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Views of US Physicians About Controlling Health Care Costs Jon C. Tilburt, MD, MPH; Matthew K. Wynia, MD, MPH; Robert D. Sheeler, MD; Bjorg Thorsteinsdottir, MD; Katherine M. James, MPH; Jason S. Egginton, MPH; Mark Liebow, MD, MPH; Samia Hurst, MD; Marion Danis, MD, MPH; Susan Dorr Goold, MD, MHSA, MA

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.

RESULTS A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” In multivariable logistic regression models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for “eliminating fee for service” (salary plus bonus: odds ratio [OR], 3.3, 99% CI, 1.8-6.1; salary only: OR, 4.3, 99% CI, 2.2-8.5). In multivariable linear regression models, group or government practice setting (β = 0.87, 95% CI, 0.29 to 1.45, P = .004; and β = 0.99, 95% CI, 0.20 to 1.79, P = .01, respectively) and having a salary plus bonus compensation type (β = 0.82; 95% CI, 0.32 to 1.33; P = .002) were positively associated with cost-consciousness. Finding the “uncertainty involved in patient care disconcerting” was negatively associated with cost-consciousness (β = −1.95; 95% CI, −2.71 to −1.18; P < .001).

CONCLUSION AND RELEVANCE In this survey about health care cost containment, US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models.

JAMA. 2013;310(4):380-388. doi:10.1001/jama.2013.8278JAMA. 2013;310(4):380-388. doi:10.1001/jama.2013.8278

Viewpoint page 371 and Editorial page 374

Author Video Interview at jama.com

Supplemental content at jama.com

Author Affiliations: Author affiliations are listed at the end of this article.

Corresponding Author: Jon C. Tilburt, MD, MPH, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]).

Research

Original Investigation

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T he increasing cost of US health care strains the economy.Because physicians’ decisions play a key role in overallhealth care spending and quality, several recent initia- tives have called on physicians to reduce waste and exercise wise stewardship of resources.1-4 Given their roles, physi- cians’ perspectives on policies and strategies related to cost containment and their perceived responsibilities as stewards of health care resources in general are increasingly germane to recent pending and proposed policy reforms.5 We sur- veyed US physicians about their views on several potential pro- posed policies and strategies to contain health care spending, assessed physicians’ perceived roles and responsibilities in ad- dressing health care costs, and ascertained physician charac- teristics associated with those views.

Methods Ethical Review This study was reviewed and deemed exempt by the Mayo Clinic Institutional Review Board and the National Institutes of Health Clinical Center’s Office of Human Subjects Re- search Protection.

Study Participants and Data Collection Using the AMA Physician Masterfile, we selected a simple ran- dom sample of 3900 physicians listed as currently practicing and representing all specialties, excluding residents, those whose primary specialty was listed as administration only, and those older than 65 years. In late May, June, and July 2012, we mailed a self-administered, 8-page survey titled “Physicians, Health Care Costs, and Society” to 3897 of the physicians in our original sampling frame (3 physicians had a primary mail- ing address outside of the United States and were therefore ex- cluded), using the Tailored Design Method,6 including a $20 bill with the first mailing. Second and third mailings were sent to nonresponders at 6-week intervals.

Survey Instrument We reviewed the literature, conducted focus groups with physicians, formulated questions, conducted cognitive interviews in which draft survey instruments were adminis- tered to colleagues whose feedback on overall survey coher- ence, balance, and fairness was collated and incorporated into subsequent instrument versions, and revised ques- tions, adapting existing measures whenever possible. The survey assessed perceived stakeholder responsibility for controlling costs, enthusiasm for cost-containment strate- gies, professional role in cost containment, and barriers to and consequences of cost-conscious practice (Appendix A in the Supplement). Enthusiasm for cost-containment strate- gies and professional role in cost containment were our 2 main outcome measures.

Perceived Stakeholder Responsibility for Controlling Costs We asked respondents’ views on the relative perceived responsibility (no, some, and major responsibility) that dif- ferent stakeholder groups (government, health insurance

companies, patients, physician professional societies, indi- vidual practicing physicians, hospitals and health systems, employers, pharmaceutical and device manufacturers, and trial lawyers) have for reducing health care costs.

Enthusiasm for Cost-Containment Strategies Respondents rated their level of enthusiasm (not, somewhat, or very enthusiastic) toward 17 specific means of reducing health care costs, including but not limited to strategies pro- posed in the Patient Protection and Affordable Care Act, di- vided into 4 main categories: improving the quality and effi- ciency of care, improving conditions for evidence-based decisions, changing how care gets paid for, and cutting pay- ment to physicians directly. We avoided using those 4 cat- egory titles in the body of the survey to minimize biasing re- spondents.

