Controlling Health Care Costs : US Physicians Views

Jon C. Tilburt, MD, MPH Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota Biomedical Ethics Program, Mayo Clinic Knowledge & Evaluation Research Unit, Mayo Clinic Healthcare Delivery Research Program, Center for the Science of Healthcare Delivery Division of Health Care Policy and Research, Mayo Clinic MedicalResearch.com Interview with:
Jon C. Tilburt, MD, MPH

Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
Biomedical Ethics Program, Mayo Clinic
Knowledge & Evaluation Research Unit, Mayo Clinic

Healthcare Delivery Research Program, Center for the Science of Healthcare Delivery
Division of Health Care Policy and Research, Mayo Clinic

What did you set out to find, what was your objective in this study?

  • We wanted to know physicians perceived roles and responsibilities in addressing health care costs as well as their enthusiasm for proposed strategies to contain health care spending.

Who did you study and what did you look at?

  • Practicing US physicians under age 65, we randomly selected 3900 physicians representing all specialties and mailed them an 8-page survey entitled “Physicians, Health Care Costs, and Society.” We received 2,556 completed surveys (65% response rate).

What were the results of the study?

  • 85% agreed that “trying to contain costs is the responsibility of every physician.”
  • Most (76%) reported being aware of the costs of tests or treatments they recommend
  • Strongly endorsed prioritizing patients’ best interests over issues of cost (78%).
  • 85% of physicians disagreed that they should “sometimes deny beneficial but costly services” for others.
  • Most ascribed “major responsibility” for reducing health care costs to entities like trial lawyers, health insurance companies, and pharmaceutical and device manufacturers
  • A minority (36%) reported individual practicing physicians have “major responsibility” while most (59%) thought physicians had “some responsibility” (4% “no responsibility”)
  • Most expressed enthusiasm for cost-containment initiatives aimed at improving the quality and efficiency of care, and favored improving conditions for evidence-based decision making.
    • Improving quality/efficiency of care: 75% very enthusiastic about “promoting continuity of care”; 70% very enthusiastic about “rooting out fraud and abuse”; 69% very enthusiastic about “promoting chronic disease care coordination”.
    • Improving conditions for evidence-based decision making: 63% very enthusiastic about “limiting corporate influence on physician behavior”; 51% very enthusiastic about “expanding access to quality and safety data”.
    • Strategies for changing how care gets paid for received mixed enthusiasm, and payment cuts were viewed least favorably.
      • 51% very enthusiastic about “limiting access to expensive treatments with little net benefit”;
      • 65% not enthusiastic about “paying a network of practices a fixed, bundled price for managing all care for a defined population”;
      • “allowing Medicare payment cuts to doctors to take effect” (94% not enthusiastic); “eliminating fee-for-service payment models” 70% not enthusiastic.
      • Physicians’ degree of enthusiasm for various cost-containment strategies were associated with practice setting and compensation structure.

What did you conclude from this study?

Physicians struggle to navigate their responsibilities not only to address health care costs but also to fulfill their primary obligation to provide the best possible quality of care to individual patients.

What do we know now that we didn’t know before the study?

  • Most physicians agree they do have obligations to address healthcare cost
  • Even though they endorse this obligation, most say it will not get in the way of doing their best for individual patients
  • Addressing cost might improving the quality and opportunities for getting evidence into practice

What’s the bottom line take-home message of this study?

  • Physicians feel stuck in a difficult position. Despite their sense of responsibility to address healthcare costs, physicians consistently express a commitment to the best interests of patients even when it is expensive. They have little appetite for rationing healthcare.

What’s important for patients to know about the results of the study?

  • The profession still wants to do the right thing for individual patients. They want to find the win-win strategies for making healthcare leaner.

Was there anything you found surprising from this study?

  • Physicians have no problem endorsing a strong commitment to address healthcare costs and at the same time saying they are willing to go to bat for their patients even if it is expensive.
  • They see no contradiction between “Limiting access to expensive treatments with little net benefit” and I “being solely devoted to my individual patients’ best interests, even if that is expensive.

Policy Implications:

  • Physicians will likely support cost-savings strategies that are a “win-win” for improving quality of care (informed speculation: these might be worth trying first)
  • Mandatory initiatives designed to redesign payment will likely meet some resistance
  • Payment reform (including incentive programs) should not create a “moral stress test” (Sulmasy) that strongly encourage individual physicians to make cost-saving choices that violate the best interests of individual patients

Citation:

Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US Physicians About Controlling Health Care Costs. JAMA. 2013;310(4):380-388. doi:10.1001/jama.2013.8278.

Press Release:

US physicians feel partly responsible for healthcare costs but patient’s needs come first

Physicians are a key part of addressing rising healthcare costs. A team of researchers led by Jon Tilburt, MD from Mayo Clinic’s Biomedical Ethics Program and Center for the Science of Health Care Delivery surveyed over 2500 US physicans in 2012 about their roles and responsibilities in addressing healthcare costs and their enthusiasm for common cost-control strategies. That study, published this week in JAMA, found that an overwhelming majority of US physicians do feel a responsibility to address healthcare costs, but prioritize their obligations to patients’ best interests over those cost concerns. They feel that patients, pharmaceutical companies, and malpractice lawyers share as much or more of the responsibility for fixing escalating healthcare costs. When asked about specific cost-containment strategies, physicians favor improvements in quality of care as well as improving conditions for evidence-based decisions. They express considerably less enthusiasm for payment reforms like bundled payment schemes, allowing Medicare cuts to take effect, and eliminating fee-for-service care. Salaried physicians and those in larger institutional practice settings reported a significantly higher degree of cost-consciousness compared to physicians whose compensation is based on billing and those with a small practice in small or solo practice. Tilburt and team conclude that cost-containment strategies aimed at physician behavior should focus on innovations that not only promote savings but also preserve their ethical commitment to individual patients.

The study was funded by the Greenwall Foundation and the Mayo Clinic Program in Professionalism and Ethics.