13 Feb Patient Demands Not A Significant Driver Of Health Care Costs
MedicalResearch.com Interview with:
Ezekiel Jonathan Emanuel MD PhD
Department of Medical Ethics and Health Policy
Perelman School of Medicine and
Department of Health Care Management
The Wharton School University of Pennsylvania
Editor’s note: Dr. Emanuel is a medical oncologist as well as director of the department of Medical Ethics and Health Policy at the University of Pennsylvania. Dr. Emanuel was kind enough to answer several questions regarding his most recent study, published in the new JAMA Oncology journal, Patient Demands and Requests for Cancer Tests and Treatments.
Medical Research: What is the background for this study? What are the main findings?
Dr. Emanuel: The genesis for this study is twofold.
One, the first referenced article, by John Tilbert1 discussed how physicians explain US health care costs. In this study, physicians felt patients, insurance companies, drug companies, government regulations and malpractice lawyers…all were more to blame than doctors themselves for the high cost of US health care.
Secondly, I give lots of presentations to doctors who offer two explanations for escalating health care costs: fear of malpractice litigation, and demanding patients, who request extensive testing and drugs. We decided to see whether the impression doctors frequently held of patients’ demands driving up health care costs, had been previously investigated. We could find no article to substantiate this belief. In addition, demanding patients were not common in my medical experience.
In our study we included 5050 patient encounters. We asked the clinician coming out of the encounter, did the patient make a demand or request? (By asking immediately after the doctor left the examination room, there was little risk of inaccurate recall of the specifics of visit). In 8.7% there was a patient request and of these, over 70% were deemed clinically appropriate as determined by the physician (i.e. a request for pain medication, palliative care or imaging to address a new symptom or finding). In only 1% of all encounters (50/5050) was a clinically inappropriate request made as determined by the doctor, and the doctors hardly filled any of these inappropriate requests (total of 7 of 5050 encounters).
We concluded that it is pretty rare for patients to make demands or requests, at least in this oncology setting, and even less common for the demands to be complied with by the doctor. Therefore it seems unlikely to us that health care costs are significantly driven by inappropriate patient requests. It is possible that there are more or different patient demands in other health care settings but we were very surprised to find no difference in patient requests based on patient-income, i.e. wealthier, more educated patients made no more demands than patients of lesser means.
Medical Research: What should clinicians and patients take away from your report?
Dr. Emanuel: Clinicians should take away that while patient demand events are rare, they loom large in the doctor’s memory, and may be negatively emotionally charged. Doctors may perceive requests by patients for more or different medications or specific testing as a vote of no confidence in the doctor’s care or management. The requests may also result in more demands on the doctor’s time and, as our data suggests, imply a less good relationship with patient. Those doctor-patients relationships that are not going well may be accompanied by more demands by the patient or family. The physician may also disproportionately remember less than ideal relationships.
For patients, the message should be ‘we’re really not to blame here for escalating health care costs’!
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Emanuel: I think we need further studies to address the impact of patient requests on health care costs but set in three different environments:
- Not in Philadelphia. Our study was based in three different Philadelphia locations. There may be regional differences in doctor-patient interactions.
- Not in oncology practices but studied perhaps in primary care or another common specialty i.e. cardiology.
- Not in exclusively outpatient venues. An inpatient or ICU setting would be ideal, although my guess is that intensive care or surgical patients are less likely to make specific demands of their physicians than in an outpatient setting.
1: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA 2013; 210(4); 380-388
MedicalResearch.com Interview with: Ezekiel Jonathan Emanuel MD PhD (2015). Patient Demands Not A Significant Driver Of Health Care Costs MedicalResearch.com