Doctors' Dilemma: Lower Costs, Please Patients, or Avoid Lawsuits?

Leigh Page, MS


September 11, 2014

In This Article

Cost-Cutting Creates Angst for Physicians

Payers used to have primary responsibility for reining in costs, but increasingly it's up to the physician, according to Jon C. Tilburt, MD, a bioethicist at Mayo Clinic in Rochester, Minnesota. Traditionally, payers create barriers such as higher copays for brand-name drugs or preapprovals for certain procedures. But Dr. Tilburt observed that the new thinking among payers is to enlist physician involvement in deciding what should be cut.

New cost-cutting approaches like those in ACOs, medical homes, and partial capitation "involve greater self-discipline," he said. "In an ACO, for example, you have to meet your targets of savings at the end of the year, which allows for more autonomy, but it also creates greater angst."

Perhaps in response to physicians' growing responsibility over costs, the medical profession has been creating improved cost-cutting tools, based on clinical evidence. Specialty societies have been issuing clinical guidelines that help physicians pinpoint precisely when certain services should be used and identify treatments that have little value and should not be used.

The latest step is to incorporate price into these guidelines, so that physicians can understand the overall value of the procedure. By 2012, 17 specialty societies had integrated cost into their guidelines.[1]

The American College of Cardiology (ACC) and the American Heart Association plan to use cost data to rate the value of treatments in their joint clinical practice guidelines and performance standards. "There is a growing awareness by many physicians that we cannot continue to ignore the cost of care," said Paul Heidenreich, MD, co-chair of the ACC writing committee. He said the guidelines, which are still being drafted, might measure cost per quality of life-year added. That would mean that a lower-cost procedure would have a higher value per life-year added than a similarly effective procedure that costs more.

Choosing Wisely, launched a few years ago by the ABIM Foundation, asks each specialty organization to identify low-value medical services. More than 50 specialty societies have each provided 5 succinct recommendations. For example, a recommendation from the American College of Physicians states: "Don't obtain imaging studies in patients with non-specific low back pain."

Physicians are also beginning to inquire about the price of services, which in itself is a way of reducing costs. A 2013 study[2] showed that giving physicians information on the price of medical laboratory tests decreased overall use of tests by about 9%.

Chris Moriates, MD, an assistant professor of medicine at the University of California at San Francisco, teaches his residents to find out the costs of services whenever possible and figure out how they will affect care. "The goal is to instill a general cost awareness," he said.

Lower prices have the additional benefit of producing better outcomes, Dr. Moriates said. For example, fewer patients will fill prescriptions for very expensive drugs than for lower-cost ones, and price differences can be huge. The annual cost of different statins ranges from $313 to $1428, according to a 2012 article in Pharmacotherapy.[3]

Some physicians are a little leery about the movement to cut costs. In a 2013 study led by Dr. Tilburt, just 51% of physicians were "very enthusiastic" about "limiting access to expensive treatments with little net benefit."[4]

One concern is that cost control can lead to rationing of care, which is a political hot potato. In any case, "you don't want the pendulum to swing so far that patients don't get what they need," Dr. Tilburt said.


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