Professional Role in Cost Containment This section included items and scales from peer-reviewed publications, including the 3-item Agreement with Rationing Scale (eg, “Cost to society is important in my decisions to use or not to use an intervention”),7 the 6-item Cost-Conscious- ness Scale (eg, “There is currently too much emphasis on costs of tests and procedures”),8 and 2 items from a Stewardship Scale developed by the American Medical Association’s Insti- tute for Ethic s (“I am aware of the costs of the tests/ treatments I recommend” and “I try not to think about the cost to the health care system when making treatment deci- sions”) (Matthew Wynia, MD, AMA Institute for Ethics, writ- ten communication, April 2012). We added several new items to assess the respondents’ consideration of cost when mak- ing treatment decisions for individual patients (eg, “I should be solely devoted to my individual patients’ best interests, even if that is expensive”).

Barriers to and Consequences of Cost-Conscious Practice We asked respondents their opinions about factors we hypoth- esized might be barriers to cost-conscious practice, including lack of continuity, as well as 1 measure each for uncertainty and fear of malpractice, borrowed from previously developed scales.8 In addition we assessed physician reactions to pos- sible consequences of following cost-conscious guidelines in their practice.

We also examined physician demographic characteris- tics (age, sex, region, specialty type, and political self- characterization) and practice characteristics (billing only, sal- ary plus bonus, salary-only compensation, and predominant practice setting type).

Data Management and Analysis Responses were double entered and imported into SAS ver- sion 9.2. We used the American Association for Public Opin- ion Research RR2 response rate definition.9 We assessed dif- ferences in response rates by physician sex, age, race, region, and specialty, using the Pearson χ2 test.

T o s u m m a r i z e t h e d e g r e e o f p h y s i c i a n s ’ c o s t - consciousness (defined as “the extent to which physicians pay attention to and feel an obligation to address health care

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cost in their practice”) with a single variable, we developed post hoc an 11-item scale with possible values ranging from 11 to 44, using standard methods of exploratory factor analysis (details in Appendix B in the Supplement). Higher s c o r e s o n t h e s c a l e r e f l e c t a g r e a t e r d e g r e e o f c o s t - consciousness, as defined above. A raw Cronbach α score was calculated with SAS PROC CORR to assess the internal consistency of items included in the final scale. Scale results formed the dependent variable in multivariable linear regression modeling (using a significance level of 2-sided P < .01), using variables manually selected according to their a priori importance, as well as suggestion of importance from unadjusted bivariate analyses. This significance level was selected according to the Bonferroni method of correc- tion for multiple comparisons.

We dichotomized enthusiasm ratings for cost-con- tainment strategies into “very enthusiastic” vs “somewhat/ not enthusiastic” and used multivariable logistic regression (with the same variable selection approach described above) to assess associations between physician characteristics (age group, sex, practice setting type, compensation type) and level of enthusiasm for each strategy, using the Bonfer- roni method of correction for multiple comparisons (speci- fying significance at P < .001, using 2-sided testing). In these models, missing data for a given observation resulted in that observation’s being dropped from the model. For concise- ness, results shown in the text summarize associations with enthusiasm for cost-containment strategies focused on the most policy-salient items from each of the following catego- ries: improving quality and efficiency of care, improving conditions for evidence-based decisions, changing how care gets paid for, and cutting payment to physicians directly. Results from all 17 multivariable logistic regression models are shown in Appendix C in the Supplement. Model fit was assessed by examining the generalized R2 measures for the fitted models, using standard assumptions in the PROC GLM function of SAS.

Results

Of the 3897 potential respondents, 2556 returned completed surveys (65%). Respondents were slightly older than nonre- spondents (mean age 51 vs 50 years, respectively; P = .01), but no other differences were found by sex, region, race, or spe- cialty (Table 1). Respondent characteristics are reported in Table 2.

Perceived Stakeholder Responsibility for Controlling Costs Respondents rated trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), and pharmaceutical and device manufacturers (56%) as having a major responsibility for reducing health care costs. Nearly all (98%) respondents reported that patients have either a major (52%) or some (46%) responsibility for reduc ing health care costs. Physicians assigned somewhat less rela- tive responsibility to practicing physicians (36% major, 59% some responsibility), employers (19% major, 63% some), and physician professional societies (27% major, 61% some) (Table 3).

