Patients May Not Be Receiving The Highest Quality Of Care

April 06, 1999

A new study by a team of researchers at the University of California San Francisco presents evidence that doctors may withhold needed services from patients in response to financial incentives to control costs.

In a nationwide survey of internists, UCSF researchers also found that up to 50 percent of physicians in managed care settings and 39 percent of physicians in fee-for-service settings failed to prescribe services recommended by national guidelines. The more restrictive the financial incentive, the less likely physicians would order recommended tests or referrals. The study appears in the March issue of the Western Journal of Medicine.

"This study shows that patient care may be compromised regardless of what financial incentives are in place," said Steven Pantilat, M.D., lead author and assistant professor of medicine at UCSF. "That can erode the public's trust." Compared to fee-for-service plans, the restrictions of managed care resulted in a decrease of 3 percent to 11 percent of physicians stating that they would order the appropriate tests and referrals. Although the researchers' findings suggest that incentives in managed care do lead physicians to withhold needed services, financial motives should not be singled out as the only factor influencing doctors' decisions, said Pantilat.

Questionnaires were mailed to 1,030 general internists (70 percent response rate) in group or solo practices across the country who belonged to the American College of Physicians. They practiced in metropolitan areas with populations of more than 250,000 where at least 30 percent of insured people belonged to managed care plans, said Pantilat.

In the survey, physicians were given four patient scenarios and asked to determine whether they would prescribe the test or referral recommended by national guidelines designed to identify or rule out life-threatening illnesses. The physicians made their treatment decisions working under various fictitious combinations of financial incentives and assessments of need.

"We used relatively straightforward, common conditions that offered at least some degree of treatment uncertainty," said Margaret Chesney, Ph.D., UCSF professor of medicine and co-author of the paper.

The percentage of physicians who recommended an indicated test or referral varied with the patient scenario. In all cases, however, physicians working under the assumption of the most restrictive managed care plan said they would order fewer services than physicians working under the assumption of a fee-for-service plan.

For example, one of the scenarios depicted a 56 year-old-woman suffering from low back pain for six weeks. According to national guidelines, the woman should be given a spinal X-ray or an orthopedic referral to evaluate for cancer or infection. When the patient was covered by the strictest managed care plan, 14 percent of physicians failed to recommend an X-ray or an appropriate referral. In comparison, 6 percent of physicians failed to prescribe the recommended treatment when the patient was covered on a fee-for-service basis.

A second scenario gave more startling results. When the recommended treatment included an upper endoscopy to look for the presence of a stomach ulcer or tumor, 50 percent of physicians operating under the strictest managed care plan did not order the endoscopy. But even under a fee-for-service plan, 39 percent of physicians failed to recommend the procedure.

"Because there has been concern in the medical community that financial incentives in managed care will lead physicians to withhold necessary services, we wanted to see if managed care members were getting sub-optimal care," said Pantilat. "We did see a tendency toward offering fewer services to managed care patients, but we also found that a significant number of all physicians did not follow nationally accepted guidelines for care, regardless of the incentives."

Based on their results, the researchers believe the medical community needs better quality control measures to ensure that physicians provide the recommended services. Because managed care organizations often have sophisticated information systems, they may be in the best position to help physicians increase compliance to guidelines, said Pantilat. In addition, instead of using incentives designed to control costs, organizations can develop incentives designed to promote the provision of indicated services, said Pantilat.

"We need to establish a system that is more responsive to the needs of the patient," said Chesney.

In addition to Pantilat and Chesney, Bernard Lo, M.D., UCSF professor of medicine was a co-author on the paper.

The study was funded by the Robert Wood Johnson Foundation, the Walter and Elise Haas Fund, and a Center Grant from the National Institutes of Mental Health.

University of California - San Francisco

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