«Tim Rosengart July 17, 2009 This is a Bucerius/WHU MLB thesis 12,832 words (excluding footnotes) Supervisor 1: Professor Dr. Bernhard Hirsch ...»
As previously described, half of all medical practitioners in Germany work in the ambulant health care sector and for that reason constantly face economic problems with regard to the management of their practices. Nevertheless, it was found that the standardized curriculum by no means provides prospective physicians with courses in business administration such as accounting or marketing, although these might be elementary for doctors who stop working in hospitals, where their entrepreneurial thinking is not required, and open their own surgeries. To further test this impression, H4 was developed and tested by reference to the previously used questions 2.2 and 4.3.
Testing H4 revealed physicians’ aversion towards economic decisions. Most doctors do not feel properly prepared for their economic problems and for that reason outsource their decision making.
The important role of tax advisors [Steuerberater] in the decision making process of doctors became apparent in many discussions.118 At the founding stage of surgeries, the role of external consultants was emphasized by some doctors.119 Several physicians describe themselves as inexperienced managers, who are easily influenced and as such potentially biased in their economic decision making i.e. by external consultants or the publications of suppliers of medical equipment and drugs.120 It becomes apparent that university education does not provide prospective physicians with any relevant knowledge in the field of business administration and consequently, H4 is rejected.
Compare section 3.2.2.
Compare Interview mit Dr. 1, p. 68ff.; Interview mit Dr. 4, p. 90ff.; Interview mit Dr. 8, p. 121ff.
Compare Interview mit Dr. 1, p. 68ff.; Interview mit Dr. 9, p. 128ff..
Compare Interview mit Dr. 3, p. 82ff.; Interview mit Dr. 9, p. 128ff..
Since its reform in 2003, the ÄApprO has had the goal of “educating prospective medical practitioners in such a way, that they are able to understand the economic consequences of their professional behavior”, as one of its key objectives. 121 The objective of the reform needs to be assumed similar to what is described by some of the interviewed doctors. “Many doctors do not understand which immense amounts of money they are in command of, when they are deciding on the appropriate treatment method for their patients.” and “Statutory health insurances provide sufficient amounts of money for a very good treatment of their members but by using large sums for inadequate treatments, much of the system’s resources are simply wasted” were statements by some of the physicians.122 However, it also needs to be said that all of the cited medical professionals studied medicine under a curriculum which was in force before the reform of the ÄApprO in 2003. Therefore, this hypothesis’ test results may create a somehow distorted impression.123 Nevertheless, it appears that university education does not provide prospective physicians with and adequate understanding of the economic scope of their decision making for society.
H5 is rejected.
Compare Art. 1.1 ÄApprO.
Compare Interview mit Dr. 1, p. 68ff.; Interview mit Dr. 8, p. 121ff.; Interview mit Dr. 9, p. 128ff.; Interview mit Frau Dr. Sewekow, Kuhrt (2009), p. 14ff..
Compare Narr (2007), p. 56ff..
In section 2.1 it was asserted that the degree of certainty in decision making depends on the amount and quality of available information. It was stated that as soon as the level of information is below the optimal level, no optimal decision making is possible, anymore.124 Complexity and supply with incomplete and imprecise information are assumed to be limitations in the decision making of doctors.125 Additionally, doctors are not optimally prepared for economic decision making by their studies.126 Because physicians are in such a disadvantageous situation, it can be assumed that doctors try to avoid any form of uncertainty in their economic decision making and that they are
willing to accept only a very limited amount of risk. Testing this assumption is the purpose of H6:
H6: Doctors try to avoid any form of uncertainty in their economic decision making and are willing to accept only a very limited amount of risk.
Testing this hypothesis revealed that all of the interviewed doctors try to avoid any form of uncertainty in their economic decision making and that their willingness to accept risk is very limited and that stable and secure returns are of larger importance than maximization of profits.127 However, some physicians explained that their risk aversion is mainly due to the fact that they are close to their retirement age and that in earlier year they were willing to accept a much higher level of risk.128 Even though doctors with their own practices describe themselves as risk averse, they should only be considered as such to a limited extent. All doctors that leave hospitals for opening their own practices take a considerable financial risk in doing so, because they forego a fixed income for a flexible payment that depends heavily on the doctors’ environment and their stakeholders.
H6 is accepted.
Compare section 2.1.
Compare chapter three and the test of H3.
Compare section 3.2.2.
Compare the interviews of all doctors, p. 68ff..
Compare Interview mit Dr. 2, p. 76ff.; Interview mit Dr. 10, p. 137ff..
External stakeholders aim to influence the economic decision making of physicians.129 Testing H4 revealed that many physicians describe themselves as easily influenced due to their inexperience as managers.
H7 aims at understanding which influence by each of the stakeholders is perceived by doctors.
H7: The perceived impact which external stakeholders have on the work of medical practitioners varies among physicians.
