A double agency problem? Linking physician altruism to opioid prescribing and guideline adherence

Abstract

Whether physicians act as good agents to their patients and third-party payers is a major policy concern in most countries. The agency relationships may be challenged by physicians’ self-interests such as financial concerns, but also by patients’ and payers’ interests not aligning. The third-party payers may use different policy tools to ensure that physicians act in their interest. However, studies show that these tools do not always yield the desired outcomes. One potential explanation may be variation in physicians’ degrees of altruism. This study aims to establish whether the degree of physicians’ altruism towards patients and payers can predict opioid prescribing and responses to a new clinical guideline. Prescribing of opioids is a well-suited case study as these drugs are often highly demanded by patients with chronic pain, while payers encourage a restrictive use due to potential adverse health outcomes and long run societal costs, pointing to a potential double agency problem. We combine unique survey data on Danish general practitioners’ (GPs) degrees of altruism towards patients and payers with rich register data on redeemed opioid prescriptions and patient and practice characteristics. First, we use simple linear regression models to estimate the associations between GPs’ altruism and redeemed opioid prescriptions, while controlling for patient and practice characteristics. Second, we employ difference-in-differences (DiD) models to estimate the impact of the degree of GPs’ altruism on responses to the introduction of an opioid guideline. We find that patients enlisted with general practices whose GPs are more altruistic towards patients redeem higher dosages of opioids, and those who are long-term opioid users redeem more short-acting opioids. Our DiD-estimates reveal that patients enlisted with general practices whose GPs are more altruistic towards the third-party payer tend to redeem opioids in greater accordance with the clinical guideline, after its introduction. Our results point to the importance of physicians’ altruism for prescribing and policy responses. Thus, policymakers should consider designing policies that appeal to differently motivated physicians to ensure equal access to high-quality care.