Physician response to financial incentives when choosing drugs to treat breast cancer



This paper considers physician agency in choosing drugs to treat metastatic breast cancer, a clinical setting in which patients have few protections from physicians’ rent seeking. Physicians have explicit financial incentives attached to each potential drug treatment, with profit margins ranging more than a hundred fold. SEER-Medicare claims and Medispan pricing data were formed into a panel of 4,503 patients who were diagnosed with metastatic breast cancer and treated with anti-cancer drugs from 1992 to 2002. We analyzed the effects of product attributes, including profit margin, randomized controlled trial citations, FDA label, generic status, and other covariates on therapy choice. Instruments and drug fixed effects were used to control for omitted variables and possible measurement error associated with margin. We find that increasing physician margin by 10% yields between an 11 and 177% increase in the likelihood of drug choice on average across drugs. Physicians were more likely to use drugs with which they had experience, had more citations, and were FDA-approved to treat breast cancer. Oncologists are susceptible to financial incentives when choosing drugs, though other factors play a large role in their choice of drug.


Agency Physician treatment decisions Financial incentives Medicare Reimbursement 

JEL Classification

I11 D82 


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  1. Afendulis C. C., Kessler D. (2007) Tradeoffs from integrating diagnosis and treatment in markets for health care. American Economic Review 97(3): 1013–1020CrossRefGoogle Scholar
  2. Alexander G., Casalino L., Meltzer D. (2003) Patient–physician communication about out-of-pocket costs. Journal of the American Medical Association 290: 953–958PubMedCrossRefGoogle Scholar
  3. Allison P., Christakis N. (1994) Logit models for sets of ranked items. Sociological Methods 24: 199–228CrossRefGoogle Scholar
  4. Azoulay P. (2002) Do pharmaceutical sales respond to scientific evidence?. Journal of Economics and Management Strategy 11(4): 551–594CrossRefGoogle Scholar
  5. Bach P. B. (2009) Limits on Medicare’s ability to control rising spending on cancer drugs. New England Journal of Medicine 360(6): 626–633PubMedCrossRefGoogle Scholar
  6. Baker L. C. (2010) Acquisition of MRI equipment by doctors drives up imaging use and spending. Health Affairs 29(12): 2252–2259PubMedCrossRefGoogle Scholar
  7. Benson L. R. (2001) Reimbursing cancer care: Medicare policies challenged. Journal of the National Cancer Institute 93(21): 1595–1597PubMedCrossRefGoogle Scholar
  8. Casalino, L. P. (2008). Physician self-referral and physician-owned specialty facilities. The Synthesis Project, Issue 15. Robert Wood Johnson Foundation, June 2008.Google Scholar
  9. Coscelli A. (2000) The importance of doctors’ and patients’ preferences in the prescription decision. Journal of Industrial Economics 48(3): 349–369CrossRefGoogle Scholar
  10. Dranove D., Meltzer D. (1994) Do important drugs reach the market sooner? RAND Journal of Economics 25(3): 402–429CrossRefGoogle Scholar
  11. Dranove D., White W. (1987) Agency and the organization of health care delivery. Inquiry 24: 405–415PubMedGoogle Scholar
  12. Earle C., Nattinger A., Potosky A., Lang K., Mallick R., Berger M., Warren J. (2002) Identifying cancer relapse using SEER-Medicare data. Medical Care 40(8S): 75–81Google Scholar
  13. Epstein A. J. (2010) Effects of report cards on referral patterns to cardiac surgeons. Journal of Health Economics 29: 718–731PubMedCrossRefGoogle Scholar
  14. Frank R., Zeckhauser R. (2007) Custom-made versus ready-to-wear treatments: Behavioral propensities in physicians’ choices. Journal of Health Economics 26: 1101–1127PubMedCrossRefGoogle Scholar
  15. Grant D. (2009) Physician financial incentives and cesarean delivery: New conclusions from the Healthcare Cost and Utilization Project. Journal of Health Economics 28(1): 244–250PubMedCrossRefGoogle Scholar
  16. Gruber J, Kim J., Mayzlin D. (1999) Physician fees and procedure intensity: The case of cesarean delivery. Journal of Health Economics 18(4): 473–490PubMedCrossRefGoogle Scholar
  17. Iglehart J. K. (2003) Medicare and drug pricing. New England Journal of Medicine 348(16): 1590–1597PubMedCrossRefGoogle Scholar
  18. Hellerstein J. (1998) The importance of the physician in the generic versus trade-name prescription decision. RAND Journal of Economics 29(1): 108–136PubMedCrossRefGoogle Scholar
  19. Hole A. (2008) Modeling heterogeneity in patients’ preferences for the attributes of a general practitioner appointment. Journal of Health Economics 27: 1078–1094PubMedCrossRefGoogle Scholar
  20. Iizuka T. (2007) Experts’ agency problems: Evidence from the prescription drug market in Japan. RAND Journal of Economics 38(3): 844–862PubMedCrossRefGoogle Scholar
