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The American Journal of Managed Care November 2015
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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
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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
Many primary care physicians in the United States reported providing unnecessary medical care in response to patient requests; several factors predicted this behavior.
Table 2 displays the bivariate associations between our independent variables and the 2 types of unnecessary medical practices. Responses varied significantly across specialty with 43.3% of pediatricians having sometimes/often referred to a specialist compared with 56.2% of family practice and 53.3% of internal medicine physicians (P = .02). Responses varied according to the composition of the PCP’s practice panel: PCPs who had more uninsured/Medicaid-insured patients were significantly less likely to provide unnecessary referrals compared with those with fewer uninsured/Medicaid-insured patients (P = .02). Slightly more than half (58.9%) of PCPs who met with representatives from drug/device companies sometimes or often referred to a specialist compared with 44.3% of those who did not (P <.001).

We found that 18% of pediatricians (vs 38.7% of family practitioners and 49.8% of general internists; P <.001) reported prescribing brand-name drugs in response to a request. Physicians with higher concentrations of uninsured/Medicaid-insured patients were similarly less likely to report prescribing brand-name drugs (P <.001). Nearly half (46.9%) of physicians with over 30 years of clinical experience versus 38.5% of those with 10 to 30 years and 27.4% of those with less than 10 years, reported prescribing brand-name drugs sometimes/often due to patient requests (P = .003). PCPs who practiced in solo/2-person organizations reported acquiescing to brand-name drug requests more often than those in larger practices (52% vs 34.3%; P <.001). Physicians who met with representatives from drug/device companies were more likely to sometimes/often prescribe brand-name drugs in response to patient requests (46.7% vs 29.6%; P <.001).

Multivariate Regression Results

Table 3 presents results of multivariate logistic regressions that predict unnecessary brand-name prescriptions and referrals by physician characteristics. Although not statistically significant at P <.05, both family practice (odds ratio [OR], 1.41; 95% CI, 0.97-2.06; P = .07) and internal medicine physicians (OR, 1.40; 95% CI, 0.95-2.06; P = .09) were more likely to sometimes/often make unwarranted specialist referrals compared with pediatricians. Physicians who met with drug/device company representatives in the preceding year were almost twice as likely to sometimes/often honor a patient request for a referral to a specialist (OR, 1.90; 95% CI, 1.36-2.64; P <.001) compared with those reporting no industry interactions. No other variables were significantly associated with the likelihood to acquiesce to patient request for specialist referral.

For prescribing brand-name drugs, compared with pediatricians, internal medicine (OR, 4.51; 95% CI, 2.87-7.06; P <.001) and family medicine (OR, 2.77; 95% CI, 1.77-4.34; P <.001) physicians were more likely to indicate they sometimes/often acquiesced to patient requests for brand-name drugs when generic equivalents were available. Physicians with over 30 years of clinical experience (vs <10 years of experience; OR, 1.82; 95% CI, 1.00-3.32; P = .05), physicians who practiced in solo/2-person organizations (vs those who did not; OR, 1.68; 95% CI, 1.11-2.55; P = .01), and physicians who met with representatives from drug/device companies (vs those who did not; OR, 1.85; 95% CI, 1.28-2.67; P = .001) were more likely to engage in this behavior. PCPs with higher concentrations of uninsured/Medicaid-insured patients were less likely to sometimes/often acquiesce to requests for brand-name drugs (P value test for this trend = .001). PCPs with more than 50% uninsured/Medicaid-insured patients (OR, 0.51; 95% CI, 0.31-0.85; P = .01) were significantly less likely to sometimes/often prescribe a requested brand-name drug compared with those who had fewer than 10% uninsured and Medicaid-covered patients. No other variables significantly affected brand-name drug prescriptions in compliance with patient requests.

DISCUSSION
In this national survey, we found that PCPs reported commonly acquiescing to patient requests for unnecessary medical services. Over half of PCPs sometimes/often provided specialty referrals due to patient requests and more than one-third reported prescribing brand-name drugs in response to patient requests. These frequencies likely underestimate the actual frequency of such practices due to social desirability bias. Nonetheless, ours is one of the first studies to provide estimates of the prevalence of service provision in response to patient requests for care that has been deemed unnecessary.

Prescribing behavior differed significantly by primary care specialty. Compared with internal and family medicine physicians, pediatricians were less likely to prescribe brand-name drugs upon patient request—an outcome potentially attributable to the patient populations cared for by these specialties and/or to the relatively standardized drugs/regimen used in pediatrics. The typical pediatric patient likely needs fewer prescriptions overall than an adult patient, which may also explain this divergence. We found similar (although not statistically significant) results for referrals to specialty providers. The volume of specialty visits in the pediatric population is much smaller than that of adults.23 As a consequence, requesting and prescribing specialty care by patients and clinicians, respectively, will be less common in pediatrics. Future research should explore factors about the training and/or practice of pediatricians that make them less responsive to unnecessary medical requests by patients.

