Reform Update: Doc survey on payment reforms triggers discussion in medical community

A recent survey of physicians suggested they are far from embracing reforms payment and delivery that policymakers and economists see as necessary to rein in costs. The results did not sit well with some, is appears from the latest issue of the Journal of the American Medical Association, but not for the same reasons.

The survey, published in the Journal of the American Medical Association in July, found healthy majorities of doctors are unenthusiastic about bundled payments, readmission penalties and eliminating fee-for-service reimbursement.

More than two-thirds (65%) of doctors reported they were “not enthusiastic” about bundled payments. At the other end of the spectrum, 6% said they were “very enthusiastic” about the model.

“Leadership will require much more than 6%,” wrote Emanuel, a physician and chairman of medical ethics and health policy at the University of Pennsylvania, and Steinmetz, his research assistant and administrative coordinator.

In an interview, Emanuel called the results “a somewhat discouraging result.” Doctors largely rebuffed the payment changes most often named as necessary to healthcare reform. “There's a lot of anxiety among docs. Understood,” he said. “We're all somewhat resistant to change. Understood. But I also think that it's the fact that doctors have not stepped up and accepted their role,” he said.

The comments were in response to others JAMA received on the July survey of physician perceptions of cost control and payment reforms.

In an accompanying editorial, Emanuel and Steinmetz argued for changes that would bolster cost-conscious medical decisions and greater emphasis on health and wellness as among the policy changes necessary to control costs.

About one-third (36%) of physicians said that doctors had a “major” responsibility to control costs. Doctors assigned a much greater responsibility to others, including trial lawyers, insurers, hospitals and health systems and pharmaceutical and medical device makers. Even patients were considered more accountable for cost control (52%).

“The moment seems to call for this kind of all-hands-on-deck mentality that should suggest that overwhelmingly physicians would embrace the challenge of cost control and accept some responsibility,” Steinmetz said. That was not evident in the numbers, he said.

Not everyone agrees. The responses more likely underscore the vexation doctors' incur as they practice medicine each day, which is compounded by the threat of litigation, one family practice doctor wrote in JAMA.

“In my view, the relegation by physicians of the responsibility to reduce costs to entities other than themselves is merely an expression of the frustration that dominates the daily practice of medicine,” wrote Jacob Korula, a physician in Arcadia, Calif., “highlighting the administrative impediments that payers, governmental agencies, pharmaceutical companies, and hospitals create for optimal delivery of care.”

Doctors may have also misunderstood the question, wrote Janet Weiner, the associate director of health policy for the University of Pennsylvania's Leonard Davis Institute of Health Economics. Perhaps, she wrote, doctors mistook the question as who bears responsibility for rising costs instead of who has the obligation to control spending.

The researchers acknowledged the possibility, but said tests of the questions, done ahead of the survey, did not unearth any confusion.

But not everyone agrees.

Prominent medical ethicist Dr. Ezekiel Emanuel, a onetime special adviser to the Office of Management and Budget and bioethics chair for the National Institutes of Health, and colleague Andrew Steinmetz, disputed those contentions in an accompanying comment.

Emanuel and Steinmetz dismissed the difference as largely irrelevant. “As is often said, the first step in solving a problem is acknowledging that one exists,” they wrote “If physicians deflect blame for increasing costs, surely they will deflect responsibility for controlling them.”

Interest in how to better engage patients in healthcare decisions is apparent in clinics, where doctors increasingly use decision aids, and the Patient Protection and Affordable Care Act, which calls for more developing and testing of tools to get patients more informed and involved in decision making. Those efforts are up against some powerful forces—income, habit, limited access to care, poor decisions—which Modern Healthcare seeks to explore in a three-part series “Channeling Choice.” You can read the first two installments on living with chronic disease and informed decision-making here and here.

The Washington Post's Wonk Blog offers some helpful tips to survive health policy talk over Thanksgiving turkey. The readable post runs through hypothetical scenarios, such as: “Your really liberal aunt from San Francisco thinks this would all be working perfectly if we'd just enacted single-payer.” Good luck out there.

Follow Melanie Evans on Twitter: @MHmevans