The Pressures on Physician Decision-Making

In an ideal world, the only factors that would go into a physician's decisions would be his or her years of clinical training and an assessment of what's best for the patient.

Unfortunately, healthcare isn't that simple. A physician may be worried about a crippling lawsuit if he or she misses a diagnosis. Or the patient may be convinced that a particular drug will do the trick and is asking for it by name. Maybe the hospital has been marketing a new piece of equipment and hinting at referrals. And who even knows if the patient's insurance will reimburse for every treatment option?

Physician decision-making has been a central focus of the reform discussions about rising healthcare costs. While most doctors make clinically-sound decisions for nearly all patients, there are external pressures that can influence and increase the tests and procedures doctors order at the margins. An occasional unnecessary test times thousands of physicians and millions of patient encounters can quickly equal billions in unnecessary healthcare spending.

To get a better idea of which pressures influence physician decisions the most, we asked physician leaders about them as part of the 2010 HealthLeaders Media Industry Survey. The question focused on four external influences:

Patients: 27.5% major influence, 54.6% minor influence, 17.9% no influence
Pressure from patients doesn't receive as much public attention as other factors in the controlling healthcare costs debate. But nearly every day physicians encounter a patient who demands a drug he saw advertised on television or asks for an extra test "just to be safe."

Physicians can try to educate patients about unnecessary treatments, but ultimately the patient is a customer, and a lot of physicians give in to demands to avoid losing them to a competitor. A few months ago, we saw how passionate patients can become about treatments when there was an outcry about recommendations to scale back mammograms. And ultimately, if the patient doesn't bear the direct costs of extra tests and procedures, there is no real incentive for holding back.

Fear of lawsuits: 33.3% major influence, 48.1% minor influence, 18.6% no influence
One-third of physician leaders said fear of lawsuits and defensive medicine is a major influence on their decision-making—more than any other category. Other studies have suggested that not only do physicians order more tests to protect themselves from malpractice lawsuits, but they also work fewer hours and change practice habits in other ways when malpractice risk increases.

As I wrote last week, it's a shame the healthcare reform debate hasn't produced more meaningful progress on reforming the malpractice system. Healthcare reform without an overhaul of the medical malpractice system is not complete reform.

Reimbursement and revenue considerations: 30.2% major influence, 38.1% minor influence, 31.7% no influence
It is clear that how physicians are paid matters—more than 68% of doctors said reimbursement and revenue considerations have at least some influence on decisions to order tests and procedures. That's why pay for performance and reforming the reimbursement system have gotten so much attention in recent years. The key to controlling healthcare costs is through physician decisions, and a lot of people think that financial carrots and sticks are the way to change them.

But J. James Rohack, MD, president of the American Medical Association, says the survey results may also reflect the complexity of the reimbursement system and the hoops physicians have to jump through to ensure that they will be reimbursed for their work. "If I'm going to provide a service and I'm not going to get paid for it then I have to communicate that with the patient ahead of time, because otherwise, that may be a non-covered benefit and I'm going to have to deal with it," he says. (Check out my full interview with Dr. Rohack online).

Pressures from administrators and other third parties: 11.2%major influence, 34.0% minor influence, 54.8% no influence
I honestly expected to see more physicians attributing pressure to hospital administration, but more than half said there was no influence at all. Perhaps this reflects the greater emphasis placed on physician-hospital alignment in recent years, and the growing number of physicians who are employed by hospitals and health systems.

Taken alone, each of these four influences would be enough to steer the occasional decision. But these pressures are felt simultaneously nearly every day. Figuring out how to alleviate pressures to order more care and creating incentives for quality may be one of the more elusive keys to reforming healthcare.