Diagnosing Expertise: Human Capital, Decision Making, and Performance among Physicians

Expert performance is often evaluated assuming that good experts have good outcomes. We examine expertise in medicine and develop a model that allows for two dimensions of physician performance: decision making and procedural skill. Better procedural skill increases the use of intensive procedures for everyone, while better decision making results in a reallocation of procedures from fewer low-risk to high-risk cases. We show that poor diagnosticians can be identified using administrative data and that improving decision making improves birth outcomes by reducing C-section rates at the bottom of the risk distribution and increasing them at the top of the distribution.

[1]  K. Kozhimannil,et al.  Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. , 2013, Health affairs.

[2]  Amitabh Chandra,et al.  Who Ordered That? The Economics of Treatment Choices in Medical Care , 2011 .

[3]  M. Degroot.  Optimal Statistical Decisions , 1970 .

[4]  Physician Financial Incentives and Cesarean Section Delivery , 1996 .

[5]  Daniel P. Kessler,et al.  Do Doctors Practice Defensive Medicine? , 1996 .

[6]  Jennifer Arlen,et al.  Torts, Expertise and Authority: Liability of Physicians and Managed Care Organizations , 2004, The Rand journal of economics.

[7]  D. Kahneman,et al.  Conditions for intuitive expertise: a failure to disagree. , 2009, The American psychologist.

[8]  A. Gawande,et al.  The Checklist Manifesto , 2009 .

[9]  Joshua D. Angrist,et al.  Identification of Causal Effects Using Instrumental Variables , 1993 .

[10]  A. Epstein,et al.  The Formation and Evolution of Physician Treatment Styles: An Application to Cesarean Sections , 2005, Journal of health economics.

[11]  Paul E. Meehl,et al.  Clinical Versus Statistical Prediction: A Theoretical Analysis and a Review of the Evidence , 1996 .

[12]  James B. Rebitzer,et al.  Physician Incentives in Health Maintenance Organizations , 2004, Journal of Political Economy.

[13]  J. Newhouse.  Patients at risk: health reform and risk adjustment. , 1994, Health affairs.

[14]  Z. Birnbaum.  Effect of Linear Truncation on a Multinormal Population , 1950 .

[15]  T. Mcguire,et al.  Economics and Mental Health , 1999 .

[16]  T. Waidmann,et al.  The impact of malpractice fears on cesarean section rates. , 1999, Journal of health economics.

[17]  Kunio Doi,et al.  Computer-aided diagnosis in medical imaging: Historical review, current status and future potential , 2007, Comput. Medical Imaging Graph..

[18]  D. Dranove,et al.  Quality Disclosure and Certification: Theory and Practice , 2010 .

[19]  W. MacLeod,et al.  First Do No Harm?: Tort Reform and Birth Outcomes , 2006 .

[20]  D. Creedy,et al.  Elective cesarean section and decision making: a critical review of the literature. , 2007, Birth.

[21]  Julie Bynum,et al.  Regional variations in diagnostic practices. , 2010, The New England journal of medicine.

[22]  W. Grove,et al.  Clinical versus mechanical prediction: a meta-analysis. , 2000, Psychological assessment.

[23]  J. Drazen.  Patients at risk. , 2005, The New England journal of medicine.

[24]  Edward P. Lazear,et al.  Salaries and Piece Rates , 1986 .

[25]  Amitabh Chandra,et al.  Preliminary & Incomplete Do Not Cite or Distribute Expertise, Underuse, and Overuse in Healthcare , 2011 .

[26]  D. Dranove,et al.  Does the Market Punish Aggressive Experts? Evidence from Cesarean Sections , 2011 .

[27]  Heidi L. Williams,et al.  Sources of Geographic Variation in Health Care: Evidence from Patient Migration , 2014, The quarterly journal of economics.

[28]  M. Rehavi,et al.  Physicians Treating Physicians: Information and Incentives in Childbirth , 2013 .

[29]  E. Fisher,et al.  Malpractice liability costs and the practice of medicine in the Medicare program. , 2007, Health affairs.

[30]  Roland G. Fryer,et al.  Getting Beneath the Veil of Effective Schools: Evidence from New York City , 2011 .

[31]  J. Skinner,et al.  Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spending , 2013, American economic journal. Economic policy.

[32]  D. Dranove,et al.  Demand inducement and the physician/patient relationship. , 1988, Economic inquiry.

[33]  B. Armour,et al.  Physician Financial Incentives in Managed Care , 2003 .

[34]  Amitabh Chandra,et al.  Productivity Spillovers in Health Care: Evidence from the Treatment of Heart Attacks , 2007, Journal of Political Economy.

[35]  J. Newhouse,et al.  Do Medicare Advantage plans select enrollees in higher margin clinical categories? , 2013, Journal of health economics.

[36]  Ian R White,et al.  Combined logistic and Bayesian modeling of cesarean section risk. , 2004, American journal of obstetrics and gynecology.

[37]  Dina Mayzlin,et al.  Physician Fees and Procedure Intensity: the Case of Cesarean Delivery , 1998, Journal of health economics.

[38]  Jason Abaluck,et al.  Negative Tests and the Efficiency of Medical Care: What Determines Heterogeneity in Imaging Behavior? , 2014 .

[39]  Jonah E. Rockoff,et al.  Information and Employee Evaluation: Evidence from a Randomized Intervention in Public Schools , 2010 .