The American Journal of Managed Care October 2008
Are Primary Care Physicians Ready to Practice in a Consumer-Driven Environment?
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.
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.
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 www.ajmc.com). 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.
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.
Readiness to Discuss and Advise Patients on Financial Matters
Next, we asked physicians “how ready” they were to discuss issues related to cost, cost-effectiveness, and budgeting. While almost three-quarters of physicians were ready to discuss issues of cost and cost-effectiveness, less than half were ready to discuss medical budgeting with patients (Table 3). Physicians with CDHP enrollees in their practices were more ready than those without CDHP enrollees to discuss the 3 topics of costs of medical care (AOR, 2.33; 95% CI, 1.48-3.68), costeffectiveness of medical care (AOR, 2.13; 95% CI, 1.33-3.41), and medical budgeting (AOR, 1.99; 95% CI, 1.35-2.92).
Turning to the costs of specific services, we asked physicians whether they were ready to advise patients on costs taking into account the resources at their practice sites. More than two-thirds of physicians were ready in the case of office visits, medications, and laboratory testing. However, approximately half or less were ready to advise patients on the costs of radiologic studies, specialist consultation, and hospitalizations. Compared with physicians without CDHP enrollees in their practices, physicians with these patients were more ready to discuss the costs of medications (AOR, 1.68; 95% CI, 1.03-2.71) but were no more ready to discuss the costs of the other 5 services.
Role of Quality-of-Care Information in Patient Decision Making
In addition to considering costs, patients in CDHPs are encouraged to use information on quality-of-care when making medical decisions. Less than half of physicians in our survey agreed that quality-of-care information from government or insurance Web sites should factor into patients’ choice of hospitals or specialists (Table 3). Having CDHP enrollees in one’s practice was not associated with attitudes regarding the use of quality-ofcare information. Less than one-quarter of physicians agreed with the statement that “Patients can generally trust the quality information provided by government websites.” Only 8% agreed that patients can trust quality-of-care information from insurer Web sites. Again, physicians with CDHP enrollees in their practices were no more or less likely to trust these sources of information.