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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.
Health policy makers also need to explore and implement patient-level incentives to effectively manage requests for unnecessary care. Consumer-directed competition can increase price sensitivity, create a system of value-seeking patients, and contain rising unnecessary spending. For example, competition-oriented Medicare Part D plans have led to lower negotiated prices for Medicare recipients.34 Consumer-directed health plans with high deductibles may also help promote cost awareness, although these plans may adversely affect the use of necessary healthcare services.35 Similarly, tiered provider networks may incentivize consumers to seek out physicians who provide high-value care and also encourage physicians to provide better quality and cost-effective care.36


Certain aspects of physician practice may have changed since 2009. Although we had high response rates and we corrected for bias using sampling weights, there may be response bias. The NSMP had only 2 specific items related to unnecessary medical practices, and patient requests may affect other forms of unnecessary care, such as diagnostic testing. Due to the nature of our survey, we could not estimate the dollar amount of unnecessary medical care that may have accrued due to the 2 practices considered in our analyses. Our results are based on physicians’ self-reports that may not be completely accurate. We did not have information on patient factors (eg, demographics, attitudes, medical needs and relationships with physicians) that may influence unnecessary care. Since a majority of PCPs indulged in unnecessary referrals, our question on unnecessary care may be limited in its ability to explain differences in this behavior across PCPs.

We may be limited in explaining variation in unnecessary referrals. Items included in our analyses may not fully capture other important factors for specialty referrals, like the market structure (eg, competitive or not), availability/number of specialists in an area, physician’s knowledge gap, defensive medicine practices, and patient preferences.5,37 Furthermore, we had no information on PCPs’ financial incentives in their practices which can influence referral patterns and use of brand-name products.38

Overall, we found that PCPs commonly acquiesce to patient requests for unnecessary referrals to specialists and for brand-name drug prescriptions, and several physician characteristics predicted this behavior. Ideally, the enormous natural experiment underway in the United States involving combinations of physician- and patient-level incentives will illuminate the solutions to the unnecessary medical practices our study reveals. Future studies should examine how differences in patient-physician relationships (eg, paternal vs autonomous, longitudinal, or acute), supply sensitivity (eg, availability of specialists), consumer incentives, and the new care models (eg, ACOs via ACA and other shared-decision models) impact these behaviors.

Author Affiliations: Department of Preventive Medicine and Community Health, University of Texas Medical Branch (SK), Galveston, TX; Department of Pediatrics, Huntsman Cancer Institute, University of Utah (ACK), Salt Lake City, UT; The Dartmouth Institute for Health Policy and Clinical Practice (NEM), Lebanon, NH; Mongan Institute for Health Policy, Massachusetts General Hospital (CSV, EGC), Boston, MA; Harvard Medical School (EGC), Boston, MA.

Source of Funding: This study was funded by the Institute on Medicine as a Profession at Columbia University, New York, NY.

Author Disclosures: Dr Kaul’s family member is employed with Humana. The remaining authors report no other relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CSV, NEM, EGC); acquisition of data (EGC); analysis and interpretation of data (SK, ACK, CSV, EGC); drafting of the manuscript (SK, ACK, NEM, EGC); critical revision of the manuscript for important intellectual content (SK, AC, NEM, CSV, EGC); statistical analysis (SK); provision of patients or study materials (EGC); obtaining funding (EGC); administrative, technical, or logistic support (ACK); and supervision (ACK).

Address correspondence to: Dr Sapna Kaul, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555. E-mail: sakaul@UTMB.EDU. 
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