Are Primary Care Physicians Ready to Practice in a Consumer-Driven Environment?

National survey reveals primary care physicians have low knowledge of consumer-directed health plans and limited readiness to engage patients on issues of cost and quality.
Published Online: October 15, 2008
Giridhar Mallya, MD; Craig Evan Pollack, MD, MHS; and Daniel Polsky, PhD

Objective: To evaluate physicians’ readiness to care for patients enrolled in consumer-directed health plans (CDHPs), which change the nature of cost sharing and medical decision making in primary care.

Study Design: Mailed cross-sectional survey of 1500 nationally representative primary care physicians.

Methods: Physicians’ knowledge of CDHP benefit design, readiness to advise patients about financial issues, and views regarding the role of quality-of-care information in patient decision making were assessed. Results were analyzed using descriptive statistics and multivariate models.

Results: Five hundred twenty-eight of 1076 eligible physicians (49%) responded to the survey. Forty percent of physicians had CDHP enrollees in their practices. Forty-three percent of physicians reported low knowledge of CDHP cost sharing, and approximately one-third reported low knowledge of how medical savings accounts function. Overall, physicians with CDHP enrollees in their practices had higher knowledge than physicians without these patients; however, 1 in 4 of these providers reported low knowledge of CDHP cost sharing. More than two-thirds of all physicians were ready to advise patients on the costs of office visits, medications, and laboratory tests; approximately half or less were ready to advise on the costs of radiologic studies, specialist visits, and hospitalizations. Forty-eight percent were ready to discuss medical budgets with patients. Twenty-one percent of physicians thought that patients could trust quality-of-care information from government Web sites, and 8% thought that patients could trust quality-of-care information from insurance Web sites.

Conclusion: Many primary care physicians report low knowledge of CDHPs, limited readiness to advise patients on issues of cost and medical budgeting, and minimal trust in quality-of-care information.

(Am J Manag Care. 2008;14(10):661-668)

Many primary care physicians have low knowledge and limited practice readiness with regard to consumer-directed health plans (CDHPs).

  • Physicians may not be aware of the coverage limitations and cost considerations faced by CDHP enrollees. Targeted educational interventions from insurers or from employers may be needed.
  • Many physicians are not prepared to advise patients on financial matters such as the costs of common interventions and medical budgets. Point-of-care access to standardized cost information should be developed.
  • Severe physician distrust of quality-of-care data may cause confusion for CDHP enrollees and may limit the ability of such data to transform patient behavior.
Consumer-directed health plans (CDHPs) present new challenges to the medical decision making of patients and physicians. Broadly conceived, CDHPs are composed of highdeductible insurance products and medical savings accounts (whether in the form of health savings accounts or health reimbursement arrangements). In theory, high deductibles create incentives to limit unnecessary care and to shop for services based on cost and quality. Medical savings accounts enable patients or their employers to save pretax dollars for future healthcare needs. With these reforms, CDHP enrollment has grown 10-fold in the past 3 years from 440,000 to 4.5 million, and 20% of employers, large and small, offer these plans.1

Early research indicates that CDHP enrollees utilize healthcare differently than patients in traditional plans.2 In some cases, they use fewer inappropriate services (ie, emergency department care for nonemergent conditions),3 while other studies4,5 demonstrate poorer adherence with follow-up care and physician-prescribed treatment regimens. When preventive services are exempt from the deductible, screening rates for breast and cervical cancer do not change.6 Such mixed effects may reflect the complexity of weighing the costs and benefits of medical care and of integrating various sources of clinical, financial, and quality-ofcare data.

As an initial point of contact for patients, primary care physicians are likely to confront these issues when discussing, recommending, and providing medical care. Moreover, many primary care services (including chronic disease visits, prescription medications, diagnostic testing, and, in some cases, preventive care7) are not exempt from the high deductibles. As a result, patients in CDHPs face financial considerations beyond copayments and coinsurance in deciding whether to use medical services. While CDHP enrollees may increasingly utilize Web-based clinical and decision-making supports,2 physicians may need to help patients interpret the information from these sources. Despite these challenges, research (to our knowledge) has yet to explore primary care physicians’ readiness to practice in a consumerdriven environment. For this study, we surveyed a national sample of primary care physicians to assess their knowledge and attitudes with regard to CDHP benefit design and their readiness to engage patients on issues of cost and quality. Along with analyzing the sample as a whole, we tested whether outcomes differed between physicians with and without CDHP enrollees in their practices.

Study Design and Population
In May and June of 2007, we mailed an anonymous survey to a nationally representative sample of 1500 US primary care physicians randomly selected from the American Medical Association Masterfile. Eligible physicians were general internists, family physicians, and general practitioners 65 years or younger (to minimize the inclusion of nonpracticing or retired providers). Each physician received a $2 incentive in the first mailing. Nonresponders were sent 2 additional mailings without a financial incentive.

