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The American Journal of Managed Care November 2015
Community Pharmacy Automatic Refill Program Improves Adherence to Maintenance Therapy and Reduces Wasted Medication
Olga S. Matlin, PhD; Steven M. Kymes, PhD; Alice Averbukh, MBA, MS; Niteesh K. Choudhry, MD, PhD; Troyen A. Brennan, MD, MPH; Andrew Bunton, MBA, CFA; Timothy A. Ducharme, MBA; Peter D. Simmons, RPh; and William H. Shrank, MD, MSHS
Testing Novel Patient Financial Incentives to Increase Breast Cancer Screening
Elizabeth Levy Merrick, PhD, MSW; Dominic Hodgkin, PhD; Constance M. Horgan, ScD; Laura S. Lorenz, PhD; Lee Panas, MS; Grant A. Ritter, PhD; Paul Kasuba, MD; Debra Poskanzer, MD; and Renee Altman Nefussy, BA
Medicare Advantage: What Explains Its Robust Health?
Anna D. Sinaiko, PhD; and Richard Zeckhauser, PhD
Moving Risk to Physicians
Katherine Chockley, BA; and Ezekiel J. Emanuel, MD, PhD
Medicare's Bundled Payments for Care Improvement Initiative: Expanding Enrollment Suggests Potential for Large Impact
Lena M. Chen, MD, MS; Ellen Meara, PhD; and John D. Birkmeyer, MD
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Physician Response to Patient Request for Unnecessary Care
Sapna Kaul, PhD, MA; Anne C. Kirchhoff, PhD, MPH; Nancy E. Morden, MD, MPH; Christine S. Vogeli, PhD; and Eric G. Campbell, PhD
Attributes Common to Programs That Successfully Treat High-Need, High-Cost Individuals
Gerard F. Anderson, PhD; Jeromie Ballreich, MHS; Sara Bleich, PhD; Cynthia Boyd, MD; Eva DuGoff, PhD; Bruce Leff, MD; Claudia Salzburg, PhD; and Jennifer Wolff, PhD
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April Lopez, MS; Charron Long, PharmD; Laura E. Happe, PharmD, MPH; and Michael Relish, MS
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Susan K. Schmitt, PhD; Mintu P. Turakhia, MD, MAS; Ciaran S. Phibbs, PhD; Rudolf H. Moos, PhD; Dan Berlowitz, MD, MPH; Paul Heidenreich, MD, MS; Victor Y. Chiu, MD; Alan S. Go, MD; Sarah A. Friedman, MSPH; Claire T. Than, MPH; and Susan M. Frayne, MD, MPH
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Colleen A. Payton, MPH; Mona Sarfaty, MD; Shirley Beckett, AAS; Carmen Campos, MPH; and Kathleen Hilbert, RN
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Nicholas L. Berlin, MD, MPH; Christina Cutter, MD, MSc; and Catherine Battaglia, PhD, RN

Physician Response to Patient Request for Unnecessary Care

Sapna Kaul, PhD, MA; Anne C. Kirchhoff, PhD, MPH; Nancy E. Morden, MD, MPH; Christine S. Vogeli, PhD; and Eric G. Campbell, PhD
Many primary care physicians in the United States reported providing unnecessary medical care in response to patient requests; several factors predicted this behavior.

Objectives: Evaluating unnecessary US medical practices, and the strategies that reduce them, are increasingly recognized as crucial to healthcare financing sustainability. Provider factors are known to affect unnecessary medical practices, yet little is known about how physician responses to patient requests for unnecessary care affect these practices. Among primary care physicians (PCPs), we investigated 2 types of unnecessary medical practices triggered by patient requests: a) unnecessary specialty referrals and b) prescriptions for brand-name drugs when generic alternatives are available.

Study Design and Methods: We used data from a survey of a nationally representative sample of 840 US PCPs in 2009. Response rates for family practice (n = 274), internal medicine (n = 257), and pediatrics (n = 309) were 67.5%, 60.8%, and 72.7%, respectively.

Results: In response to patient requests, 51.9% of PCPs reported making unnecessary specialty referrals and 38.7% prescribed brand-name drugs. Family physicians (odds ratio [OR], 2.77; 95% CI, 1.77-4.34) and internal medicine physicians (OR, 4.51; 95% CI, 2.87-7.06) were more likely than pediatricians to prescribe brand-name drugs. PCP specialty was similarly associated with unnecessary referrals. Other predictors of acquiescence to patient requests included interactions with drug/device representatives, more years of clinical experience, seeing fewer safety net patients, and solo/2-person practice organizations. Area-level Medicare spending was not associated with the 2 unnecessary practices.