Meeting with representatives from drug/device companies to stay up-to-date with developments in the field was significantly associated with acquiescing to patient requests for unnecessary care.24,25 Although there is a strong association between these behaviors, the mechanisms by which drug representatives influence unnecessary referrals is not clear. Physicians who meet with drug representatives may be less concerned with managing healthcare costs, and thus more likely to give into patient requests for unnecessary medical services. Physicians who meet with industry representatives to “keep current” may be, in relative terms, less confident in their knowledgebase, and thus more inclined than others to seek specialty input whether clearly indicated or not. Also, drug representatives may emphasize the value of specialist referrals to PCPs as a mechanism to market their drugs via specialists. Future research should explore other unobserved factors that affect the association between physician–representative interaction and unnecessary care, and whether this relationship is causal in nature.

We found older physicians more likely to report engaging in unnecessary medical practices by prescribing brand-name drugs upon patient request.26 Physicians working in solo/2-person organizations were more likely to prescribe brand-name drugs compared with those in larger practices. Experienced physicians and those working in small practices who have established rapport with patients and are devoted to customer satisfaction may seek to avoid conflict with patients, thus potentially making them more receptive to patient requests. It may also be that older physicians and those who work in small practices do not view their role in avoiding unnecessary medical care in the same ways as other physicians, which should be an area for future research. Since physicians in these situations may feel that their incomes are tightly linked to productivity, these physicians may feel strongly limited by time constraints in the exam room and large patient panel size, factors that could deter lengthy educational efforts.

Safety net PCPs who provide services to a greater percentage of financially needy patients (ie, uninsured or Medicaid patients) prescribe brand-name drugs in response to patient requests significantly less often. Uninsured and Medicaid patients are exposed to different healthcare incentives (eg, out-of-pocket costs) and may behave distinctly. Existing evidence shows that poorer patients are less likely to prefer brand-name drugs compared with wealthier patients.27 Uninsured and Medicaid patients are also more likely to be prescribed generic drugs relative to privately insured patients, which may explain our finding.28 Also, we found no statistical differences in specialty referrals across safety net provider categories.

We found no evidence to suggest that physicians in higher spending areas are more likely to acquiesce to patient requests for unnecessary care. Our spending variable was based on Medicare, accounting for less than a quarter of total healthcare spending,29 and may not be a sensitive indicator of individual physician decisions. Spending statistics that combine data from multiple sources such as Medicare, Medicaid, and private payers may better inform efforts to correlate spending with acquiescence to patient requests.

From a policy perspective, we recommend that efforts to reduce unnecessary practices generated in response to patient requests should include educating and training PCPs about the direct (cost-saving) and indirect (time-saving and minimizing physical/mental harm to patients) benefits that can result from avoidance of overuse/underuse of medical services.30 However, this responsibility cannot be fixed solely by physician education—it requires systems-level improvements to meet patient needs.

PCPs may lack the time needed to effectively manage patient requests. Therefore, providing physicians with real-time support to effectively manage unnecessary requests can cause desirable outcomes. The Choosing Wisely initiative has developed lists of practices and procedures that should be questioned by physicians, and patient education materials disseminated through Consumer Reports, which may help patients understand physicians’ reluctance to provide specific treatments (eg, electroencephalograms for headaches).31 Certain PCPs (ie, family and internal medicine physicians) may require additional support to change their response to patient requests for unnecessary medical services. More experienced physicians in solo practices could benefit from guidance on how to appropriately incorporate patient preferences into patient-centered care, without engaging in unnecessary care.

Our findings suggest gatekeeping of referrals by PCPs may not be an effective strategy for controlling unnecessary practices within the current payment structure and systems organization. Existing healthcare policies, such as encouraging the formation of ACOs under the Affordable Care Act (ACA), may help in providing well-coordinated, high-value, patient-centered primary care, but the tension between patient satisfaction and cost-saving incentives may make the impact on unnecessary care uncertain. Similarly, the Physician Quality Reporting System incentivizes physicians to report specific patient quality measures, receive feedback on their comparative performance, and improve the quality of care.32 Healthcare transparency (ie, public reporting of patient satisfaction and quality measures) may also be sufficient to drive quality-related behavior changes.33 Future research should investigate empirical effectiveness of these policies and alternatives (eg, compensation models for holding physicians accountable for unnecessary care) to limit wastage of medical resources.

 
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