Survey Instrument
We developed the survey instrument after a literature review of CDHPs, patient cost sharing, and primary care decision making and pilot tested it among 50 academic and community-based primary care physicians. The final survey instrument included a clinical vignette and a questionnaire about knowledge and attitudes related to CDHPs. This study focuses on results from the questionnaire. The full survey is shown in the eAppendix (available at The institutional review board of the University of Pennsylvania approved this study.

The questionnaire first asked physicians about their baseline knowledge and overall impression of CDHPs. It then provided a brief description of the plans’ deductible requirements and medical savings account options. Next, physicians were asked about (1) their general readiness to discuss issues of cost, cost-effectiveness, and medical budgeting with patients; (2) their ability to advise patients on the costs of commonly prescribed services; (3) their views regarding the effects of CDHPs on clinical care; and (4) their views on the role of publicly available quality-of-care information in patient decision making. Questions were answered on a 5-point scale. In the demographics section, we asked physicians whether any of their patients were enrolled in CDHPs and, if so, what percentage of their practice panel. We did not ask specifically whether physicians were aware of CDHP insurance status at the time of care.

Statistical Analysis
We reported proportions and calculated approximate 95% confidence intervals (CIs) for each survey question. Five-item response frames were collapsed into 3 categories to generate these proportions. For example, knowledge was categorized as “high” if physicians answered “much” or “a great deal,” “medium” if physicians answered “somewhat,” and “low” if they answered “a little” or “not at all.”

Using bivariate analyses with χ2 tests of significance and multivariate logistic regression, we tested whether physician and practice characteristics (age, sex, specialty, board certification, practice size, academic affiliation, percentage of patients with Medicaid coverage, and geographic region) were associated with having CDHP enrollees in one’s  practice. Using multivariate logistic regression analyses adjusting for physician and practice characteristics, we also tested whether having CDHP enrollees in one’s practice was associated with physicians’ knowledge, readiness, and views with regard to these plans.

Of the 1500 total sample, 528 eligible physicians responded to the survey (Table 1). After excluding 124 physicians who did not practice primary care and 300 physicians with undeliverable or inaccurate mailing addresses, the adjusted response rate was 49% (528 of 1076). Respondents were more likely than nonrespondents to be female (32% vs 27%, P = .04), board certified (86% vs 81%, P = .02), and family physicians or general practitioners (58% vs 49%, P = .002). There were no significant differences between respondents and nonrespondents with regard to age or region.

Experience With CDHPs
Forty percent of physicians indicated that CDHP enrollees were part of their practice panels (Table 1). Among these physicians, patients in CDHPs comprised a median of 5% of their practice panels. In bivariate and multivariate analyses, physicians with CDHP enrollees in their practices were less likely to care for a high percentage of patients with Medicaid coverage and were less likely to be from the Northeast. Physician age, sex, specialty, board certification, practice size, and academic affiliation were not associated with having CDHP enrollees in one’s practice.

Baseline Knowledge of CDHPs
In response to the question “Prior to this study, how much had you heard about consumer-directed health plans (CDHPs)?,” 43% reported having heard “a little” or “not at all,” 33% reported having heard “somewhat,” and 24% reported having heard “much” or “a great deal” (Table 2). Similarly, 43% indicated low knowledge of out-of-pocket costs faced by CDHP enrollees. Last, approximately one-third had low knowledge of how money is contributed to (35%) and spent from (31%) medical savings accounts.

Two hundred ten physicians with CDHP enrollees in their practices had higher knowledge across all 4 domains than physicians without CDHP enrollees in their practices (Figure). They were more likely to have heard about CDHPs (adjusted odds ratio [AOR], 5.31; 95% CI, 3.29-8.58), understand out-of-pocket costs (AOR, 3.34; 95% CI, 2.12-5.26), and understand how money is contributed to (AOR, 2.76; 95% CI, 1.85-4.14) and spent from (AOR, 2.47; 95% CI, 1.66-3.68) medical savings accounts. However, low knowledge among physicians with CDHP enrollees in their practices was not uncommon: 24% reported low knowledge about cost sharing, and 18% and 14%, respectively, reported low knowledge about how money is contributed to and spent from medical savings accounts.

Impression of CDHPs
Before providing a brief description of CDHPs, we asked physicians about their overall impression of these plans. Fortysix percent reported a favorable impression, 37% were neutral, and 17% reported an unfavorable impression. Physicians with patients enrolled in CDHPs were more likely to have a favorable impression (AOR, 2.27; 95% CI, 1.54-3.35) than physicians without these patients.

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