Enthusiasm for Various Cost-Containment Strategies For various means of reducing health care costs (Table 3), phy- sicians expressed a high degree of enthusiasm for interven- tions that improve quality of care such as “promoting conti- nuity of c are” ( 75% ver y enthusiastic, 23% somewhat enthusiastic). More than 90% of physicians expressed some or strong enthusiasm for improving conditions for evidence- based decisions, including “expanding access to quality and safety data,” “promoting head-to-head trials of competing treatments,” and “limiting corporate influence on physician behavior.”

Respondents’ ratings for changing how care gets paid for were more mixed. Although they expressed relatively strong support for strategies such as “limiting access to

Table 1. Characteristics of US Physicians to Whom a Survey Was Mailed, Including Respondents and Nonrespondentsa

Characteristic Overall Sample

(N = 3897) Respondents (n = 2556)

Nonrespondents (n = 1341) P Valueb

Age, mean (SD), y 50.8 (8.5) 51.0 (8.5) 50.3 (8.6) .01

Male sex 2742 (70) 1784 (70) 958 (71) .29

Region

South 1295 (33) 829 (33) 466 (35)

.26

Midwest 876 (23) 594 (23) 282 (21)

Northeast 822 (21) 548 (22) 274 (21)

West 879 (23) 570 (22) 309 (23)

All others 2476 (64) 1615 (63) 861 (64)

Practice setting type

Group/HMO 2553 (66) 1641 (64) 912 (68)

.17 Small/solo 731 (19) 498 (19) 233 (17)

City/state/federal government 499 (13) 336 (13) 163 (12)

Medical school 86 (2) 59 (2) 27 (2)

Abbreviation: HMO, health maintenance organization. a Numbers in each column may not

sum to the total N for that column because of missing data.

bχ2 P values (and t test P value for age variable) for differences between respondents and nonrespondents.

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expensive treatments with little net benefit” (51% very enthusiastic, 38% somewhat enthusiastic) and using cost- effectiveness data to determine available treatments (47% very enthusiastic, 42% somewhat enthusiastic), measures that reduce or limit reimbursement such as “penalizing pro- viders for avoidable readmissions” and bundled payment schemes (“paying a network of practices a fixed, bundled price for managing all care for a defined population”) were less supported (59% and 65% not enthusiastic, respec- tively). Physicians expressed mixed enthusiasm for strate- gies that require greater patient financial contribution, including “higher patient co-pays” and “high-deductible health plans” (40% and 43% not enthusiastic, respectively). Strategies that might involve cutting payment to physicians directly such as “eliminating fee-for-service payment mod- els,” “allowing Medicare payment cuts to doctors to take effect,” and “reducing compensation for the highest-paid specialties” received far less support (70%, 94%, and 44% not enthusiastic, respectively).

Professional Role in Cost-Containment and Cost-Consciousness Scale Physicians’ perceived roles regarding paying attention to and addressing health care costs were mixed (Table 4). Most physicians reported being “aware of the costs of the tests/ treatments [they] recommend” (76%) and agreed they “should adhere to clinical guidelines that discourage the use of interventions that have a small proven advantage over standard interventions but cost much more” (79%) while endorsing that they “should be solely devoted to [their] individual patients’ best interests, even if that is expensive” (78%).

Eighty-five percent of respondents disagreed that “[they] should sometimes deny beneficial but costly services to cer- tain patients because resources should go to other patients that need them more.” In addition, an equal majority (85%) dis- agreed “the cost of a test or medication is only important if the patient has to pay for it out of pocket.”

Respondents’ scores in the 11-item cost-consciousness scale derived from the above-described measures (included measures highlighted in Table 4) ranged from 11 to 44, with mean and median scores of 31 and a raw Cronbach α score of .77 (Appendix B in the Supplement).

Barriers to and Consequences of Cost-Conscious Practice Regarding the influence that lack of continuity may play in use, just under half of physicians reported that they “gener- ally order more tests when [they] don’t know the patient well” (43% moderately and strongly agree), whereas most expressed moderate or strong agreement with the role that uncertainty (56%) and worry about malpractice liability (70%) play in their practice. When asked about the conse- quences of following cost-conscious guidelines in practice, a majority reported that “it would be the right thing to do” (55%), but fewer thought it would be effective in limiting unreasonable patient demands (40%), whereas some thought it could undermine patients’ trust (28%) or be unfair (24%).

