Almost half of the doctors surveyed by Mayo Clinic researchers acknowledge that they "try not to think about the cost to the healthcare system when making treatment decisions." More than half blame attorneys, health plans, and hospitals for growing costs.
More than half of practicing physicians say trial lawyers, insurers, drug and device makers, and hospitals bear a major responsibility for rising health costs, but only one third point to themselves as the primary driver of the problem, according to national survey by Mayo Clinic researchers.
Moreover, nearly one in three said they did not think that electronic health records shared a responsibility to reduce healthcare costs, one in four did not think expanding access to quality and safety data would bend the cost curve, and 65% said they did not think bundled or fixed payment models for managing population health would do the job, preferring to stick with fee for service.
"What they might be saying is that they don't think these are effective care improvement strategies, or they may be saying, 'it's the right thing to do, but don't expect it to save a heck of a lot of money,' " says Jon Tilburt, MD, the principal investigator of the report.
Three-fourths of the responders said they strongly agreed or moderately agreed with the statement, "I am aware of the costs of the tests/treatments I recommend." But one in four disagreed with that statement.
And 42% strongly or moderately agreed with the statement that they "try not to think about the cost to the healthcare system when making treatment decisions.
Tilburt and colleagues launched the survey project in June, 2012 because, he says, physicians largely direct the intensity and extent of the care their patients receive, and as such are increasingly looked upon to be good stewards, and avoid advising unnecessary tests and procedures.
"The landscape is changing so much, we felt it was reasonable to get a baseline to assess physicians' opinions in depth," he says.
The questionnaire prompted 2,556 doctors to identify which segments of the healthcare industry—trial lawyers, insurers, pharmaceutical and device manufacturers, hospitals, patients, government, individual doctors, professional societies or employers—had "major," "some," or "no" responsibility to reduce healthcare costs.
Responders also were asked whether they were "very," "somewhat," or "not" enthusiastic about the ability of certain strategies to reduce costs, such as continuity of care, rooting out fraud and abuse, coordinating care, preventive care, expanding EHR, expanding quality and safety data access, or promoting trials of competing treatments.
The survey findings are published in the Journal of the American Medical Association.
Tilburt says one finding from the survey surprised him, and indicated that physicians may be talking "out of both sides of their mouths" in the way they answered two questions.
"On one hand, the majority of physicians were very willing to say, 'I need to go to go to bat for my patients even when it's expensive.' But at the same time, a majority also endorsed the idea—they were perfectly comfortable with—having limits on insurance coverage for marginally beneficial therapies."
But on reflection, Tilburt says, "we don't think that's contradictory to doing the best for our patients. Doing the best for patients often means starting with good, sound, tried-and-true old therapies and moving to more fancy bells and whistles down the road."
The survey revealed some other significant findings about physician attitudes as well.
Eighty-five percent of responders said they "should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more."
Nearly half (42%) strongly agreed with the statement "Doctors need to take a more prominent role in limiting use of unnecessary tests," and 47% moderately agreed with that statement.
Asked their views on the statement, "It is unfair to ask physicians to be cost-conscious and still keep the welfare of their patients foremost in their minds," 14% strongly agreed and 28% moderately agreed, while 58% moderately or strongly disagreed.
In an accompanying editorial, Ezekiel Emanuel, MD, and Andrew Steinmetz, BA, of the Department of Medical Ethics and Health Policy of the Wharton School at the University of Pennsylvania, wrote that the Tilburt survey results "are somewhat discouraging" because "they suggest that physicians do not yet have that 'all-hands-on-deck' mentality this historical moment demands."
Rather, it suggests "that in the face of this new and uncertain moment in the reform of the healthcare 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.' "
"Indeed," they continued, "only employers and physicians' professional societies were reported to bear less responsibility than the individual practitioner. This is a denial of responsibility… Can they really be both captain of the healthcare ship and cede responsibility for cost control to almost everyone else?"
Tilburt says that he thinks that as a society, "we're reaching a point where these kinds of 'I don't know (what it costs) responses aren't going to fly anymore. The belt tightening of the economy has everybody thinking about price and making everybody more price-sensitive.
That's tough, and gets into a muddy ethical area doctors call "dual-agency," in which the physician is called upon to look at both sides of the issue, from the patients perspective and society's.
"There will be a lot of questions on how to do this best. If we're going to expect physicians to uphold the best interests of patients, and at the same time do a lot of dirty work on behalf of society to keep costs down, we have to give doctors the vocabulary to do that with integrity."
However, he says, this doesn't have to undermine patient-centered nature of their obligations.
"The profession and healthcare institutions are finally at the point where they are ready to say, 'Look, there's no reason why we can't put cost information in front of patients and doctors in a clinical interaction.' It's material information."