Are Primary Care Physicians Ready to Practice in a Consumer-Driven Environment?Results of a National Survey

Giridhar Mallya, M.D.Robert Wood Johnson Clinical Scholars Program

Leonard Davis Institute of Health EconomicsUniversity of Pennsylvania

Why focus on primary care physicians?

• CDHP benefit design is complicated

• Many common primary care services are not exempt from deductible

• Cost and quality information are limited

• Clinical decision-making is difficult

• Primary care doctors are a source of guidance

Aims

• To assess primary care physicians’• Knowledge of CDHP cost-sharing and savings accounts

• Readiness to advise patients on costs and budgeting for medical needs

• Attitudes with regard to quality-of-care information

• To compare physicians with and without CDHP enrollees in their practices

Methods

• Mailed survey of 1500 nationally-representative primary care physicians

• May-June 2007• GPs, FPs, general internists• $2 incentive with first mailing; 2 non-repsonse mailings

• 4-page questionnaire about CDHPs• CDHP knowledge• Brief description of plans• Advice on costs, budgeting• Attitudes regarding quality-of-care information

Methods

• 5-item response frames collapsed into 3 categories for analysis

• Descriptive statistics

• Multivariate regression for comparison of physicians with and without CDHP patients

• Adjusted for age, gender, specialty, board certification, practice size, academic affiliation, percent Medicaid, and geographic region

Results

• 49% adjusted response rate (528/1076)• 124 not primary care physicians

• 300 with undeliverable or inaccurate addresses

• Respondents more likely to be:• Female (32% vs. 27%, p=0.04)

• Board certified (86% vs. 81%, p=0.02)

• Family physicians/general practitioners (59% vs. 49%, p=0.002)

• No differences based on age or region

Experience with CDHPs

• 41% (210/528) of physicians had CDHP enrollees in their practices

• CDHP enrollees comprised a median of 5% of practice panels

• Interquartile range, 3%-7%

• Physicians with CDHP patients were less likely to care for a high percentage of Medicaid patients and less likely to be from the Northeast

Knowledge of CDHPs

Low

Low

Low

Low

Medium

Medium

Medium

Medium

High

High

High

High

0% 20% 40% 60% 80% 100%

How money is spentfrom medical savings

account

How money iscontributed to

medical savingsaccount

Out-of-pocket costsfor CDHP enrollees

CDHPs in general

Knowledge among physicians with CDHP patients

• More likely to have high knowledge of: • CDHPs in general (5.31, 3.29-8.58)

• Patient cost-sharing in CDHPs ( 3.34, 2.12-5.26)

• How money is contributed to savings account (2.76, 1.85-4.14) • How money is spent from savings accounts (2.47, 1.66-3.68)

• 21% with low knowledge of CDHPs in general• 24% with low knowledge of cost-sharing • 18% with low knowledge of MSA contributions

Readiness to advise patients on financial matters

Ready or somewhat ready

Readiness to discuss:

  Costs of medical care (in general) 73 (69-77)

  Cost-effectiveness of medical care 76 (73-80)

  Medical budgeting 48 (43-52)

Readiness to advise patients on the specific costs of:

  Office visits 85 (82-88)

  Medications 79 (76-83)

  Laboratory tests 67 (63-71)

  Radiologic studies 54 (50-59)

  Specialist consultation 38 (33-42)

  Hospital costs 33 (29-37)Notes: Percentage and 95% CI

Readiness among physicians with CDHP patients

• More ready to discuss costs of• Medical care in general (2.33, 1.48-3.68) • Medical budgeting (1.99, 1.35-2.92)

• No more ready to advise patients on costs of 5/6 specific services

• Office visits, lab tests, radiologic studies, specialty consultation, and hospitalization

• More ready with regard to costs of medications (1.68, 1.03-2.71)

Role of quality-of-care information in patient decision-making

Agree or strongly agree

Quality-of-care information should factor into patients’ choice of: (%)

  Hospitals 45 (41-49)

  Specialists 41 (37-45)

Patients can generally trust the quality-of-care information provided by: (%)

  Government websites 21 (17-24)

  Insurer websites 8 (6-10)Notes: Percentage and 95% CI

Role of quality-of-care information among physicians with CDHP patients

• No more likely to believe quality-of-care information should factor into patients’ choice of hospitals or specialists

• No more likely to trust quality-of-care information from government or insurer websites

Conclusions

• Physician knowledge of CDHP cost-sharing and savings accounts is limited

• Lesser but still significant extent among those with CDHP patients

• Generally ready to discuss issues of cost, but many not ready to advise patients on medical budgeting and the costs of certain common services

• Trust in quality-of-care information is very low and patients’ use of this information is not broadly supported

Implications

• Potential for poor decision-making• Non-exempt services, non-guaranteed employer contributions

• Limited time, disjointed decisions

• Low-income enrollees

• Possible tension in doctor-patient relationship, confusion for patients

• Track knowledge, adherence, outcomes

• Develop educational interventions for physicians and patients

• Expand access to standardized, point-of-care cost info

• Encourage doctor-patient dialogue about quality information and physician involvement in development of quality metrics

Co-Investigators

• Craig Pollack, MD, MHS• University of Pennsylvania, Robert Wood Johnson Clinical

Scholars Program, Philadelphia VA Hospital, Leonard Davis Institute of Health Economics

• Dan Polsky, PhD• University of Pennsylvania, Division of General Internal

Medicine, Leonard Davis Institute of Health Economics

Limitations

• Response bias• Board certification associated with higher knowledge

• Physician self-report rather than testing• Patients have resources other than physicians• Plan prevalence is still limited

• Skewed enrollment

• Physicians with CDHP enrollees: what’s the directionality?• Physicians’ roles: agency vs. aspiration