Associations With Enthusiasm for Cost-Containment Strategies and Cost-Consciousness Table 5 depicts percentages and point estimates of the asso- ciation between physician characteristics and enthusiasm for the top-ranking cost-containment strategies delineated in Table 3 (ie, “promoting continuity of care,” “expanding ac- cess to quality and safety data,” “limiting access to expensive treatments with little net benefit,” and “eliminating fee-for- service payment models”). R2 values for each model ranged from 0.01 to 0.03, suggesting these models explain little of the variance in physician enthusiasm for cost-containment strat- egies. Physician sex was associated with “promoting continu- ity of care” (odds ratio [OR], 0.4, 99% CI, 0.3 to 0.6 for men com- pared with women). Older physicians were more likely than those younger than 50 years to be “very enthusiastic” about “limiting access to expensive treatments with little net ben- efit” (OR, 1.4; 99% CI, 1.1 to 1.8), whereas salaried physicians (with or without bonus) were significantly more likely than those with a billing-only compensation model to express en- thusiasm for “eliminating fee-for-service” (salary plus bo- nus: OR, 3.3, 99% CI, 1.8 to 6.1; salary only: OR, 4.3, 99% CI, 2.2 to 8.5 ).

In unadjusted linear regression models (Table 6) examin- ing relationships with our cost-consciousness scale, we found that physicians’ practice settings, compensation types, de- gree of worry about malpractice lawsuits, and finding the uncertainty involved in patient care to be disconcerting were characteristics and attitudes associated with average levels of cost-consciousness. For example, after adjusting for age, sex, region, specialty, political self-characterization, and the other variables shown in Table 6, the overall mean level of cost- consciousness (as calculated by our scale) is 0.87 units higher (95% CI, 0.29 to 1.45) for physicians practicing in a group set- ting compared with those in a small/solo practice, whereas those with salary plus bonus compensation have a mean level of cost-consciousness 0.82 units higher (95% CI, 0.32 to 1.33)

Table 2. Self-reported Data From Survey (n = 2556)a

Characteristic No. (%) Race or ethnic group

White or Caucasian 1958 (77)

Asian 369 (15)

Other 124 (5)

Black or African American 80 (3)

Practice compensation type

Billing only 1036 (41)

Salary plus bonus 874 (35)

Salary only 460 (18)

Other 154 (6)

Political self-characterization

Very conservative 254 (10)

Somewhat conservative 709 (28)

Independent/moderate 726 (29)

Somewhat liberal/progressive 495 (20)

Very liberal/progressive 247 (10)

a Numbers may not sum to 2556 because of missing data.

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than those compensated via billing. These differences were found to be statistically significant. In contrast, greater mal- practice worry and lower comfort with uncertainty were as- sociated with lower mean cost-consciousness scores (β = −1.93 vs −2.77 and P < .001 vs P < .001, respectively) after adjusting for age, sex, region, specialty, political self-characterization, and the other variables shown in Table 6.

In a single multivariate model with cost-consciousness as the dependent variable (Table 6), most of the above relation- ships remained independently significant after controlling for age, sex, and region, with particularly strong associations re- lated to practicing with a salary plus bonus compensation model (β = 0.82; P = .002), and either moderately (β = −1.39; P < .001) or strongly (β = −1.95, P < .001) agreeing that the un- certainty involved in patient care is disconcerting.

Discussion

US physicians’ opinions about their role in containing health care costs are complex. In this survey, we found that they express considerable enthusiasm for several proposed cost- containment strategies that aim to enhance or promote high-quality care such as improved continuity of care. How- ever, there is considerably less enthusiasm for more sub- stantial financing reforms, including bundled payments, penalties for readmissions, and eliminating fee-for-service reimbursement; Medicare pay cuts are unpopular across the board. They were also more likely to identify other groups, rather than physicians, such as insurers, lawyers, hospitals, and health systems, as having a major responsibility to

Table 3. Self-reported Responsibility and Enthusiasm for Various Means of Reducing Health Care Costs Among 2556 US Physician Survey Respondents

No. (%)a

Major Responsi-

bility

Some Responsi-

bility

No Responsi-

bility

Entities with potential responsibility to reduce cost of health care

Trial lawyers (n = 2433) 1449 (60) 630 (26) 353 (15)

Health insurance companies (n = 2446) 1439 (59) 923 (38) 84 (3)

Pharmaceutical and device manufacturers (n = 2445) 1377 (56) 938 (38) 129 (5)

Hospitals and health systems (n = 2439) 1373 (56) 1037 (43) 29 (1)

Patients (n = 2439) 1265 (52) 1124 (46) 50 (2)

Government (n = 2440) 1073 (44) 1186 (49) 181 (7)

Individual practicing physicians (n = 2438) 889 (36) 1448 (59) 101 (4)

Physician professional societies (n = 2433) 667 (27) 1491 (61) 275 (11)

Employers (n = 2429) 457 (19) 1524 (63) 448 (18)

