quality of comparable medical records, particularly pregnancy-related data within health care facilities. Future research is needed to assess the effectiveness of nonfinancial incentives across diverse contexts to support successful scale-up.

A new look at physicians' responses to financial incentives: Quality of care, practice characteristics, and motivations

There is considerable controversy about what causes (in)effectiveness of physician performance pay in improving the quality of care. Using a behavioral experiment with German primary-care physicians, we study the incentive effect of performance pay on service provision and quality of care. To explore whether variations in quality are based on the incentive scheme and the interplay with physicians' real-world profit orientation and patient-regarding motivations, we link administrative data on practice characteristics and survey data on physicians' attitudes with experimental data. We find that, under performance pay, quality increases by about 7pp compared to baseline capitation. While the effect increases with the severity of illness, the bonus level does not significantly affect the quality of care. Data linkage indicates that primary-care physicians in high-profit practices provide a lower quality of care. Physicians' other-regarding motivations and attitudes are significant drivers of high treatment quality.

Changing preferences: An experiment and estimation of market-incentive effects on altruism

This paper studies how altruistic preferences are changed by markets and incentives. We conduct a laboratory experiment with a within-subject design. Subjects are asked to choose health care qualities for hypothetical patients in monopoly, duopoly, and quadropoly. Prices, costs, and patient benefits are experimental incentive parameters. In monopoly, subjects choose quality by trading off between profits and altruistic patient benefits. In duopoly and quadropoly, subjects play a simultaneous-move game. Uncertain about an opponent's altruism, each subject competes for patients by choosing qualities. Bayes-Nash equilibria describe subjects' quality decisions as functions of altruism. Using a nonparametric method, we estimate the population altruism distributions from Bayes-Nash equilibrium qualities in different markets and incentive configurations. Competition tends to reduce altruism, but duopoly and quadropoly equilibrium qualities are much higher than monopoly. Although markets crowd out altruism, the disciplinary powers of market competition are stronger. Counterfactuals confirm markets change preferences.

Medical occupation preference under the influence of the COVID-19 pandemic: The role of risk and altruistic preferences

We examine the influence of the COVID-19 pandemic on medical occupation preference, focusing on Wuhan, China. We conducted a survey of 5686 respondents in China regarding the influence of the COVID-19 pandemic on medical occupation preference. We also conducted a complimentary survey in the UK with 1198 respondents, as well as a field experiment in Wuhan with 428 first and second-year medical students. We find a significant negative impact of the pandemic on the willingness to let a loved one choose a medical occupation. Individuals who were heavily influenced by the pandemic, that is, Wuhan residents, especially medical workers, express significantly lower medical occupation preference. Further analysis from Sobel-Goodman mediation tests reveals that around half of the total negative effect can be mediated by enhanced risk aversion and reduced altruism. The UK survey and the field experiment with medical students in Wuhan reinforce these findings. Our results suggest a shift in medical workers' risk- and altruistic-preferences has led to a reduced medical occupation preference. Non-medical workers and students who are more altruistic and risk-seeking are more likely to choose a medical occupation.

Who benefits from quality competition in health care? A theory and a laboratory experiment on the relevance of patient characteristics

We study how competition between physicians affects the provision of medical care. In our theoretical model, physicians are faced with a heterogeneous patient population, in which patients systematically vary with regard to both their responsiveness to the provided quality of care and their state of health. We test the behavioral predictions derived from this model in a controlled laboratory experiment. In line with the model, we observe that competition significantly improves patient benefits as long as patients are able to respond to the quality provided. For those patients, who are not able to choose a physician, competition even decreases the patient benefit compared to a situation without competition. This decrease is in contrast to our theoretical prediction implying no change in benefits for passive patients. Deviations from patient-optimal treatment are highest for passive patients in need of a low quantity of medical services. With repetition, both, the positive effects of competition for active patients as well as the negative effects of competition for passive patients become more pronounced. Our results imply that competition can not only improve but also worsen patient outcome and that patients' responsiveness to quality is decisive.

Should physicians team up to treat chronic diseases?

This paper studies referral strategy and effort provision of a primary care physician and a specialist who are responsible for the treatment of chronically ill patients who can be in a mild or severe condition. Two organizational settings are compared, a team in which physicians cooperate and solo practices in which they do not. Team care is strictly superior to solo practice care if the difference in expected treatment costs between disease severities is relatively larger for the primary care physician. Otherwise, solo practice care is weakly superior to team care under reasonable assumptions.