Changing physicians' behavior: the pot and the kettle

Article Abstract:

The goal of medical research is to discover new information that can lead to improvements in the diagnosis and treatment of diseases. But when convincing evidence in favor of a change in standard procedure is published, physicians do not always respond. They did react promptly and appropriately to studies that showed a shorter hospital stay after a heart attack promotes recovery, but physicians have ignored other cases of conclusive research findings. A study by Tierney et al. in the May 24, 1990 issue of the New England Journal of Medicine demonstrates that providing new information to physicians does not always lead to behavior change. Doctors working in an outpatient practice were ordering diagnostic tests for their patients at a computer terminal. For the study, half the physicians were shown the cost of each test on the computer screen, while the other half did not have this information. During the six-month intervention, those shown the charges ordered 14 percent fewer tests, for an average savings of $6.68 per patient visit over the control group. This was considered a positive move towards cost containment. The patients suffered no adverse consequences, such as increased hospital admissions. Yet after the study ended, the physicians who had ordered fewer tests returned to their previous habits so that eventually no significant difference remained between the two groups of physicians. Most notable was that the doctors did not learn anything from the six months of seeing the costs of all tests they ordered; when asked to recall the charges for various tests, they were just as inaccurate after the study as before it. Physicians often complain that their patients refuse to lose weight or quit smoking despite the indisputable health benefits of these changes. Doctors should learn how to change their own behavior, rather than feel frustrated about their patients', or it will be a case of the pot calling the kettle black, as the saying goes. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Behavior modification, editorial

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The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests

Article Abstract:

Expenditures for health care are rising rapidly in the United States, and it has been estimated that physicians make the decisions that control as much as 80 percent of the cost of health care. A study was designed to determine whether informing physicians of the charges for outpatient diagnostic tests would affect their decisions to order them. The 121 physicians studied were working in an academic primary care setting and they ordered the diagnostic tests at a computer terminal. For the study, half the physicians were shown on the computer screen the cost of the test and the total cost for the patient that day. The other physicians ordered the tests in the same manner but were not shown the charges. Over the course of the 26-week study, physicians shown the cost information ordered 14 percent fewer tests than doctors who were not aware of the costs. In the intervention group, the charges were 13 percent lower, which translated into $6.68 per patient visit. Greater differences between the groups were found for scheduled patient appointments than for urgent visits. Indices of adverse outcomes, such as hospitalizations and emergency room visits, were the same for the two groups. While the intervention was effective at lowering the number of tests ordered and the cost of outpatient diagnostic services, the effect weakened after the intervention ended; in the next 19 weeks, physicians who had been in the group shown the costs ordered only 7.7 percent fewer tests, for a savings of only 3.5 percent. (Consumer Summary produced by Reliance Medical Information, Inc.)

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Physicians' responses to financial incentives: evidence from a for-profit ambulatory care center

Article Abstract:

A recent trend in health care has been the proliferation of for-profit ambulatory care centers. Physicians practicing in these clinics may be affected by pressure from management or investors to generate revenues. Little research has been done on the behavior and decisions of doctors in response to financial incentives in outpatient settings. A study was done of physicians working for Health Stop, a large chain of for-profit ambulatory medical care centers. In 1985, Health Stop changed the compensation plan for its physicians from an hourly rate to a system of financial incentives in which the individual doctor would get bonuses based on the amount of income that he or she generated. The medical care and diagnostic tests ordered by 15 physicians were evaluated before and after the change to the financial incentive plan. After the change, physicians ordered 23 percent more laboratory tests per patient and 16 percent more X-rays per visit. The total charges per month rose by an average of 20 percent, and much of this increase was attributed to a 12 percent increase in the number of patient visits. Several doctors who frequently earned bonuses received an average 19 percent pay raise. This study demonstrated that physicians may respond to significant financial incentive by intensifying their medical practice, particularly by ordering more diagnostic procedures. (Consumer Summary produced by Reliance Medical Information, Inc.)

Ambulatory care facilities, Clinics

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