When Reducing Low-Value Care in Hospital Medicine Saves Money, Who Benefits?
One emerging policy solution for deterring low-value care is to financially penalize physicians who prescribe it. However, physicians’ willingness to support such policies may depend on whether they perceive that benefits accrue to patients or to insurers and hospitals. We surveyed physicians practicing hospital medicine to evaluate the association between policy support and physician beliefs about who benefits from the money saved through reducing low-value services in hospital medicine. Overall, physicians believed that more of any money saved would go to profits and leadership salaries for insurance companies and hospitals and/or health systems rather than to patients. These beliefs were associated with policy support: 66% of those supporting physician penalties were more likely to believe that benefits accrue to patients or physicians, compared to 39% of those not supporting policies (P < 0.001). Our findings are consistent with a sense of healthcare justice, in which physicians are less likely to support penalties imposed on themselves if the resulting benefits accrue to corporate or organizational interests. Effective physician penalties will likely need to address the belief that insurers and provider organizations stand to gain more than patients when low-value care services are reduced.
© 2018 Society of Hospital Medicine
Statistical Analysis
We used a χ2 test and multivariable logistic regression analysis to evaluate the association between policy support and physician beliefs about who benefits from reductions in low-value care. A χ2 test and a Kruskal-Wallis test were also used to evaluate the association between other respondent characteristics and beliefs about who benefits from reductions in low-value care. Analyses were performed by using Stata version 14.1 (StataCorp, College Station, TX). Tests of significance were 2-tailed at an alpha of .05.
RESULTS
Compared with nonrespondents, the 187 physicians who responded (39% response rate) were more likely to be female (30% vs 26%, P = 0.001), older (mean age 41 vs 36 years old, P < 0.001), and practicing clinicians rather than internal medicine residents (87% vs 69%, P < 0.001). Twenty-one percent reported that their personal compensation was tied to cost incentives.
Overall, respondents believed that more of any money saved from reducing low-value services would go to profits and leadership salaries for insurance companies and hospitals and/or health systems rather than to patients (panel A of Figure). Few respondents felt that the money saved would ultimately go toward physician compensation.
Sixty-six percent of physicians who supported penalties believed that benefits from reducing low-value care accrue to patients or physicians, compared to 39% among those not supporting penalties (P < 0.001). In multivariable analyses, policy support was associated with the belief that the money saved from reducing low-value services would accrue as benefits to patients or physicians rather than as salaries and profits for insurance companies or hospitals and/or health systems and their leaders (Table). There were no statistically significant associations between respondent age, gender, or professional status and beliefs about who benefits from reductions in low-value care.
DISCUSSION
Despite ongoing efforts to highlight how reducing low-value care benefits patients, physicians in our sample did not believe that much of the money saved would benefit patients.
This result may reflect that while some care patterns are considered low value because they provide little benefit at a high cost, others yield potential harm, regardless of cost. For example, limiting stress ulcer prophylaxis largely aims to avoid clinical harm (eg, adverse drug effects and nosocomial infections). Limiting telemetric monitoring largely aims to reduce costly care that provides only limited benefit. Therefore, the nature of potential benefit to patients is very different—improved clinical outcomes in the former and potential cost savings in the latter. Future studies could separately assess physician attitudes about these 2 different definitions of low-value services.
Our study also demonstrates that the more physicians believe that much of any money saved goes to the profits and salaries of insurance companies, hospitals and/or health systems, and their leaders rather than to patients, the less likely they are to support policies financially penalizing physicians for prescribing low-value services.
Our study does not address why physicians have the beliefs that they have, but a likely explanation, at least in part, is that financial flows in healthcare are complex and tangled. Indeed, a clear understanding of who actually benefits is so hard to determine that these stated beliefs may really derive from views of power or justice rather than from some understanding of funds flow. Whether or not ideological attitudes underlie these expressed beliefs, policymakers and healthcare institutions might be advised to increase transparency about how cost savings are realized and whom they benefit.
Our analysis has limitations. Although it provides insight into where physicians believe relative amounts of money saved go with respect to 6 common options, the study did not include an exhaustive list of possibilities. The response rate also limits the representativeness of our results. Additionally, the study design prevents conclusions about causality; we cannot determine whether the belief that savings go to insurance companies and their executives is what reduces physicians’ enthusiasm for penalties, whether the causal association is in the opposite direction, or whether the 2 factors are linked in another way.
Nonetheless, our findings are consistent with a sense of healthcare justice in which physicians support penalties imposed on themselves only if the resulting benefits accrue to patients rather than to corporate or organizational interests. Effective physician penalties will likely need to address the belief that insurers and provider organizations stand to gain more than patients when low-value care services are reduced.
