Physicians’ views about health care costs are germane to pending policy reforms.
Objective
To assess physicians’ attitudes toward and perceived role in addressing health care costs.
Design, Setting, and Participants
A cross-sectional survey mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile.
Main Outcomes and Measures
Enthusiasm for 17 cost-containment strategies and agreement with an 11-measure cost-consciousness scale.
Results
A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” In multivariable logistic regression models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for “eliminating fee for service” (salary plus bonus: odds ratio [OR], 3.3, 99% CI, 1.8-6.1; salary only: OR, 4.3, 99% CI, 2.2-8.5). In multivariable linear regression models, group or government practice setting (β = 0.87, 95% CI, 0.29 to 1.45,P = .004; and β = 0.99, 95% CI, 0.20 to 1.79,P = .01, respectively) and having a salary plus bonus compensation type (β = 0.82; 95% CI, 0.32 to 1.33;P = .002) were positively associated with cost-consciousness. Finding the “uncertainty involved in patient care disconcerting” was negatively associated with cost-consciousness (β = −1.95; 95% CI, −2.71 to −1.18;P < .001).
Conclusion and Relevance
In this survey about health care cost containment, US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models.
Burden of treatment refers to the workload of health care as well as its impact on patient functioning and well-being. We set out to build a conceptual framework of issues descriptive of burden of treatment from the perspective of the complex patient, as a first step in the development of a new patient-reported measure.We conducted semistructured interviews with patients seeking medication therapy management services at a large, academic medical center. All patients had a complex regimen of self-care (including polypharmacy), and were coping with one or more chronic health conditions. We used framework analysis to identify and code themes and subthemes. A conceptual framework of burden of treatment was outlined from emergent themes and subthemes.Thirty-two patients (20 female, 12 male, age 26-85 years) were interviewed. Three broad themes of burden of treatment emerged including: the work patients must do to care for their health; problem-focused strategies and tools to facilitate the work of self-care; and factors that exacerbate the burden felt. The latter theme encompasses six subthemes including challenges with taking medication, emotional problems with others, role and activity limitations, financial challenges, confusion about medical information, and health care delivery obstacles.We identified several key domains and issues of burden of treatment amenable to future measurement and organized them into a conceptual framework. Further development work on this conceptual framework will inform the derivation of a patient-reported measure of burden of treatment.
BACKGROUND Telehealth has been increasingly adopted by health care systems since the start of the COVID-19 pandemic. Although telehealth may provide convenience for patients and clinicians, there are several barriers to accessing it and using it effectively to provide high-quality patient care. OBJECTIVE This study was part of a larger multisite community-engaged study conducted to understand the impact of COVID-19 on diverse communities. The work described here explored the perceptions of and experience with telehealth use among diverse and underserved community members during COVID-19. METHODS We used mixed methods across three regions in the United States (Midwest, Arizona, and Florida) from January to November 2021. We promoted our study through social media and community partnerships, disseminating flyers in English and Spanish. We developed a moderator guide and conducted focus groups in English and Spanish, mostly using a videoconferencing platform. Participants were placed in focus groups with others who shared similar demographic attributes and geographic location. Focus groups were audio-recorded and transcribed. We analyzed our qualitative data using the framework analytic approach. We developed our broader survey using validated scales and with input from community and scientific leaders, which was then distributed through social media in both English and Spanish. We included a previously published questionnaire that had been used to assess perceptions about telehealth among patients with HIV. We analyzed our quantitative data using SAS software and standard statistical approaches. We examined the effect of region, age, ethnicity/race, and education on the use and perceptions of telehealth. RESULTS We included data from 47 focus groups. Owing to our mode of dissemination, we were not able to calculate a response rate for the survey. However, we received 3447 English-language and 146 Spanish-language responses. Over 90% of participants had internet access and 94% had used telehealth. Approximately half of all participants agreed or strongly agreed that telehealth would be beneficial in the future because it better fit their schedules and they would not need to travel. However, approximately half of the participants also agreed or strongly agreed they would not be able to express themselves well and could not be examined when using telehealth. Indigenous participants were especially concerned about these issues when compared to other racial groups. CONCLUSIONS This work describes findings from a mixed methods community-engaged research study about telehealth, including perceived benefits and concerns. Although participants enjoyed the benefits of telehealth (eg, not having to travel and easier scheduling), they also had concerns (eg, not being able to express themselves well and not having a physical exam) about telehealth. These sentiments were especially notable among the Indigenous population. Our work highlights the importance of fully understanding the impact of these novel health delivery modalities on the patient experience and actual or perceived quality of care received.
