Physicians view other parties as responsible for reducing costs of health care

Physicians believe other parties, including trial lawyers, health insurance companies, and hospitals and health systems, bear greater responsibility than they do for reducing health care costs, according to a recent survey.

Researchers conducted a cross-sectional survey in 2012 designed to determine physicians' beliefs about methods of addressing health care costs as well as the role physicians should play. The surveyed physicians were randomly selected from the American Medical Association Masterfile and were asked to assess perceived stakeholder responsibility for controlling costs, enthusiasm for different cost-controlling strategies, their professional role in cost containment, and perceived barriers to and consequences of cost-conscious practice. The degree of the respondents' cost-consciousness, defined as the extent to which they pay attention to and feel an obligation to address health care costs in their practice, was derived from an 11-point scale, with higher scores reflecting a greater level of cost-consciousness. The study results appear in the July 24/31 Journal of the American Medical Association.

The survey was mailed to 3,897 physicians, and 2,556 (65%) responded. Those who responded were mostly men (70%) and were most likely to work in a group/HMO practice (64%). In the survey results, the parties most commonly reported to have a “major responsibility” for reducing costs of health care were trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%) and patients (52%). In contrast, 36% of respondents thought practicing physicians had a major responsibility, 19% thought employers did, and 27% thought physician professional societies did. Most of the physicians surveyed reported being “very enthusiastic” about reducing health care costs by “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%). Seventeen percent of respondents were very enthusiastic about high-deductible health care plans and about higher patient copayments. Only 6% were very enthusiastic about penalties for avoidable readmissions, and only 7% were very enthusiastic about elimination of fee-for-service payment models.

Most of the physicians surveyed said they were aware of the costs of the tests and treatments they recommend (76%), should follow clinical guidelines that discourage marginally beneficial care (79%), should work primarily toward patients' best interests even when doing so is costly (78%) and should be more involved in limiting use of unnecessary tests (89%). Eighty-five percent of respondents disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” Seventy percent of respondents agreed that they enjoyed practicing medicine less because of the threat of lawsuits.

In multivariable logistic regression models, compensation by salary plus a bonus or salary only was independently associated with enthusiasm for eliminating fee for service (odds ratios, 3.3 and 4.3, respectively), while in multivariable linear regression models, working in a group or government practice and receiving a salary plus a bonus were associated with increased levels of cost-consciousness. A negative association was observed between cost-consciousness and responding affirmatively that the uncertainty involved with patient care is disconcerting.

The study authors pointed out that data in the American Medical Association Masterfile are self-reported and that the opinions of all U.S. physicians may not be represented in their study, among other limitations. They said that their study results may reflect tensions in physicians' professional role, which requires them to serve both individual patients and society as a whole.

“Physicians clearly struggle with these tensions and how they can act individually and collectively to provide optimal, sustainable quality care,” the study authors wrote. “They also recognize themselves as just one component of a multifaceted system of stakeholders responsible for addressing increasing costs.”

Given the survey findings, the authors wrote, cost-conscious care should start with strategies that physicians largely support in order to “create momentum for such efforts.” The authors also recommended that more drastic financing changes be phased in gradually and be carefully monitored to avoid unintended negative effects.

The authors of an accompanying editorial called the current state of U.S. health care “an ‘all-hands-on-deck’ moment” and said that the survey results indicate physicians are not yet ready to lead. The fact that only one-third of physicians claimed a major role in controlling costs “is a denial of responsibility,” the authors wrote. In addition, although physicians supported the use of cost-effectiveness data, limited access to costly treatments with little benefit, and incorporation of cost information into electronic decision support tools, these methods “largely relieve the physician from being the decision-maker and taking responsibility for cost control,” they said.

Physicians now recognize that health care costs are a problem but are not willing to accept primary responsibility for finding a solution and would prefer others to do so, the study authors wrote. “This could marginalize and demote physicians,” they concluded. “Physicians must commit themselves to act like the captain of the health care ship and take responsibility for leading the United States to a better health care system that provides higher-quality care at lower costs.”