Doctors: Responsible for health care costs?

A survey of physicians demonstrates an abdication of their responsibility over cost containment in health care.

A July 2013 study describes physicians’ perceived responsibility for controlling health care costs and enthusiasm for various cost-containment strategies. The researchers randomly surveyed 3897 physicians from the AMA Masterfile with a 65% response rate. In addition, they looked into barriers to and consequences of cost-conscious practice. Responders were classified as being either “very enthusiastic” or “somewhat/not very enthusiastic” about participating in cost-containment strategies as determined by a total score calculated from their responses.

More than half of physician responders believed that “major” responsibility for containing health care costs lie with each of the following stakeholders: trial lawyers (60%), insurance companies (59%), hospitals (56%), and pharmaceutical manufacturers (56%). On the other hand, only 36% of physicians believed that they themselves have a “major” role in cost-containment. Physicians named fear of liability and lack of continuity (unfamiliarity with patients) as predominant barriers to containing costs. Interestingly, physicians who endorsed that their enjoyment practicing medicine was decreased because of the threat of liability were approximately half as enthusiastic about cost-containment measures than physicians not as concerned by liability fears.

Based on this survey, the most popular cost-containment strategies were 1) promoting continuity of care, 2) expanding access to quality and safety data, 3) limiting access to expensive treatments with little net benefit, and 4) eliminating fee-for-service payment. The authors analyzed which physician characteristics correlated with enthusiasm for each of the above strategies. For example, women were twice as likely as men to be enthusiastic for promoting continuity of care. Physicians in the Western region were almost 3 times as likely as those in the South or Midwest to be enthusiastic about eliminating fee-for-service payment. Academic physicians were about twice as likely to be enthusiastic about each of the four strategies as compared to physicians working in solo practices, in groups, or for the government.

Commentary

This study uncovers the irony of the physicians’ role within the health care system and the hesitancy felt by physicians as they are challenged to rearrange that role.  A physician’s loyalty is to the individual patient. That loyalty stems from his or her motivation for pursuing a career in medicine, is bolstered by knowledge of medicine based on individual outcomes, and is reinforced by frequent daily contact with individual patients.

However, there is a paradigm shift in physician reimbursement; physicians must take on risk and responsibility in making decisions not only for individual patients but for entire populations.  The survey’s results  exemplify this two-way pull.  Physicians are enthusiastic about eliminating expensive treatments with little net benefit but were almost wholly against limiting reimbursement for readmissions.  Physicians agree they should follow clinical guidelines to avoid expensive interventions that add little benefit but also report that they “should be solely dedicated to [their] individual patients’ best interest, even if that is expensive.”  Most importantly, physicians do not see themselves as a major responsible party in cost containment. In the future, that “spare all expense” mindset must change.

Tilburt, JC, et al. JAMA. 2013; 310 (4): 380-388.

by

Lisa Maurer, MD