But Fowler says that even though the fee-for-service Medicare system, which reimburses specialists and surgeons on the basis of how many procedures they do, "I don't feel comfortable with a purely monetary explanation for the physician's motives."
Rather, he says, "I think physicians are genuinely trying to do good for their patients, but that they just don't come by shared-decision making naturally."
Doctors generally make decisions about whether to insert a stent during the course of an angiography, when the patient is least equipped to discuss alternatives, Fowler says. "We would argue that a discussion about the potential decision to insert a stent should be a routine part of the decision to perform a diagnostic angiogram," Fowler and colleagues wrote in the paper.
Additionally, they stress, these kinds of decisions should include input from the primary care provider. In this survey, fewer than 3% of the prostate cancer and stent patients who responded said their primary care provider played a major role in their decisions.
Fowler says he hopes this trend—to inform and include patients in the decision-making process—will change in coming months and years with the launch of accountable care models, patient-centered medical homes and bundled payments, in which payment to doctors is based on quality measures and wellness, not on the number of procedures.
"That there would be redistribution of medical care dollars, and maybe some reductions—that is a possibility when the world is working right," he says.