Potential means of reducing health care costs Very

Enthusiastic Somewhat

Enthusiastic Not

Enthusiastic

Improving quality and efficiency of care

Promoting continuity of care (n = 2484) 1872 (75) 580 (23) 32 (1)

Rooting out fraud and abuse (n = 2487) 1736 (70) 575 (23) 176 (7)

Promoting chronic disease care coordination (n = 2487) 1723 (69) 715 (29) 49 (2)

Expanding access to free preventive care (n = 2472) 1174 (47) 939 (38) 359 (15)

Expanding electronic health records (n = 2476) 857 (35) 904 (37) 715 (29)

Improving conditions for evidence-based decisions

Limiting corporate influence on physician behavior (n = 2458) 1535 (63) 653 (27) 252 (10)

Expanding access to quality and safety data (n = 2475) 1258 (51) 1017 (41) 200 (8)

Promoting head-to-head trials of competing treatments (n = 2474) 1243 (50) 1024 (41) 207 (8)

Changing how care gets paid for

Limiting access to expensive treatments with little net benefit (n = 2472) 1265 (51) 945 (38) 262 (11)

Using cost-effectiveness data to determine available treatments (2480) 1170 (47) 1041 (42) 269 (11)

High-deductible health plans (n = 2474) 410 (17) 1005 (41) 1059 (43)

Higher patient co-pays (n = 2479) 419 (17) 1079 (44) 981 (40)

Paying a network of practices a fixed, bundled price for managing all care for a defined population (n = 2467) 160 (6) 696 (28) 1611 (65)

Penalizing providers for avoidable readmissions (n = 2472) 138 (6) 869 (35) 1465 (59)

Cutting payment to physicians directly

Reducing compensation for the highest-paid specialties (n = 2474) 589 (24) 794 (32) 1091 (44)

Eliminating fee-for-service payment models (n = 2443) 175 (7) 550 (23) 1718 (70)

Allowing Medicare payment cuts to doctors to take effect (n = 2480) 35 (1) 112 (5) 2333 (94)

a Percentages not all based on denominator of 2556 because of missing responses to some survey items.

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reduce cost. These data document professional sentiments about addressing health care costs and speak directly to the acceptability of several key policy strategies for curbing those costs.

Beyond these general conclusions, US physicians’ atti- tudes and perceived obligations on issues related to cost con- trol are complex. Their opinions are related to their practice setting and type of compensation. For instance, despite resis- tance to bundled payment schemes that typically include qual- ity provisions, physicians appear to support quality of care ini- tiatives such as enhancing continuity of care and chronic disease management as stand-alone measures.10-13 These data also suggest that changing how physicians get paid is very un- popular in the profession. For instance, 70% of our respon- dents were not enthusiastic about eliminating fee-for-service reimbursement. Efforts to implement such changes, like the recent National Commission on Physician Payment Reform’s recommendations to eliminate fee-for-service reimburse- ment, could face stiff opposition from within the profession.14

These data speak to the feasibility and acceptability of key policy strategies outlined in recent and pending policy pro- posals.

Physicians also hold nuanced views about their per- ceived responsibility for health care costs. Most (78%) agree that they “should be solely devoted to [their] individual pa- tients’ best interests, even if that is expensive,” whereas 85% disagree that they “should sometimes deny beneficial but

costly services to certain patients because resources should go to other patients that need them more.” Yet 85% also agree that “trying to contain costs is the responsibility of every physi- cian,” and 89% agree that “doctors need to take a more promi- nent role in limiting use of unnecessary tests.” This apparent inconsistency may reflect inherent tensions in professional roles to serve patients individually and society as a whole. Pre- vious smaller studies have suggested that US physicians en- dorse the ideal of prudent stewardship but are reluctant to withhold available but costly services that could benefit indi- vidual patients.15-18 Similarly, Campbell et al found that 98% of physicians endorse “just distribution of finite resources” but 36% would order magnetic resonance imaging that is not indicated.19 Antiel et al20 found that a majority of US physi- cians were willing to accept lower reimbursement for expen- sive drugs and procedures if that would expand health insurance coverage, but 55% also objected to using cost- effectiveness analysis to guide what treatments are used in practice. Physicians clearly struggle with these tensions and how they can act individually and collectively to provide op- timal, sustainable quality care. They also recognize them- selves as just one component of a multifaceted system of stake- holders responsible for addressing increasing costs. Indeed, they ascribe a higher degree of responsibility for controlling costs to external forces such as health systems, insurance com- panies, and even patients and trial lawyers than they do to themselves.

