Physicians ‘ration’ medical interventions because of cost

More than half of doctors in the United States have refrained from ordering certain medical interventions--including prescribing medications, ordering a scan or repeating a laboratory test--that had small benefits for their patients because of cost, a national survey found.

The survey, published in the Journal of General Internal Medicine, found that 53 percent of 1,348 respondents said they had personally refrained in the past six months from using clinical services that would have provided the best patient care because of cost. The services most often rationed by doctors were prescription drugs (48.3 percent) and ordering magnetic resonance imaging scans (44.5 percent), according to the survey. The rationing, which the study noted is a controversial topic for physicians, was more prevalent among physicians in solo practice and done less by doctors with liberal leanings.

Researchers mailed a survey to randomly selected physicians to evaluate their self-reported rationing behavior and the facts that influence their decisions. The survey asked doctors about the frequency they refrained because of cost to the healthcare system from using 10 different interventions.

The study found specialty, practice setting and political leanings had an influence on whether physicians rationed treatment options. Surgical and procedural specialists were less likely to refrain from ordering treatment options compared with primary care physicians, the survey found. Physicians in medical school settings were least likely to report rationing. However, physicians in small or solo practices were more likely to report rationing than those in settings where physicians might be more expected to focus on cost, such as group or health maintenance organizations or government programs, according to a study announcement.

Researchers said the behavior in solo practice may be explained by what’s called "rationing by proxy." Doctors "become rationing agents of insurance companies because of the paperwork burden and excessive hoops of prior authorizations or excessive out-of-pocket costs that are set up by payers and pharmacy benefit managers," Robert Sheeler, M.D., a family medicine doctor at the Mayo Clinic who led the study, said in the announcement. "Solo practitioners have fewer resources to deal with the paperwork and other barriers; it may be easier not to make the effort in the first place when they know that their efforts will likely be in vain or will not be compensated."

The survey also found it mattered what term is used to describe resource allocation. Eighty-eight percent of physicians agreed it is their responsibility to exercise “wise financial resource stewardship” in the care of patients; 81 percent agreed it is their responsibility to promote “cost consciousness” in the care of patients; but just 22 percent agreed it is their responsibility to “ration” care.

The survey comes at a time when physicians are actively pursuing or developing capabilities around value-based payments for their practices.

- read the study
- find an accompanying editorial
- check out a study announcement