Conclusions: Many PCPs reported acquiescing to patient requests for unnecessary care. Provider and organizational factors predicted this behavior. Policies aimed at reducing such practice could improve care quality and lower cost. Patient and physician incentives that can potentially reduce unnecessary medical practices warrant exploration.

Am J Manag Care. 2015;21(11):823-832
Take-Away Points
Data on 840 US primary care physicians (PCPs) in 2009 were used to investigate 2 types of unnecessary medical practices in response to patient requests: a) unnecessary specialty referrals and b) brand-name drug prescriptions when generics were available.
  • Little is known about how PCPs balance cost-control expectations in the face of patient requests for unnecessary care that contribute to the provision of low-value care.
  • About 52% of PCPs reported making unnecessary referrals; 38.7% yielded to patient requests for brand-name drugs when generic equivalents were available. Provider and organizational factors predicted these behaviors.
  • Efforts should focus on identifying and evaluating patient and physician incentives that can potentially reduce unnecessary medical practices in the United States.
Currently, 30% of annual healthcare expenditures in the United States are believed to be unnecessary,1,2 including, but not limited to, avoidable hospitalizations, unnecessary procedures and testing, and poor prescribing practices.3 Patients influence some of this spending by asking physicians for unnecessary medical services. Recent research shows that almost half of physicians report at least 1 patient request per week for an unnecessary test or procedure.4 Also, US specialty referral rates have more than doubled in the last decade,5 raising questions about the drivers of this pattern.

Physicians are increasingly expected to consider healthcare costs when making medical decisions.6,7 The Physician Charter on Medical Professionalism, authored by the American Board of Internal Medicine (ABIM) in 2002, requires physicians to be good stewards of scarce medical resources.8 The ABIM’s Choosing Wisely initiative encourages physicians, patients, and other stakeholders to discuss the need for common tests and procedures that can often be wasteful. This led to the creation of a coalition of several professional societies and consumer groups dedicated solely to addressing unnecessary care.7,9 Although these are important initiatives, we know little about how physicians balance cost-control expectations in the face of patient requests for unnecessary care, which contributes to the provision of low-value care.

A strong primary care workforce is essential for an effective healthcare system.10,11 New payment models, such as the CMS Pioneer Accountable Care Organization (ACO) model, seek to reorient fee-for-service incentives,12 which may once again result in primary care providers serving as gatekeepers to effectively manage the care their patients receive. These newer models aim to balance control of healthcare utilization with improvements in quality and patient satisfaction. Therefore, the challenge for primary care physicians (PCPs) will be to achieve efficient utilization decisions without compromising patient satisfaction.13-15 This challenge is heightened by the short supply of PCPs, which result in high patient loads and inefficient work environments, and subsequently lead to insufficient time to manage patient requests.16

To understand how these potentially conflicting incentives affect physicians, we used data from a national survey of physician professionalism17-20 to examine the association of physician characteristics and area-level factors with 2 types of unnecessary medical practices among PCPs inspired by patient requests: a) the provision of unnecessary referrals to specialists and b) prescription of brand-name drugs when generic alternatives were available. Identifying factors associated with unnecessary specialty referrals and brand-name drug prescriptions may help inform strategies to reduce avoidable spending that results from patient requests for unnecessary care.

Survey Design Overview

This study uses data collected as part of the 2009 National Survey on Medical Professionalism (NSMP).17,18 The NSMP surveyed actively practicing board-certified physicians in the United States with 110 questions related to many aspects of physicians’ professional and social background, professional opinions, and activities. Details on survey development and testing have been published previously.19,20 The survey was approved by the Institutional Review Board of Massachusetts General Hospital.

Survey Participants and Administration

The American Medical Association’s 2008 Masterfile was used to identify eligible US physicians for our study. The Masterfile includes information on all doctors of medicine in the United States.21 We excluded all osteopathic physicians, resident physicians, physicians practicing in federally owned hospitals, as well as all who had no listed address, had requested not to be contacted, or had retired. From the remaining physicians in the Masterfile, we randomly selected 500 within each of the 3 primary care specialties (ie, family practice, internal medicine, and pediatrics) and 4 nonprimary care specialties (ie, anesthesiology, cardiology, general surgery, and psychiatry), resulting in a total of 3500 sampled physicians. Of these, 562 physicians were ineligible because they were deceased, out of the country, practicing a nonsampled specialty, on leave, or not practicing. Therefore, the final sample consisted of 2938 eligible physicians.

In May 2009, priority mail services were used to send initial survey packets containing a cover letter, fact sheet, and questionnaire with the random participant identification number, postage-paid return envelope, and a $20 incentive. To solicit participation, all nonrespondents were telephoned and were mailed up to 2 additional survey packets.

