Docs on Controlling Costs – “Not My Job”

Make the lawyers, insurance companies, hospitals, device makers and patients do it.

That’s the opinion of most of the 2, 500 physicians surveyed by Mayo Clinic researchers about who is most responsible to reduce health care costs.

Jon Tilburt, M.D., a general internist at Mayo Clinic and his colleagues set out to discover what physicians thought their role is in controlling health care costs, and which strategies they thought were most promising. In 2012 they sent out 3, 897 surveys by mail using the American Medical Association’s (AMA) Physician Masterfile. Over 65% of those surveyed responded.

Survey Says

Besides discovering that only a third of the respondents thought they had a major responsibility in controlling costs, the researchers found:

• Few physicians expressed enthusiasm for eliminating fee-for-service payment models (7%)
• Most physicians reported being aware of the costs of the tests/treatments they recommend (76%)
• Agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%)
• Agreed that they should be solely devoted to individual patients’ best interests, even if that is expensive (78%)
• Doctors need to take a more prominent role in limiting use of unnecessary tests (89%)

So if these physicians don’t think they bear “major responsibility” to control costs, who do they think does?

• Trial lawyers (60%)
• Health insurance companies (59%)
• Hospitals and health systems (56%)
• Pharmaceutical and device manufacturers (56%)
• Patients (52%)

Paycheck Divide

Where one stands apparently depends upon where one sits. Tilburt said that whether physicians were salaried or not was a major predictor of their enthusiasm for cost control strategies. For instance, salaried physicians were three to four times more likely to be ok with eliminating the fee-for-service system.

Overall, just 30% of the surveyed docs supported eliminating fee-for-service. Penalizing clinicians for avoidable readmissions received just 6% support. Bundled payments received a mere 6% support.

Emanuel: “Denial of Responsibility”

Ezekiel Emanuel, M.D., Ph.D. calls this attitude “a denial of responsibility…In the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious instinctual approaches humans adopt whenever confronted by uncertainty: blame others and persevere with ‘business as usual.’”

In an accompanying editorial in the July 24, 2013 edition of the Journal of the American Medical Association (JAMA), Emanuel, wrote that controlling health care costs is the fundamental domestic policy challenge facing the U.S. Increasing costs are crowding out spending on other public priorities like education, defense, law enforcement, environmental protection and other important public purposes.

He said health care must be transformed in at least six ways.

1. More value consciousness in medical decisions
2. Keep patients healthy to avoid chronic illnesses
3. More team care and away from individual practitioners
4. More organized and coordinated systems
5. More process standardization
6. Greater price and quality transparency

Captains of the Ship

“Physicians must lead, ” said Emanuel, “They are the captains of the health care ship.” He added that physicians decide who gets seen, how often and by whom. They decide who gets hospitalized, which tests are ordered and which diagnostic procedures and surgical operations are administered. They decide which medications to prescribe. “If physicians oppose the changes, reform will fail.”

With only about a third of physicians believing they bear some major responsibility, he asks if they can really be “both the captain of the ship and cede responsibility to almost everyone else?”

Unless physicians want to be marginalized, Emanuel writes that physicians must accept that they are responsible for controlling health care costs.

Emanuel wasn’t all negative and found some good news in that physicians seem to recognize that health care costs are important with 51% strongly agreeing that the cost of a test or medication is only important if the patient has to pay for it.

Steinmann: “We’re Doing a Miserable Job”

John Steinmann, D.O., who has been one of the most active physicians in challenging existing health care cost structures in device distribution, agrees that this study is discouraging and not reflective of the mindset he and his fellow physicians and surgeons should have at this time.

In a response to OTW, Steinmann wrote that treatment decisions that physicians make on behalf of their patients, ranging from which tests and procedures to perform to which drugs and medical devices to use, account for 60% of the health care spend in America. “Couple that with the fact that health care spending per capita in the U.S. is nearly twice that of the next closest country with no evidence of any superiority in quality. Then ask, if an individual were making purchase decisions for a company and that company spent twice as much as their competitors to produce the same product, would not that individual who was responsible for making those purchase decisions have to be replaced?”

“Like it or not, we as physicians, far more than anyone else, have the responsibility to spend the countries health care dollar wisely and current data would suggest that we are doing a miserable job of this. As a result, we should understand that we are at serious risk of losing this responsibility—a direction that would have equally disastrous effects on health care in America.”

Gross Market Failure

In the area of orthopedic and spinal devices, Steinmann writes that surgeons know that the majority of devices have reached a status whereby there are a number of quality manufacturers making products that will perform equally well. “Yet this commoditization of this industry has not resulted in any cost savings.”

Steinmann says physicians owe it to the American public to “correct the gross market failure that has persisted in this area and cause products and manufacturers to compete on value. If we continue to ignore the fact that our decisions cause the U.S. health care system to spend twice what it should for medical devices we should be subject to losing the privilege of making that decision.”

He says there is no disputing that physicians are the most qualified individuals to make health care treatment decisions including decisions on which drugs and devices to use. “But what is becoming clear is that if we cannot demonstrate greater responsibility in ensuring those decisions are made on the basis of value, then we as physicians will assuredly and rightfully lose that right.”

Loss of Control

Why might physicians think other stakeholders have a greater responsibility?

“They could have a highly virtuous view of themselves—that they are trying to do the right thing and are victims in a system of villains, ” Tilburt said. “Or they might say: ‘Look, I’m a cog in a wheel of a large system that I don’t really control.’”

“They see drug company profits going up and hospital executives taking seven digits (of income), and the only patients they remember from the previous day in clinic were the super-demanding ones.”

Patients Come First

For what did physicians in the survey think they are responsible? Well, patients.

“Most physicians say that trying to address health care costs is part of their job, ” Tilburt said. “On the other hand, physicians have no problem at the same time saying: ‘Look, when push comes to shove, my patients come first and I don’t care how much it costs.’”

Physicians also hold nuanced views about their perceived responsibility for health care costs. Most (78%) agree that they should be solely devoted to their individual patients’ best interests, even if that is expensive, whereas 85% disagree that they should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.

Society Second

Yet 85% also agree that trying to contain costs is the responsibility of every physician, and 89% agree that doctors need to take a more prominent role in limiting use of unnecessary tests.

This apparent inconsistency, write the survey authors, “May reflect inherent tensions in professional roles to serve patients individually and society as a whole.”

They note that previous studies have suggested that U.S. physicians endorse the ideal of prudent stewardship but are reluctant to withhold available but costly services that could benefit individual patients.

“Similarly, Campbell et al. found that 98% of physicians endorse ‘just distribution of finite resources’ but 36% would order magnetic resonance imaging that is not indicated. Antiel et al. found that a majority of U.S. physicians were willing to accept lower reimbursement for expensive drugs and procedures if that would expand health insurance coverage, but 55% also objected to using cost-effectiveness analysis to guide what treatments are used in practice. Physicians clearly struggle with these tensions and how they can act individually and collectively to provide optimal, sustainable quality care, ” wrote the authors.

What Do Docs Want?

Moving toward cost-conscious care starts with strategies for which there is widespread physician support, says Tilburt. Those efforts may include improving quality and efficiency of care and bringing transparent cost information and evidence from comparative effectiveness research into electronic health records with decision support technology. More aggressive (and potentially necessary) financing changes may need to be phased in, with careful monitoring to ensure that they do not infringe on the integrity of individual clinical relationships.

The authors conclude that health reform efforts that don’t create a stress test for physicians to choose against the needs of patients would be the first step physicians would want to see.

You can read the details of the survey here.