Surprisingly, the influence of statutory health insurances is perceived as critical only by a limited number of physicians.130 Most doctors believe that they are provided with enough money to treat their patients satisfactorily and accordingly they do not perceive strong influence by insurance.131 Patients and their satisfaction are considered as a much stronger influence.132 The influence of colleagues was described by two doctors with specializations as very important.133 Section 3.3.4 explained that German patients, before going to a specialist, first need to consult a general practitioner who, in most cases, recommends a specialist and makes good relationships with colleagues a top priority for specialized physicians.134 Bureaucracy and limitations in the freedom to perform their work were also described as influential issues by some interviewed doctors.135 As shown, medical practitioners’ perceived impact by external stakeholders varies. There is no uniform ranking with regard to the importance of stakeholders.
H7 is therefore rejected.
Compare section 3.3.
Compare Interview mit Dr. 2, p. 76ff.; Interview mit Dr. 6, p. 105ff.; Interview mit Dr. 7, p. 114ff.; Interview mit Dr. 10, p. 137ff..
Compare Interview mit Dr. 3, p. 82ff.; Interview mit Dr. 4, p. 90ff.; Interview mit Dr. 5, p. 97ff..
Compare Interview mit Dr. 1, p. 68ff.; Interview mit Dr. 2, p. 76ff.; Interview mit Dr. 5, p. 97ff.; Interview mit Dr. 6, p. 105ff.; Interview mit Dr. 8, p. 121ff.; Interview mit Dr. 10, p. 137ff..
Compare Interview mit Dr. 1, p. 68ff.; Interview mit Dr. 6, p. 105ff..
Compare section 3.3.4.
Compare Interview mit Dr. 5, p. 97ff.; Interview mit Dr. 6, p. 105ff.; Interview mit Dr. 7, p. 114ff.; Interview mit Dr. 8, p. 121ff..
H7’s findings suggest that doctors are provided with satisfactory resources for the treatment of their patients. A common belief by patients and the impression which is communicated by many politicians, however, is based on the assumption that members of statutory health insurance are entitled to an optimal treatment.136 Consequently, H8 was derived in order to test whether economic
reasons prevent doctors from providing optimal treatments:
H8: Patients are treated sub optimally by their physicians because of economic reasons.
”Dr. 1“ and “Dr. 7” are the only doctors who say that their treatment is optimal from a medical perspective.137 All other doctors come to the conclusion that their treatments are somehow suboptimal, however, satisfactory on a very high level.138 These doctors argue that providing patients with the best state of the art equipment and treatment methods would be excessively expensive and would go beyond what they are reimbursed for by the statutory health insurances. Furthermore, they justify their behavior by means of Art. 12 SGB V which requires physicians to provide a “satisfactory, appropriate and cost-effective treatment”. The interviewed dentists argue that with regard to their treatments, achieving the maximal possible result is only of minor importance because many of their treatments are exclusively done for aesthetic reasons.139 Due to the strong economic pressure which is perceived by many doctors and a reimbursement policy that favors technical diagnostics over doctors’ counseling time, there is also a tendency among medical practitioners to prescribe technical treatments which are not necessary. The doctors, who were interviewed and admittedly prescribe non-necessary treatments, added that their treatments, in comparison to these of other colleagues’, do not “seriously hurt their patients.”140 Additionally, some doctors said that there is an increasing tendency to sell extra services to their patients which these need to pay for privately.141 The extent to which doctors engage in the aforementioned behavior is positively correlated with the economic pressure perceived by physicians.142 The burden of loan-repayments for the acquisitions of their practices is mentioned by some physicians in this context, too.143 Compare section 3.3.2.
Compare Interview mit Dr. 1, p. 68ff.; Interview mit Dr. 7, p. 114ff..
Compare Interview mit Dr. 2, p. 76ff.; Interview mit Dr. 5, p. 97ff.; Interview mit Dr. 6, p. 105ff.; Interview mit Dr. 8, p. 121ff.; Interview mit Dr. 10, p. 137ff..
Compare Interview mit Dr. 4, p. 90ff.; Interview mit Dr. 5, p. 97ff.; Interview mit Dr. 10, p. 137ff..
Compare Interview mit Dr. 9, p. 128ff..
Compare Interview mit Dr. 9, p. 128ff.; Interview mit Dr. 3, p. 82ff..
Compare Interview mit Dr. 9, p. 128ff..
Compare Interview mit Dr. 1, p. 68ff..
H7 is accepted on the grounds that patients are treated sub optimally. The reason for the suboptimal treatment, however, is not attributable to the economic interests of doctors but rather to the legal framework that they are given by politics.
Testing the previous hypothesis demonstrated that the legislative by means of Art. 12 SGB V expects physicians to provide a “satisfactory, appropriate and cost-effective treatment”. It can be assumed that in many cases conflicts arise with regard to what doctors are expected to provide according to SGB V and what they actually believe to be optimal for their patients’ well being.
It is assumed that doctors could provide a treatment that is better than expected from them but as a result would need to forego some of their own utility i.e. by contribution of personal wealth or unpaid working time.
In its pure form, the theoretical concept of the homo oeconomicus, which was described in section
2.1 and which is a central assumption underlying all decision making theory, however, does not expect such behavior.144 H9 aims at testing whether the theoretical assumptions of the homo oeconomicus are in line with what can actually be observed in practice with regard to the economic decision making behavior of
H9: Doctors’ decision making is in line with what had to be expected under the assumption of the homo oeconomicus. Physicians rank their own utility higher than the utility of their patients.