Penalizing Physicians for Low-Value Care in Hospital Medicine: A Randomized Survey

Reducing low-value care—services for which there is little to no benefit, little benefit relative to cost, or outsized potential harm compared with benefit—is an essential step toward maintaining or improving quality while lowering cost. Unfortunately, low-value services persist widelydespite professional consensus, guidelines, and national campaigns aimed to reduce them.^1-3 In turn, policy makers are beginning to consider financially penalizing physicians in order to deter low-value services.^4,5 Physician support for such penalties remains unknown. In this study, we used a randomized survey experiment to evaluate how the framing of harms from low-value care—in terms of those to patients, healthcare institutions, or society—influenced physician support of financial penalties for low-value care services.

Study Sample

By using a stratified random sample maintained by the American College of Physicians, we conducted a web-based survey among 484 physicians who were either internal medicine residents or internists practicing hospital medicine.

Instrument Design and Administration

Our study focused on 3 low-value services relevant to inpatient medicine: (1) placing, and leaving in, urinary catheters for urine output monitoring in noncritically ill patients; (2) ordering continuous telemetry monitoring for nonintensive care unit (non-ICU) patients without a protocol governing continuation; and (3) prescribing stress ulcer prophylaxis for medical patients not at a high risk for gastrointestinal (GI) complications. Although the nature and trade-offs between costs, harms, and benefits vary by individual service, all 3 are promulgated through the Choosing Wisely^® guidelines as low value based on existing data and professional consensus from the Society of Hospital Medicine.⁶

To evaluate intended behavior related to these 3 low-value services, respondents were first presented with 3 clinical vignettes focused on the care of patients hospitalized for pneumonia, congestive heart failure, and alcohol withdrawal, which were selected to reflect common inpatient medicine scenarios. Respondents were asked to use a 4-point scale (very likely to very unlikely) to estimate how likely they were to recommend various tests or treatments, including the low-value services noted above. Respondents who were “somewhat unlikely” and “very unlikely” to recommend low-value services were considered concordant with low-value care guidelines.

Following the vignettes, respondents then used a 5-point scale (strongly agree to strongly disagree) to indicate their agreement with a policy that financially penalizes physicians for prescribing each service. Support was defined as “somewhat or strongly” agreeing with the policy. Respondents were randomized to receive 1 of 3 versions of this question (supplementary Appendix).

All versions stated that, “According to research and expert opinion, certain aspects of inpatient care provide little benefit to patients” and listed the 3 low-value services noted above. The “patient harm” version also described the harm of low-value care as costs to patients and risk for clinical harms and complications. The “societal harm” version described the harms as costs to society and utilization of limited healthcare resources. The “institutional harm” version described harms as costs to hospitals and insurers.

Other survey items were adapted from existing literature^7-9 and evaluated respondent beliefs about the effectiveness of physician incentives in improving the value of care, as well as the appropriateness of including cost considerations in clinical decision-making.

The instrument was pilot tested among study team members and several independent internists affiliated with the University of Pennsylvania. After incorporating feedback into the final instrument, the web-based survey was distributed to eligible physicians via e-mail. Responses were anonymous and respondents received a $15 gift card for participation. The protocol was reviewed and deemed exempt by the University of Pennsylvania Institutional Review Board.

Statistical Analysis

Respondent characteristics (sociodemographic, intended clinical behavior, and cost control attitudes) were described by using percentages for categorical variables and medians and interquartile ranges for continuous variables. Balance in respondent characteristics across survey versions was evaluated using χ² and Kruskal-Wallis tests. Multivariable logistic regression, adjusted for characteristics in the Table, was used to evaluate the association between survey version and policy support. All tests of significance were 2-tailed with significance level alpha = 0.05. Analyses were performed using STATA version 14.1 (StataCorp LLC, College Station, TX, https://www.stata.com).