A very troubling article in the
Journal of the American Medical Association [JAMA] which analyzed the likelihood that a patient with carotid stenosis, narrowing of the artery in the neck leading to the brain, would have a surgical intervention.
Records of patients in the TRICARE military health insurance system were reviewed. Within that insurance there are both fee for service [FFS] doctors and salaried doctors. Obviously one of these kinds of doctors makes more money if there is an operation, the other does not. Only patients seen by a specialist with a confirmed diagnosis were included.
The result summary:
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Conclusions and Relevance - Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.
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The authors attempted to control for some variation in the patients who were enrolled in the FFS vs Salaried systems. After adjusting for these differences the FFS patients had 150% to 200% more surgeries than the salaried patients.
But you ask, didn't those who received surgery do better? Maybe those salaried doctors were not sending patients who needed operations to the OR? The authors also looked at outcome data.
Outcomes were evaluated at 30 days, one year, and two years:
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For all patients, those in the FFS group had a higher odds than those in the Salaried group of stroke at 30 days (OR, 1.981; P < .001), 1 year (OR, 1.599; P < .001), and 2 years (OR, 1.486; P < .001) (Table 5). Odds of all-cause mortality were also higher in the FFS group than the Salaried group for all patients at 30 days (OR, 1.976; P = .39), 1 year (OR, 1.673; P = .005), and 2 years (OR, 1.777; P < .001)
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Caveats.. Who needs surgery is not settled and doctors can see the same patient and make differing recommendations even if they do not have a financial stake in the outcome. Additionally it could have been that patients seen by FFS doctors were sicker and therefore needed more surgery. But the majority of patients had no symptoms and even with no symptoms the FFS patients had 150% of the surgeries of the salaried patients.
My conclusion is you should get more than one opinion before having carotid stenosis surgery. This is not to suggest that the surgeon is consciously thinking about dollars when recommending surgery. It can all be a subconscious influence of being aware of the need to generate billings to keep the practice afloat, or pay for the next trip to Tahiti.