Study Sample

Overall, 64.4% of the 2938 eligible physicians completed the survey. Because of our interest in primary care, we limited our analyses to the 840 PCPs who responded. Response rates for family practice (n = 274), internal medicine (n = 257), and pediatrics (n = 309) were 67.5%, 60.8%, and 72.7%, respectively.

Statistical Analyses

We examined 2 survey items—unnecessary referrals and prescriptions—that reflected unnecessary care resulting from patient requests. The survey asked, “In the last year, how often have you given a patient a referral to a specialist because the patient wanted it when you believed it was not indicated?” Physicians were also asked, “In the last year, how often have you prescribed a brand-name drug when an equivalent generic was available because the patient asked for the brand-name drug specifically?” Responses to these questions were: “Never,” “Rarely,” “Sometimes,” or “Often.” For statistical analyses, the “Sometimes” or “Often” responses were coded as “1” and “Never” or “Rarely” responses were coded as “0.” The frequency of extreme responses (eg, “Often” and “Never”) were fairly small and could prevent meaningful statistical modeling of individual response categories.

The independent variables represented physicians’ personal characteristics, professional characteristics, and a geographic indicator for healthcare spending. Personal characteristics included sex (female vs male) and race (white/Asian vs others [African-American, Hispanic, Native American, Pacific Islander, and other]). Professional characteristics included medical specialty (pediatrics, family practice, or internal medicine), years of clinical experience (<10, 10 to 30, or >30), solo/2-person practice (“Yes” if physicians indicated they practiced in solo/2-person organizations, and “No” otherwise), working in a practice with easy access to specialists (“Yes” if physicians indicated that they practiced in a hospital, multi-specialty hospital, or medical school, and “No” otherwise); and percent of patients uninsured or Medicaid-insured (categorized into quartiles). We also asked, “How often do you meet with representatives from drug or device companies to stay up-to-date with the latest developments in your field?” We coded the “Sometimes” or “Often” responses as “1” and “Never” or “Rarely” responses as “0” for this variable.

We included a geographic indicator for healthcare spending, as regional differences exist in healthcare utilization among physicians. Using the physician-reported practice area zip code, we assigned each respondent to 1 of 3436 Hospital Service Areas (HSAs) as defined by the Dartmouth Atlas of Health Care.22 Of the total 840 PCPs, 16 did not report zip codes and 5 reported zip codes that could not be mapped. For the remaining 819 PCPs, we assigned area-level spending using the 2009 HSA-level claims-based, adjusted total Medicare Parts A and B reimbursements per enrollee from the Dartmouth Atlas of Health Care. We examined different categorizations for reimbursements, including deciles, tertiles, and quartiles.

All analyses included sampling weights that were computed as inverse probability of sampling, and response rates by physician specialty. Univariate distributions of independent variables and Pearson’s correlation coefficient between our 2 dependent variables were examined. Bivariate analyses were conducted using χ2 tests to investigate the associations of dependent and independent variables. Multivariate logistic regression models were estimated to predict independent variables (defined above) that were significantly associated with our markers of unnecessary care. Analyses were performed using Stata version 13.0 (Stata Corp, College Station, Texas). All reported P values are 2-sided and were considered significant at α = .05.

Characteristics of Respondents

Respondent characteristics are summarized in Table 1. Of the PCPs, 39.2% were female, 84.8% were white or Asian, 23.5% were general pediatricians, 32.8% practiced family medicine, and 43.7% practiced internal medicine. The majority of PCPs (60.9%) had 10 to 30 years of clinical experience and 22.6% had over 30 years. Only 24% of PCPs reported practicing in solo/2-person practice groupings. Less than 25% reported that more than half of their patients were either uninsured or Medicaid-insured, and 52.6% reported that they sometimes/often met with representatives from drug/device companies. The per-enrollee age-, sex-, and race-adjusted HSA-level Medicare reimbursements for respondents’ area of practice ranged from $4797 to $20,599. Our results were consistent among different categorizations for reimbursements. For brevity, we present results with reimbursements categorized into deciles.

Univariate Analyses

The Figure shows more than half (51.9%) of PCPs reported they sometimes or often gave a patient a referral to a specialist because the patient wanted it, even when they believed it was not indicated. Only 10.6% reported they never gave such a referral in the last year. At the same time, more than one-third of PCPs (38.7%) sometimes or often prescribed a brand-name drug because the patient asked for it although an equivalent generic was available. The Pearson’s correlation coefficient for these 2 unnecessary practice questions was 0.34 (P <.001), indicating these measures are significantly, positively related to each other.

Bivariate Analyses

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