Study Examines Physicians’ Views on Cost-Containment
While California doctors generally agree that they should play a role in reducing health care costs, they hold disparate views on how to incorporate cost-effectiveness into their clinical decisions, according to a new survey published in this month's issue of the Western Journal of Medicine. The survey, conducted by Sacramento Healthcare Decisions and funded by the California HealthCare Foundation, included responses from 512 Sacramento-area physicians on a range of questions regarding "the role of cost and cost-effectiveness in treatment decisions, perceived barriers to cost-effective medical practice and response of physicians and patients if there are conflicts about treatment that physicians consider either not indicated or not cost-effective." The survey's major findings include:
- Eighty-eight percent of respondents said that physicians should consider costs "when weighing different" medical treatments for their patients, and 84% said they were "comfortable with clinical practice guidelines that took account of cost." However, 53% agreed with the statement that "if a medical intervention has any chance of helping the patient, it is the physician's duty to offer it."
- When questioned about "[p]erceived barriers to cost effective practice," 66% thought society's unwillingness "to acknowledge limited resources" contributed a "great deal" to difficulties in practicing cost-effective medicine, and 62% thought "patients with unrealistic expectations of medicine" contributed a great deal.
- When they encounter patients who insist on having "unnecessary or cost-ineffective medical interventions," physicians said that on average, they would not order the treatment 56% of the time, while 34% of the time they would order it.
- Physicians reported that 45% of patients get "angry or upset if cost or cost-effectiveness is mentioned," while 49% of patients accept cost-driven explanations "once they understand that the intervention would waste resources" (Ginsburg et al., Western Journal of Medicine, Dec. 2000).
The results of the study indicate the difficulties physicians face in balancing the need to reduce costs and their duties to their patients, the Sacramento Bee reports. David Lehman, a Sacramento internist who participated in the survey, said, "I want to do the best for my patients. But my obligation is also to society at large. So every time I order a consultation, or put someone in the hospital, or write a prescription, I am thinking cost." The conflict is reinforced by patient demand for treatments that may or may not be worth their costs, according to Dr. Daniel Fields, a Sutter Medical Group family practitioner and proponent of managed care. "Patients don't appreciate the cost of medication or of procedures, and so their assumption is, it's been paid for already, just do it," Fields said. When it comes down to an individual patient requesting a treatment, societal concern "becomes irrelevant," and doctors often succumb to the individual's wishes, Fields added (Griffith, Sacramento Bee, 12/8).
The real-world implications of the study could mean that patients with similar problems will receive "inconsistent" care depending on their doctors' views on cost-effective treatment, according to the report's authors. "[B]ecause physicians vary considerably in their willingness to provide care they judge to be cost-ineffective or inappropriate, inconsistencies in patient care are inevitable. ... At a time when many patients appear to mistrust the health care system, such inequities -- perceived or real -- could exacerbate already strained relationships," they wrote (Western Journal of Medicine, Dec. 2000). The survey, titled "A Survey of Physician Attitudes and Practices Concerning Cost-Effectiveness in Patient Care," represents the first phase of the Visible Fairness project, a year-long Sacramento-area initiative designed by Sacramento Healthcare Decisions to study how health care costs affect medical decisions (Sacramento Bee, 12/8). To view the full survey, go to http://www.ewjm.com/cgi/content/full/173/6/390.This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.