To assess US physicians’ attitudes towards using shared decision-making (SDM) to achieve cost containment.
Design
Cross-sectional mailed survey.
Setting
US medical practice.
Participants
3897 physicians were randomly selected from the AMA Physician Masterfile. Of these, 2556 completed the survey.
Main outcome measures
Level of enthusiasm for “Promoting better conversations with patients as a means of lowering healthcare costs”; degree of agreement with “Decision support tools that show costs would be helpful in my practice” and agreement with “should promoting SDM be legislated to control overall healthcare costs”.
Results
Of 2556 respondents (response rate (RR) 65%), two-thirds (67%) were ‘very enthusiastic’ about promoting SDM as a means of reducing healthcare costs. Most (70%) agreed decision support tools that show costs would be helpful in their practice, but only 24% agreed with legislating SDM to control costs. Compared with physicians with billing-only compensation, respondents with salary compensation were more likely to strongly agree that decision support tools showing costs would be helpful (OR 1.4; 95% CI 1.1 to 1.7). Primary care physicians (vs surgeons, OR 1.4; 95% CI 1.0 to 1.6) expressed more enthusiasm for SDM being legislated as a means to address healthcare costs.
Conclusions
Most US physicians express enthusiasm about using SDM to help contain costs. They believe decision support tools that show costs would be useful. Few agree that SDM should be legislated as a means to control healthcare costs.
ABSTRACT BACKGROUND While decision aids have been proven effective to facilitate patient-centered discussion about evidence-based health information in practice and enable shared decision making (SDM), a chasm remains between the promise and the use of these SDM tools in practice. AIMS To promote evidence-based patient-centered care in primary care by using encounter SDM tools for medication management of chronic conditions. METHODS We conducted a mixed methods study centered around a practice-based, multi-centered pragmatic randomized trial comparing active implementation (active) to passive dissemination (passive) of a web-based toolkit, ShareEBM, to facilitate the uptake in primary care of four SDM tools designed for use during clinical encounters. These tools supported collaborative decisions about medications for chronic conditions. ShareEBM included activities and tactics to increase the likelihood that encounter SDM tools will be routinized in practice. Study team members worked closely with practices in the active arm to actively integrate and promote the use of SDM tools; passive arm practices received no support from the study team. The embedded qualitative evaluation included clinician phone interviews (n=10) and site observations (n=5) for active practices, and exit focus groups for all practices (n=11). RESULTS Eleven practices and 62 clinicians participated in the study. Clinicians in the active arm used SDM tools in 621 encounters (Mean [SD]: 21 [25] encounters per clinician, range: 0-93) compared to 680 in the passive arm (Mean [SD]: 20 [40] encounters per clinician, range: 0-156, p=0.4). Six of 29 (21%) clinicians in the active arm and 14 of 33 (42%) in the passive arm did not use any tools (p=0.1). Clinicians’ views covered four major themes: general views of using encounter SDM tools, perceived impact on patients, strategies used, and how encounter SDM tools are incorporated into practice flow. CONCLUSION Neither active nor passive implementation of a toolkit improved the uptake and use of encounter SDM tools in primary care. Overcoming clinician reluctance to consider using encounter SDM tools, their seamless integration into the electronic and practice workflows, and ongoing feedback about the quality of their use during encounters appear necessary to implement their use in primary care practices.
