• Who’s responsible for controlling health care costs?

    That’s the question that a recent study in JAMA asked doctors. “Views of US Physicians About Controlling Health Care Costs“:

    Importance  Physicians’ views about health care costs are germane to pending policy reforms.

    Objective  To assess physicians’ attitudes toward and perceived role in addressing health care costs.

    Design, Setting, and Participants  A cross-sectional survey mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile.

    Main Outcomes and Measures  Enthusiasm for 17 cost-containment strategies and agreement with an 11-measure cost-consciousness scale.

    So who do docs think is responsible? Evidently, everyone but them. Those who have a “major” responsibility for lowering health care costs included trial lawyers (60%), insurance companies (59%), hospitals and health systems (56%), drug and device companies(56%), and, of course,  patients (52%). Only about a third of them thought they they themselves has a “major” responsibility. Lots of them approve of quality initiatives to reduce cost, but almost none (7%) thought that getting rid of fee-for-service reimbursement was a good idea.

    Ezekiel Emanuel and Andrew Steinmetz, who wrote an editorial on this study, noted something important:

    These attitudes, however, have an interesting character: while supporting cost-consciousness in health care, they largely relieve the physician from being the decision-maker and taking responsibility for cost control. Someone outside—either insurance companies, a government board, or some organization determining cost-effectiveness ratios—would bear the responsibility for bringing cost into the health care equation. This would allow physicians to point to someone else doing the resource allocation and cost control.

    One of the reasons I’ve often supported “more” government involvement is that someone has to be the “bad guy” at some point. Physicians, amongst others, often don’t want to do that. But sometimes, someone has to say “no”.

    Both the study and the editorial are worth your time.


    • Years ago at a public forum on health care quality and cost, one prominent local MD fessed up: “The most expensive item in American health care,” he said, ” is the pen in a physician’s hand.”

      Do MDs really not see this, or are they living in an advanced state of denial? If they’re ordering the tests and procedures, the hospital admissions and the prescriptions — sometimes in the face of evidence that those actions have no or very limited benefit for patients — why do they persist in pointing the finger of responsibility at others?

    • This is an issue of how much as well as an issue of who. When I first began working with physicians in the early 1980s, their incomes were much, much, much lower than today. Few earned more than $100,000 per year, and $60,000 to $80,000 was common. Today, many physicians are shocked that in the future (meaning now) they may earn $1 million, $800,000, $500,000, or even less per year. Even more shocking to young physicians is the very idea that they must help develop the practice, by courting referral sources, such as other physicians, hospitals, nursing homes, and insurers, and working nights and weekends. Shocking! So it’s not surprising that physicians believe they bear little or no responsibility for controlling health care costs. Unfortunately for them, physicians with this attitude are likely to see the greatest decline in incomes.

      • $60K in 1980 dollars is $170K in today’s dollars or roughly what a primary care doc makes.

      • I know this is shocking to your dearly-held belief that all doctors are rich, but it just isnt so.

        The US Labor Dept, which has IRS tax data from every physician in the United States, puts the median pre-tax income of doctors at 170k.

        A very nice income. Nowhere near what you are talking about though (1 million dollar doctors put you in the top 0.5% of incomes among all physicians)

        Lets use real numbers please, not made up fantasy numbers that only a few plastic surgeons in Beverly Hills make.

        Also, doctor take home incomes only account for 10% of total healthcare spending. You need to find another bogeyman for your high costs. Doctors DECISIONS drive costs, not their incomes. There’ s a huge difference between those 2 things.

    • Outside of education and healthcare, do “bad guys” exist in other industries?

      Take the real estate market for example. Homes are the biggest investment most individuals will make, and most are clueless about the quality and value of what they purchase, relying on experts to guide their decision. When I can’t buy my dream house (or incrementally that nice feature like a pool), who is the bad guy?

      • the bank, I s’pose. They are the ones that won’t finance the loan on the basis of your income and assets (at least, post 2008).

        Banks are often seen more as the bad guy during evictions. That might be a better example, as people feel entitled to good health in a similar way as they feel entitled to continue to inhabit the space they call ‘home’. Even though a bank may follow the letter of the contract, they are still seen as the bad guy in these highly emotional situations

    • Do we want physicians to help control costs because its so expensive? or because its a legitimate role for a clinician? Do other countries where costs are not as out of control have the same concerns about their physicians controlling cost?