  21. Jacobson M., Earle C., Price M., Newhouse J. (2010) How Medicare’s payment cuts for cancer chemotherapy drugs changed patterns of treatment. Health Affairs 29(7): 1391–1399PubMedCrossRefGoogle Scholar
  22. Jacobson M., O’Malley A., Earle C., Pakes J., Newhouse J. (2006) Does reimbursement influence anti-cancer drug treatment for cancer patients? Health Affairs 25(2): 437–443PubMedCrossRefGoogle Scholar
  23. Lancaster K. (1966) A new approach to consumer theory. Journal of Political Economy 74: 132–157CrossRefGoogle Scholar
  24. Lerner A. P. (1934) The concept of monopoly and the measurement of monopoly power. Review of Economic Studies 1: 157–175CrossRefGoogle Scholar
  25. Ling D., Berndt E., Kyle M. (2002) Deregulating direct-to-consumer marketing of prescription drugs: Effects on prescription and over-the-counter product sales. Journal of Law and Economics 45(2): 691–723CrossRefGoogle Scholar
  26. Liu Y., Yang Y., Hsieh C. (2009) Financial incentives and physicians’ prescription decisions on the choice between brand-name and generic drugs: Evidence from Taiwan. Journal of Health Economics 28: 341–349PubMedCrossRefGoogle Scholar
  27. Louviere J., Hensher D., Swait J. (2000) Stated choice methods: Analysis and applications. Cambridge University Press, New YorkCrossRefGoogle Scholar
  28. Manning W., Newhouse J., Duan N., Keeler E., Leibowitz A. (1987) Health insurance and the demand for medical care: Evidence from a randomized experiment. American Economic Review 77(3): 251–277PubMedGoogle Scholar
  29. Manski C. (1977) The structure of random utility models. Theory and Decision 8: 229–254CrossRefGoogle Scholar
  30. McFadden, D. (1974). Conditional logit analyses of qualitative choice behavior. In Frontiers of econometrics. New York: Academic Press.Google Scholar
  31. McGuire T., Pauly M. (1991) Physician response to fee changes with multiple payers. Journal of Health Economics 10(4): 385–410PubMedCrossRefGoogle Scholar
  32. Narayanan S., Desiraju R., Chintagunta P. (2004) Return on investment implications for pharmaceutical promotional expenditures: The role of marketing-mix interactions. Journal of Marketing 68: 90–105CrossRefGoogle Scholar
  33. Office of the Inspector General Report. (2001). Medicaid Pharmacy—Actual acquisition costs of brand name prescription drug products (A-06-00-00023).Google Scholar
  34. Office of the Inspector General Report. (2002). Medicaid Pharmacy—Actual acquisition costs of generic prescription drug products (A-06-01-00053).Google Scholar
  35. Petrin A., Train K. (2010) A control function approach to endogeneity in consumer choice models. Journal of Marketing Research 47: 3–13CrossRefGoogle Scholar
  36. Revelt D., Train K. (1998) Mixed logit with repeated choices: Households’ choices of appliance efficiency level. Review of Economics and Statistics 80(4): 647–657CrossRefGoogle Scholar
  37. Rischatsch, M., & Trottmann, M. (2009). Physician dispensing and the choice between generic and brand-name drugs: Do margins affect choice? Working paper. Accessed July 6, 2012, from
  38. Schondelmeyer, S. W., & Wrobel, M. V. (2004). Medicaid and Medicare drug pricing: Strategy to determine market prices. Cambridge, MA: Abt Associates, Inc., Prepared for Centers for Medicare and Medicaid Services, Contract #500-00-0049.Google Scholar
  39. Shafrin J. (2010) Operating on commission: Analyzing how physician financial incentives affect surgery rates. Health Economics 19(5): 562–580PubMedGoogle Scholar
  40. Shen J., Andersen R., Brook R., Kominski G., Albert P., Wenger N. (2004) The effects of payment method on clinical decision-making: Physician responses to clinical scenarios. Medical Care 42(3): 297–302PubMedCrossRefGoogle Scholar
  41. Terza J., Basu A., Rathouz P. (2008) Two-stage residual inclusion estimation: Addressing endogeneity in health econometric modeling. Journal of Health Economics 27: 531–543PubMedCrossRefGoogle Scholar
  42. Train K. (2003) Discrete choice methods with simulation. Cambridge University Press, New YorkCrossRefGoogle Scholar
  43. Warren J., Klabunde C., Schrag D., Bach P., Riley G. (2002) Overview of the SEER-Medicare data: Content, research applications, and generalizability to the United States elderly population. Medical Care 40(8S): 3–18Google Scholar
  44. Yip W. (1998) Physician response to Medicare fee reductions: changes in the volume of coronary artery bypass graft (CABG) surgeries in the Medicare and private sectors. Journal of Health Economics 17: 675–699PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Center for Health Equity Research and PromotionPhiladelphia Veterans Affairs Medical CenterPhiladelphiaUSA
  2. 2.Division of General Internal Medicine, Department of Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.Leonard Davis Institute for Health EconomicsUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Precision Health EconomicsBostonUSA

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