Doctors: Major responsibility for cost control is not ours

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Attitude could marginalize doctors

If there was ever an "all-hands-on-deck" moment in the history of health care, that moment is now. The findings of this study suggest that physician do not yet have the mentality this historical moment demands. Indeed, this survey suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious, instinctual approaches humans adopt whenever confronted by uncertainty: Blame others and persevere with "business as usual."

Physicians have moved beyond denying that health care costs are a problem. Yet, they are not quite willing to accept physicians’ primary responsibility and take action. The study findings suggest that physicians are ambivalent; they reject transformative solutions, such as eliminating fee-for-service or bundled payments, which address the seriousness of the cost problem.

This study by Tilburt et al. indicates that the medical profession is not there yet – that many physicians would prefer to sit on the sidelines while other actors in the health care system do the real work of reform.

This could marginalize and demote physicians.

Dr. Ezekiel J. Emanuel is an ethicist at the University of Pennsylvania, Philadelphia. He reported no related conflicts. These remarks were taken from an editorial accompanying Dr. Tilburt’s study.(JAMA 2013;310:374-5)



When it comes to reducing health costs, physicians believe burden of responsibility lies primarily with plaintiffs attorneys, followed by insurers, hospitals, drug and device makers, patients, and, lastly, themselves.

Those conclusions are based on 2,438 responses from some 3,900 physicians randomly surveyed in 2012. Dr. Jon C. Tilburt of the Mayo Clinic, Rochester, Minn., and his colleagues reported their findings July 23 in JAMA.

When asked whether individual physicians should have a major responsibility in reducing health costs, 36% of respondents said yes. Sixty percent said that trial lawyers bore the major burden, with health insurers coming in a close second.

More than half said that drug and device companies, hospitals and health systems, and patients also should have major responsibility for cost containment. A total of 44% said the government had that responsibility (JAMA 2013;310:380-8 [doi:10.1001/jama.2013.8278]).

Physicians also were asked about their enthusiasm for various cost-control strategies and to examine their own role in cost containment by assessing their knowledge of prices of procedures and tests and their desire to personally curb costs in their practice. The authors asked about and analyzed potential barriers to physicians becoming more cost conscious, as well.

Doctors were very enthusiastic about improving the quality and efficiency of care, primarily through promoting continuity of care and going after fraud and abuse. Expanding access to preventive care was also warmly received. Physicians were also enthusiastic about limiting access to expensive treatments that had shown little benefit, using cost-effectiveness data to choose a therapy, and promoting head-to-head trials of competing therapies.

Just over half of respondents said that cutting pay for the highest-paid specialists should be embraced.

Eliminating fee for service altogether was rejected by 70% of respondents. Ninety percent said that they weren’t enthusiastic about letting the Medicare Sustainable Growth Rate cuts take effect. Two-thirds said that bundled pay and penalties for readmissions – both cost-control keystones advanced by the Obama administration – were not attractive.

Not surprisingly, increasing use of electronic health records also got a strong negative response, with 29% saying they were "not enthusiastic."

When it came to their own practice, 76% said they were aware of the costs of treatments or tests they recommended, and 84% said that cost is important whether a patient pays out of pocket or not.

When it comes to individual physicians’ responsibility for reducing health costs, the responses were very mixed.

The survey participants largely agreed that "trying to contain costs is the responsibility of every physician" (85%) and that physicians should take a more prominent role in eliminating unnecessary tests (89%). But by almost the same percentages, physicians also said that they should be devoted to their individual patients, even if a test or therapy was expensive, and that they should not deny services to their patients because someone else might need it more.

"This apparent inconsistency may reflect inherent tensions in professional roles to serve patients individually and society as a whole," Dr. Tilburt and colleagues wrote.

Finally, physicians overwhelmingly said that fear of malpractice had substantially decreased their enjoyment of practicing medicine. The authors rated that fear as a barrier to cost-conscious practice. They also found that 43% of physicians admitted they ordered more tests when they did not know the patient as well. Half said that being more cost conscious was the right thing to do, but large numbers said that it might not make a difference or could make things worse. A total of 40% said it would not limit unreasonable patient demands, and 28% said it could erode patients’ trust.

Dr. Tilburt and his colleagues pointed out that the findings should be viewed with caution in part because it could not fully reflect the opinions of all American physicians. Further, opinions could be in flux, given how much has changed since even a year ago.

They suggested that policy makers move slowly when it comes to changing payment models, and instead target areas where doctors seem to be enthusiastic, including improving quality of care and using comparative effectiveness data.

The study was funded by the Greenwall Foundation and the Mayo Clinic. The authors reported having no financial conflicts.

On Twitter @aliciaault

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