To provide the simultaneous 7-year estimates of incremental costs of smoking and obesity among employees and dependents in a large health care system.We used a retrospective cohort aged 18 years or older with continuous enrollment during the study period. Longitudinal multivariate cost analyses were performed using generalized estimating equations with demographic adjustments.The annual incremental mean costs of smoking by age group ranged from $1274 to $1401. The incremental costs of morbid obesity II by age group ranged from $5467 to $5530. These incremental costs drop substantially when comorbidities are included.Obesity and smoking have large long-term impacts on health care costs of working-age adults. Controlling comorbidities impacted incremental costs of obesity but may lead to underestimation of the true incremental costs because obesity is a risk factor for developing chronic conditions.
Purpose: Novel approaches are needed to enhance employee well-being and perhaps supervisors can be an effective agent for worksite health promotion. The aim of this study was to examine the supervisor’s perceived needs, barriers, and role for influencing employee well-being for incorporation into program development. Design: Semistructured, qualitative interviews of supervisors. Setting: Large, integrated academic health-care organization with over 30 000 employees and 2600 supervisors having access to comprehensive well-being programs and a successful well-being champion network comprised of 600 champions. Participants: Twenty supervisors representing clinical, research, and administrative units. Methods: Semistructured, one-on-one interviews were conducted and audio recorded. Analysis included content log development and open coding by a trained analyst to reveal key themes. More formalized content coding using specialized software for qualitative analyses was also conducted. Results: Supervisor responses were wide ranging regarding their perceived and desired role in promoting workplace well-being. Barriers from the supervisor perspective included high current workload, ambivalence about promoting wellness, lack of support from leadership, lack of flexibility and control at work, and difficulty accessing on-site resources. They perceived their potential role in well-being as remaining a positive role model and encouraging their staff in wellness activities. Conclusion: Although findings are generated from a small sample size, these qualitative data provide compelling and early insights into building a workplace well-being strategy leveraging an underutilized key stakeholder, the workplace supervisor.
Abstract Background This systematic review and meta-analysis aims at assessing the composition and performance of care management models evaluated in the last decade and their impact on patient important outcomes. Methods A comprehensive literature search of electronic bibliographic databases was performed to identify care management trials in type 2 diabetes. Random effects meta-analysis was used when feasible to pool outcome measures. Results Fifty-two studies were eligible. Most commonly reported were surrogate outcomes (such as HbA1c and LDL), followed by process measures (clinic visit or testing frequency). Less frequently reported were quality of life, patient satisfaction, self-care, and healthcare utilization. Most care management modalities were carved out from primary care. Meta-analysis demonstrated a statistically significant but trivial reduction of HbA1c (weighted difference in means -0.21%, 95% confidence interval -0.40 to -0.03, p < .03) and LDL-cholesterol (weighted difference in means -3.38 mg/dL, 95% confidence interval -6.27 to -0.49, p < .02). Conclusions Most care management programs for patients with type 2 diabetes are 'carved-out', accomplish limited effects on metabolic outcomes, and have unknown effects on patient important outcomes. Comparative effectiveness research of different models of care management is needed to inform the design of medical homes for patients with chronic conditions.
The COVID-19 pandemic has exacerbated existing income inequality and health disparities in the United States (US). The objective of this study was to conduct timely, community-engaged research to understand the disproportionate impact of the COVID-19 pandemic on historically under-resourced communities with the goal of improving health equity. The initiative focused on priorities identified by Community Health Needs Assessments (CHNA) conducted every 3 years per Federal funding requirements. These were access to healthcare, maternal/child health, obesity/food insecurity/physical activity, and mental health/addiction.In the first three quarters of 2021, we developed and employed mixed methods in three simultaneous phases of data collection. In phase 1, we used purposive sampling to identify key informants from multiple stakeholder groups and conducted semi-structured interviews. In phase 2, we held focus groups with community members from historically marginalized demographics. In phase 3, we developed a survey using validated scales and distributed it to diverse communities residing in the geographic areas of our healthcare system across four states.Healthcare systems may use the methodology outlined in this paper to conduct responsive community engagement during periods of instability and/or crisis and to address health equity issues. The results can inform sustainable approaches to collaborate with communities to build resilience and prepare for future crises.