Table 4. Degree of Agreement/Disagreement Among 2556 Physician Respondents Regarding Their Role in Containing Health Care Costs and Potential Barriers to and Consequences of Cost-Conscious Practice

No. (%)a

Strongly Agree

Moderately Agree

Moderately Disagree

Strongly Disagree

Attention to and role in addressing health care costs

I am aware of the costs of the tests/treatments I recommend (n = 2446) 556 (23) 1307 (53) 423 (17) 160 (7) I try not to think about the cost to the health care system when making treatment decisionsb (n = 2449) 265 (11) 747 (31) 935 (38) 502 (21) I should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more (n = 2428) 61 (3) 305 (13) 748 (31) 1314 (54)

Cost to society is important in my decisions to use or not to use an interventionb (n = 2439) 268 (11) 1039 (43) 788 (32) 344 (14) Physicians should adhere to clinical guidelines that discourage the use of interventions that have a small proven advantage over standard interventions but cost much moreb (n = 2434) 807 (33) 1123 (46) 402 (17) 102 (4) The cost of a test or medication is only important if the patient has to pay for it out of pocketb (n = 2449) 81 (3) 306 (13) 824 (34) 1238 (51)

Doctors are too busy to worry about costs of tests and proceduresb (n = 2451) 138 (6) 515 (21) 761 (31) 1037 (42)

Trying to contain costs is the responsibility of every physicianb (n = 2442) 900 (37) 1179 (48) 256 (10) 107 (4)

There is currently too much emphasis on costs of tests and proceduresb (n = 2437) 244 (10) 598 (25) 1112 (46) 483 (20)

Doctors need to take a more prominent role in limiting use of unnecessary testsb (n = 2442) 1016 (42) 1146 (47) 214 (9) 66 (3) It is unfair to ask physicians to be cost-conscious and still keep the welfare of their patients foremost in their mindsb (n = 2439) 339 (14) 684 (28) 1007 (41) 409 (17) I should be solely devoted to my individual patients’ best interests, even if that is expensiveb (n = 2438) 927 (38) 975 (40) 436 (18) 100 (4)

Decision support tools that show costs would be helpful in my practiceb (n = 2461) 483 (20) 1240 (50) 487 (20) 251 (10)

Barriers to and consequences of cost-conscious practice

I find the uncertainty involved in patient care disconcerting (n = 2449) 362 (15) 1008 (41) 649 (27) 430 (18)

I generally order more tests when I don’t know the patient well (n = 2463) 185 (8) 868 (35) 769 (31) 641 (26) My enjoyment of the practice of medicine is substantially lessened because of the threat of lawsuits (n = 2550) 696 (27) 1096 (43) 473 (19) 285 (11)

a Percentages not all based on denominator of 2556 because of missing responses to some survey items. b Included in 11-item cost-consciousness scale.

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Table 5. Respondents in Each Subgroup Who Selected “Very Enthusiastic” for the Top-Ranking Cost-Containment Strategies and Odds of Selecting “Very Enthusiastic” for Each Strategy From a Single Multivariable Logistic Regression Model Including All Listed Characteristics

Characteristic Cost-Containment Strategies Promoting Continuity of

Care Expanding Access to Quality

and Safety Data Limiting Access to Expensive

Treatments With Little Net Benefit Eliminating Fee-for-Service

Payment Models

No. (%) OR (99% CI) No. (%) OR (99% CI) No. (%) OR (99% CI) No. (%) OR (99% CI) Age, y

<50 788 (76) 1 [Reference] 511 (49) 1 [Reference] 484 (47) 1 [Reference] 70 (7) 1 [Reference]

≥50 1084 (75) 1.1 (0.9-1.5) 747 (52) 1.2 (1.0-1.6) 781 (54) 1.4 (1.1-1.8)a 105 (7) 1.1 (0.7-1.7)

Sex

Female 635 (85) 1 [Reference] 408 (55) 1 [Reference] 367 (49) 1 [Reference] 55 (8) 1 [Reference]

Male 1237 (71) 0.4 (0.3-0.6)a 850 (49) 0.8 (0.6-1.0) 898 (52) 1.1 (0.9-1.4) 120 (7) 1.0 (0.6-1.6)

Region

South 597 (74) 1 [Reference] 410 (51) 1 [Reference] 381 (47) 1 [Reference] 36 (5) 1 [Reference]

Midwest 419 (73) 1.0 (0.7-1.4) 274 (48) 0.9 (0.7-1.2) 309 (55) 1.3 (0.9-1.7) 60 (11) 1.2 (0.6-2.4)

