Who should contain health care costs? Doctors weigh in

Most doctors don't see themselves at the frontline of responsibility for controlling health care costs, a new survey finds.

The results of the national survey of more than 2,500 physicians showed that although 85 percent agreed they have a responsibility to control health care costs, most identified other groups, such as insurers, lawyers, government and patients, as having a "major responsibility" to reduce health care costs.

"The vast majority of physicians believe that trying to contain cost is their responsibility," said report author Dr. Jon Tilburt, a bioethicist at Mayo Clinic in Rochester, Minn. "They also believe that they are, if anything, a little bit less responsible for fixing health care cost than other key stakeholders."

About one-third of doctors in the survey saw themselves having "major responsibility" for cost reduction, according to the report, published July 23 in the Journal of the American Medical Association (JAMA).

Dr. Ezekiel Emanuel, a professor of bioethics and health policy at the University of Pennsylvania, said the survey's findings are somewhat discouraging, and suggested that doctors must lead health care transformations. Physicians do not have the "all-hands-on-deck" mentality that true reform would demand, he argued in an editorial accompanying the study also published in JAMA.

"The biggest concern is the fact the doctors, on the one hand, want to be the captains of the health care ship, on the other hand, [they] think that everyone else is responsible for cost control," Emanuel said. "I don't think you can have those simultaneously."

Surveying doctors

For their survey, Tilburt and his colleagues mailed questionnaires to practicing members of the American Medical Association, including doctors of all specialties, in 2012. They asked physicians how much responsibility for containing health care costs they ascribed to various groups. The survey also asked doctors about their level of enthusiasm for strategies proposed to control costs.

"Physicians are most enthusiastic about strategies that are more focused on improving the quality and efficiency of care and bringing evidence to the bed side, but are very nervous about serious, potentially biting payment reform," Tilburt said.

The survey found that 75 percent of doctors said they were very enthusiastic about strategies to promote continuity of care, meaning those aimed at helping patients develop relationships with their health care professionals, improving communication among providers working with the same patient.

Nearly half of respondents said they were strongly enthusiastic about expanding access to free preventive care.

Just 7 percent said they were strongly enthusiastic about eliminating fee-for-service payment system, and 6 percent said the same about penalizing providers for avoidable readmissions.

Physicians who practiced in large-group or government settings, and those who were salaried were generally more cost-conscious, according to the report.

"Some of these findings may reflect a general uneasiness about change," Tilburt said. If the proposals can be implemented in a way that preserves physician income and improves patients' care, "then some of that small worrying and anxiety that we see in these findings might go away," he said.

Changes to come

Because physicians determine the care patients receive, such as lab tests, hospitalization and surgeries, they have a crucial role in preventing unnecessary procedures and costs, Emanuel said. Implementing health care transformations requires physicians active participation, he wrote.

Part of doctors' resistance to change comes from their concerns about an uncertain future, Emanuel said. "Doctors don't know how to change their practices, we're not trained in medical school with management skills, and changing practices and standard operating procedures requires knowing how to implement change. That's management skills."

The report also found that physicians hold nuanced views about their role to serve patients individually and society as a whole. About 78 percent of doctors agreed that they should be solely devoted to [their] individual patients best interests, even if that is expensive, whereas 85 percent disagreed that they " should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more."

"There are things we do for patients all the time, but don't really improve care. We should stop doing those things. Physicians certainly have a huge role to play in getting very serious about waste in health care," Tilburt said.

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