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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

Limitations

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

CONCLUSIONS
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. 
REFERENCES
 
1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516.

2. Boat TF, Chao SM, O’Neill PH. From waste to value in health care. JAMA. 2008;299(5):568-571.

3. Health policy brief: reducing waste in health care. Health Affairs website. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82. Published December 13, 2012. Accessed October 15, 2015.

4. PerryUndem Research/Communication, ABIM Foundation. Unnecessary tests and procedures in the health care system: what physicians say about the problem, the causes, and the solutions—results from a national survey of physicians. Choosing Wisely website. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf. Published May 1, 2014. Accessed October 15, 2015.

5. Song Z, Sequist TD, Barnett ML. Patient referrals: a linchpin for increasing the value of care. JAMA. 2014;312(6):597-598.

6. Sirovich B, Gallagher PM, Wennberg DE, Fisher ES. Discretionary decision making by primary care physicians and the cost of U.S. health care. Health Aff (Millwood). 2008;27(3):813-823.

7. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802.

8. ABIM Foundation, American Board of Internal Medicine; ACP-ASIM Foundation, American College of Physicians—American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.

9. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign. Acad Med. 2014;89(7):990-995.

10. Jerant A, Fenton JJ, Franks P. Primary care attributes and mortality: a national person-level study. Ann Fam Med. 2012;10(1):34-41.

11. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.

12. Centers for Medicare and Medicaid Services. Pioneer ACO model fact sheet. http://innovation.cms.gov/initiatives/Pioneer-ACO-Model/PioneerACO-FactSheet.html, Updated August 26, 2015. Accessed October 15, 2015.

13. Kerr EA, Hays RD, Mitchinson A, Lee M, Siu AL. The influence of gatekeeping and utilization review on patient satisfaction. J Gen Intern Med. 1999;14(5):287-296.

14. Kroneman MW, Maarse H, van der Zee J. Direct access in primary care and patient satisfaction: a European study. Health Policy. 2006;76(1):72-79.

15. Papp R, Borbas I, Dobos E, et al. Perceptions of quality in primary health care: perspectives of patients and professionals based on focus group discussions. BMC Fam Prac. 2014;15:128.

16. Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff (Millwood). 2010;29(5):799-805.

17. Campbell EG, Rao SR, DesRoches CM, et al. Physician professionalism and changes in physician-industry relationships from 2004 to 2009. Arch Intern Med. 2010;170(20):1820-1826.

18. López L, DesRoches CM, Vogeli C, Grant RW, Iezzoni LI, Campbell EG. Characteristics of primary care safety-net providers and their quality improvement attitudes and activities: results of a national survey of physician professionalism. Am J Med Qual. 2013;28(2):151-159.

19. DesRoches CM, Rao SR, Fromson JA, et al. Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA. 2010;304(2):187-193.

20. Regan S, Ferris TG, Campbell EG. Physician attitudes toward personal relationships with patients. Med Care. 2010;48(6):547-552.

21. Keenan PS, Neumann PJ, Phillips KA. Biotechnology and Medicare’s new technology policy: lessons from three case studies. Health Aff (Millwood). 2006;25(5):1260-1269.

22. The Dartmouth Atlas of Health Care Working Group. The Dartmouth Atlas of Health Care website. http://www.dartmouthatlas.org/tools/downloads.aspx. Accessed October 15, 2015.

23. National Center for Health Statistics. Health, United States, 2013: with special feature on prescription drugs. Hyattsville, MD: National Center for Health Statistics; 2014. DHHS publication 2014-1232. http://www.cdc.gov/nchs/data/hus/hus13.pdf. Published May 2014. Accessed October 15, 2015.

24. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283(3):373-380.

25. Caudill TS, Johnson MS, Rich EC, McKinney WP. Physicians, pharmaceutical sales representatives, and the cost of prescribing. Arch Fam Med. 1996;5(4):201-206.

26. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260-273.

27. Shrank WH, Cox ER, Fischer MA, Mehta J, Choudhry NK. Patients’ perceptions of generic medications. Health Aff (Millwood). 2009;28(2):546-556.

28. Mott DA, Kreling DH. The association of insurance type with costs of dispensed drugs. Inquiry. 1998;35(1):23-35.

29. NHE fact sheet, 2013. CMS website. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html. Updated July 28, 2015. Accessed October 15, 2015.

30. Cooke M. Cost consciousness in patient care—what is medical education’s responsibility? N Eng J Med. 2010;362(14):1253-1255.

31. American Academy of Allergy, Asthma & Immunology. Ten things physicians and providers should question. Choosing Wisely website. http://www.choosingwisely.org/societies/american-academy-of-allergy-asthma-immunology/. Published April 4, 2012. Updated March 3, 2014. Accessed October 15, 2015.

32. Physician quality reporting system. CMS website. http://www.cms.hhs.gov/PQRI. Updated June 12, 2015. Accessed October 15, 2015.

33. Werner RM, Kolstad JT, Stuart EA, Polsky D. The effect of pay-for-performance in hospitals: lessons for quality improvement. Health Aff (Millwood). 2011;30(4):690-698.

34. Duggan MG, Morton FS. The medium-term impact of Medicare Part D on pharmaceutical prices. Am Econ Rev. 2011;101(3):387-392.

35. Davis K. Consumer-directed health care: will it improve health system performance? Health Serv Res. 2004;39(4, pt 2):1219-1234.

36. Freedman JD, Gottlieb AB, Lizzul PF. Physician performance measurement: tiered networks and dermatology (an opportunity and a challenge). J Am Acad Dermatol. 2011;64(6):1164-1169.

37. Wennberg JE, Fisher ES, Goodman DC, Skinner JS. Tracking the care of patients with severe chronic illness: The Dartmouth Atlas of Health Care 2008. The Dartmouth Atlas Project website. http://www.dartmouthatlas.org/downloads/atlases/2008_Chronic_Care_Atlas.pdf. Published 2008. Accessed October 15, 2015.

38. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163-170.
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