Northeast 420 (79) 1.2 (0.9-1.8) 275 (51) 1.0 (0.7-1.3) 254 (48) 1.0 (0.7-1.3) 45 (9) 1.7 (0.9-3.3)

West 422 (76) 1.1 (0.8-1.5) 284 (51) 1.1 (0.8-1.5) 316 (57) 1.4 (1.1-1.9) 33 (6) 3.0 (1.6-5.4)a

Practice setting type

Small/solo 360 (74) 1 [Reference] 221 (46) 1 [Reference] 213 (44) 1 [Reference] 15 (3) 1 [Reference]

Group/HMO 1200 (76) 1.2 (0.9-1.7) 810 (51) 1.3 (1.0-1.7) 830 (53) 1.4 (1.0-1.9) 112 (7) 1.7 (0.8-4.0)

City/state/federal government 246 (75) 1.0 (0.6-1.6) 178 (54) 1.3 (0.9-2.0) 181 (55) 1.4 (0.9-2.1) 37 (12) 2.3 (0.9-6.0)

Medical school 48(83) 1.9 (0.7-5.1) 33 (57) 1.6 (0.7-3.9) 33 (57) 1.6 (0.7-3.4) 8 (14) 2.6 (0.7-10.1)

Compensation type

Billing only 743 (74) 1 [Reference] 475 (47) 1 [Reference] 485 (48) 1 [Reference] 29 (3) 1 [Reference]

Salary plus bonus 639 (75) 1.0 (0.8-1.4) 386 (54) 1.3 (1.0-1.7) 437 (52) 1.1 (0.9-1.4) 78 (9) 3.3 (1.8-6.1)a

Salary only 345 (78) 1.2 (0.8-1.7) 228 (52) 1.1 (0.8-1.5) 246 (56) 1.2 (0.9-1.7) 57 (13) 4.3 (2.2-8.5)a

Abbreviation: HMO, health maintenance organization. a P < .001.

Table 6. Associations Between Physician Characteristics and Attitudes Toward Malpractice and Uncertainty and Mean Cost-Consciousness Scores

Characteristics and Attitudes

Mean Cost-Consciousness

Unadjusted Adjusteda

β Coefficient (95% CI) P

Value β Coefficient (95% CI) P

Value Practice setting type

Small/solo 1 [Reference] 1 [Reference]

Group/HMO 1.00 (0.46 to 1.55) <.001 0.87 (0.29 to 1.45) .004

City/state/federal government 1.26 (0.51 to 2.01) .001 0.99 (0.20 to 1.79) .01

Medical school 1.85 (0.40 to 3.30) .01 1.37 (−0.14 to 2.89) .08

Other nonpatient care 1.38 (−0.88 to 3.65) .23 1.02 (−1.25 to 3.29) .38

Practice compensation type

Billing only 1 [Reference] 1 [Reference]

Salary plus bonus 0.91 (0.42 to 1.40) <.001 0.82 (0.32 to 1.33) .002

Salary only 0.96 (0.36 to 1.56) .002 0.40 (−0.23 to 1.03) .21

Other 0.42 (−0.53 to 1.36) .39 0.06 (−0.90 to 1.01) .90

My enjoyment of the practice of medicine is substantially lessened because of the threat of lawsuits

Strongly disagree 1 [Reference] 1 [Reference]

Moderately disagree 0.34 (−0.46 to 1.15) .40 0.85 (0.05 to 1.65) .04

Moderately agree −0.77 (−1.49 to −0.06) .03 −0.08 (−0.80 to 0.64) .83

Strongly agree −1.93 (−2.69 to −1.18) <.001 −0.75 (−1.53 to 0.03) .06

I find the uncertainty involved in patient care disconcerting

Strongly disagree 1 [Reference] 1 [Reference]

Moderately disagree −0.75 (−1.39 to −0.10) .02 −0.70 (−1.35 to −0.05) .03

Moderately agree −1.64 (−2.24 to −1.04) <.001 −1.39 (−2.00 to −0.78) <.001

Strongly agree −2.77 (−3.51 to −2.03) <.001 −1.95 (−2.71 to −1.18) <.001

Abbreviation: HMO, health maintenance organization. aAdjusted model includes all items shown in the table plus sex, age, region of practice, specialty, and political self-characterization.

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How physicians resolve these tensions appears to be re- lated to the structures, context, and nature of their work. Our results suggest there are subgroups within the profession with distinct identities and professional self-conceptualizations that shape their judgments about addressing health care costs. In particular, physicians who share a common way of receiving payment, a common type of work context, may share a simi- lar sense of professional obligation. Such relationships are wor- thy of further investigation.

