Effect of Financial Relationships on the Behaviors of Health Care Professionals: A Review of the Evidence

Abstract

This paper explores the empirical evidence regarding the impact financial relationships on the behavior of health care providers, specifically, physicians. We identify and synthesize peer-reviewed data addressing whether financial incentives are causally related to patient outcomes and health care costs. We cover three main areas where financial conflicts of interest arise and may have an observable relationship to health care practices: (1) physicians' roles as self-referrers, (2) insurance reimbursement schemes that create incentives for certain clinical choices over others, and (3) financial relationships between physicians and the drug and device industries. We found a well-developed scientific literature consisting of dozens of empirical studies, some that allow stronger causal inferences than others, but which altogether show that such financial conflicts of interests can, and sometimes do, impact physicians' clinical decisions. Further research is warranted to document the causal relationship of such changes on health outcomes and the cost of care, but the current base of evidence is sufficiently robust to motivate policy reform.

Industry payments to physician journal editors

“…Requiring full transparency in declaring financial COI among medical editors may be a reasonable first step in identifying potential conflicts, though one could argue that mere transparency is not sufficient. 27 Financial COI have been shown to result in biased behavior both outside 28 and within the medical field, 29 among prescribing physicians, 30,31 and within clinical trials. [32][33][34] Since editorial decisions are a black box, it is difficult to determine the explicit reasons why an editor makes a manuscript decision and cognitive research suggests that they might very well not be conscious of the reasons themselves, 35 so any amount of financial COI, even declared, may result in unacceptable bias.…”

“Too much medicine”: Insights and explanations from economic theory and research

“…Two recent reviews provide excellent overviews of common health care provider payment mechanisms and the likely impacts they may have on utilisation rates in both primary health care and hospital systems (Langenbrunner, Cashin & O'Dougherty 2009;Robertson, Rose & Kesselheim 2012). In broad terms, they show how line-item or global budgets and salaried payment systems tend to encourage under provision; capitation-based systems may incentivise underutilisation or risk selection and "cream-skimming"; while fee-for-service, case-based and per diem payment systems tend to encourage overutilisation.…”

“…In particular, experience to date with payment for performance or quality systems (P4P) suggests they may not be as discriminating as hoped for in their beneficial effects on provider behaviours and utilisation levels (Robertson, Rose & Kesselheim 2012), or in weeding out "low value care" (Schwartz et al 2014).…”

“…Beyond the direct action of payment mechanisms, Robertson et al (2012) also summarise the available evidence on the existence of other forms of financial conflict of interest which may affect health care providers' clinical behaviour.…”

Open Letter on Ethical Norms in Intellectual Property Scholarship

“…For example, a recent analysis by Robertson et al summarized several studies on the effects of pharmaceutical industry gifts in the form of paid travel and accommodation, food and beverages, sponsorship for continuing medical education, as well as free tickets to cultural and sporting events. 12 Robertson et al tracked changes in prescribing behavior after physicians received such benefits. Notably, physicians who received money for continuing medical education insisted that such funding would not influence their medical practice.…”