      As long as physicians reimbursement is tied to the care provided I think we have a right to have some scrutiny of the cost consciousness of their behavior and interaction with patients. Take that out of the equation and I think it becomes a much more straightforward. Physicians should be partners with patients to help them understand the implications of the treatment options – clinically and financially. Particularly as patients bear more and more of the burden for cost through increased deductibles and co-pays. Patients decisions about treatment options can be both positively and negatively impacted by cost.

      Its also interesting to note that physicians seemed to read the question as “who is responsible for high health care costs”, not who has responsibility for controlling costs. Two different things.

    • The key to the moral problem of rationing, in my opinion, is to separate decisions about healthcare costs from decisions about what care to provide. This can be done, and in this survey doctors are asking for it to be done.
      Doctors are telling the rest of society, “Take this responsibility away from me.”
      But doctors (79%) are willing “to adhere to clinical guidelines that discourage the use of interventions that have a small proven advantage over standard interventions but cost much more.”
      Doctors, then, are effectively telling the rest of society, “Give me clinical guidelines for everything I do.”

    • Seventeen “cost-containment strategies” and competition doesn’t even make the list. Amazing, truly amazing.

    • “So who do docs think is responsible? Evidently, everyone but them.”

      Foolish me, at the bedside I always thought the patient was the physician’s responsibility. I didn’t realize that the patient at the bedside was secondary to political and social ills.

      • Yes, but how the physician gets paid is, in part, his or her responsibility. The fee-for-service mechanism encourages over use and more spending, and docs do NOT want it changed. I’m not suggesting docs be “parsimonious” in their care, as evidenced by many posts on the topic. Look it up.

        • “docs do NOT want it changed”

          It is not the docs decision. It should be the patient’s.

          I so happen to agree with you. FFS, hourly wage and capitation all have their benefits and faults so I don’t advocate one way of paying, but prefer the different methods to compete especially since circumstances and the individuals involved sometimes make one way preferable.

          FFS’s major problem as you well recognize is it provides too much marginal care, but that care is relatively transparent to the patient and the attorneys. Capitation or anything that is closely related such as ACO’s is a different matter. Necessary care can be denied the patient without transparency or the paper trail seen in FFS. Which is less dangerous to the patient? Without question FFS where documentation must exist even when marginal care is provided. Denial of treatment can mean no paper trail and can mean a bonus for the physician or some other type of action that is similar in nature to a bonus.

          Think of an older man out in the heat who climbs a ladder and passes out. A logical diagnosis absent any other data could be dehydration. If a systolic murmur is heard and not recorded there is no paper trail so the diagnosis can stand alone and money can be saved. In FFS it starts with the recording of the murmur and continues with each additional test both in the record and ever increasing personal being involved. An investigation of wrong doing in the former will likely reveal nothing while in the latter a conviction can be obtained.

          Barring any other significant illness the HMO death will be listed as arteriosclerotic heart disease and no one will be the wiser even though the patient should have had an echocardiogram to start. Since bonus’s and similar things are frequently based upon how much money was spent there is a strong incentive to gamble with another person’s life.

    • Most doctors care about their patients and they even care about their patient’s budgets but they could hardly care less about saving insurance companies or governments money. So how to get doctors to control costs? The first thing that I think is that we need more out of pocket spending, then GPs might consider costs for their patents.

    • -When the patient has zero incentive to care about costs, neither does the physician. When the patient has an incentive to care about costs, then so does the physician.

      Not only does incentivizing the patient to care about costs lead to lower spending, it also leads to improved communication and more efficient care. When patients are footing the bill, you start to hear questions like “What is that test for? Are there less expensive options? Is this something that we can hold off on and eliminate all together if my symptoms start to improve?”

      It’s true that sometimes patients want to decline even relatively cheap and necessary treatments, like antibiotics, the second that they have any out of pocket costs. That’s 1) an opportunity for the physician to make his case with greater force and clarity 2) something that could be mitigated with improved plan design and 3) something that sane adults are within their rights to do.

      -There’s another reason that doctors don’t want to be rationing agents. Anyone out there practice in the glory days of the HMO? When patients suspect that they are not getting the care they need because their doctor is incentivized to restrict access to or withhold the care that they need, the sense of trust that patients have in their physicians is significantly degraded. When it comes to the pantheon of reasons why doctors are reluctant to be the ones restricting access to care, I think that this is at least as significant as any threats to their income.

      -Finally, doctors have zero ethical standing, and no moral obligation to withhold care in order to save a third party money, which is another reason why many are disinclined to play this role.