Whether, how, and to what extent physicians ought to con- sider broader societal health care concerns when caring for in- dividual patients are challenging questions addressed by the ABIM Charter on Professionalism,21 the American College of Phy- sicians’ Ethics Manual,22 and a resolution from the American Medical Association’s Council on Ethical and Judicial Affairs.23

How and to what extent physicians should ethically consider limited or expensive resources need additional study. Our data suggest that physicians struggle with navigating the tensions between their responsibilities to address overall health care re- source use and their primary obligation to do what is best for individual patients.

Although this survey had a good response rate, reducing concerns about response bias, its findings should be treated with caution for several reasons. The AMA Masterfile is the most comprehensive listing of US physicians but relies on phy- sician self-report for key practice characteristics. For in- stance, specialty data listed in the AMA Masterfile list self-

reported specialty that is not verified with specialty boards. The descriptive statistics reported here may not fully reflect the opinions of all US physicians. Moreover, the significant as- sociations we found do not explain most of the variance in phy- sician perceived cost-consciousness, and cross-sectional sur- veys cannot establish cause-effect relationships. Moreover, physician opinions on these issues may be in flux, with group restructuring, emerging changes in electronic information sys- tems, and value-based purchasing all being in a state of change. In light of these recent movements, as well as the ABIM Foun- dation’s Choosing Wisely campaign,1 such cross-sectional data should be treated with caution.

Nevertheless, US physicians reported having some respon- sibility to address health care costs in their practice and ex- pressed general agreement with quality initiatives that may also reduce cost, but they also expressed less enthusiasm for cost containment involving changes in payment models. Moving toward cost-conscious care in the current environment in which physicians practice starts with strategies for which there is widespread physician support might create momentum for such efforts, including improving quality and efficiency of care and bringing transparent cost information and evidence from comparative effectiveness research into electronic health rec- ords with decision support technology. More aggressive (and potentially necessary) financing changes may need to be phased in, with careful monitoring to ensure that they do not infringe on the integrity of individual clinical relationships.

ARTICLE INFORMATION

Author Affiliations: Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota (Tilburt, Liebow); Biomedical Ethics Program, Mayo Clinic (Tilburt, Thorsteinsdottir, James); Knowledge & Evaluation Research Unit, Mayo Clinic (Tilburt); Healthcare Delivery Research Program, Center for the Science of Healthcare Delivery (Tilburt); Division of Health Care Policy and Research, Mayo Clinic (Tilburt, Egginton); Institute for Ethics, American Medical Association, Chicago, Illinois (Wynia); Department of Family Medicine, Mayo Clinic (Sheeler); Division of Primary Care Internal Medicine, Mayo Clinic (Thorsteinsdottir); Institute for Biomedical Ethics, University of Geneva, Switzerland (Hurst); Department of Bioethics, National Institutes of Health, Bethesda, Maryland (Danis); Department of General Internal Medicine, University of Michigan Medical Center, Ann Arbor (Goold); Department of Medicine, University of Chicago, Chicago, Illinois (Wynia).

Author Contributions: Dr Tilburt had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Tilburt, Wynia, Sheeler, Thorsteinsdottir, Egginton, Hurst, Danis, Goold. Acquisition of data: Wynia, Sheeler, James. Analysis and interpretation of data: Tilburt, Wynia, Thorsteinsdottir, James, Egginton, Liebow, Hurst, Danis, Goold. Drafting of the manuscript: Tilburt, Wynia, James, Goold. Critical revision of the manuscript for important intellectual content: Wynia, Sheeler,

Thorsteinsdottir, Egginton, Liebow, Hurst, Danis, Goold. Statistical analysis: James, Goold. Obtained funding: Tilburt. Administrative, technical, or material support: James. Study supervision: Goold.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr Tilburt’s research was funded by the Faculty Scholars Program of the Greenwall Foundation, Mayo Clinic Program in Professionalism and Ethics, and an Early Career Development Award from the Mayo Clinic Foundation. Dr Hurst is funded by a grant from the Swiss National Science Foundation (PP00P3_123340).

Role of the Sponsor: None of the funders had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors and do not reflect the official position of the National Institutes of Health, Department of Health and Human Services, or the US government.

Previous Presentations: An earlier version of this work was presented as a poster at the 2013 Society of General Internal Medicine National Meeting, April 25, 2013, Denver, Colorado.

Additional Contributions: We are grateful to Bernie Lo, MD, and Christine Cassel, MD, for their thoughtful review of early versions of the manuscript. Correction: This article was corrected online November 4, 2013, for the addition of a Disclaimer and correction of wording in the Results section..

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