Discretionary decision making by primary care physicians and the cost of U.S. Health care

Abstract

Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians' clinical judgment in discretionary settings.

EXHIBIT 2. Routine Revisit Intervals For Patients With Well-Controlled Hypertension, Reported By Physicians In Regions With Low, Moderate, And High Spending

SOURCE: Authors’ calculations using survey data and Medicare claims data. NOTES: Low spending includes the quintile of lowest per capita Medicare spending (based on the 2003 End-of-Life Expenditure Index); moderate spending includes the three intermediate quartiles; and high spending includes the quintile of highest spending.

EXHIBIT 3. Tendency To Screen For Various Cancers Among Physicians In Regions With Low, Moderate, And High Spending, By Patient Age

SOURCE: Authors’ calculations using survey data and Medicare claims data. NOTES: Physicians were asked about mammography for women at average risk of breast cancer, prostate-specific antigen (PSA) testing for men at average risk of prostate cancer, and spiral computed tomography (CT) screening for smokers, in each of the age categories shown. Low spending includes the quintile of lowest per capita Medicare spending (based on the 2003 End-of-Life Expenditure Index); moderate spending includes the three intermediate quartiles; and high spending includes the quintile of highest spending. Statistical significance denotes test for trend, based on logistic regression in which the physician’s tendency to screen (yes/no) was the dependent variable and the independent variable was spending in the physician’s region, expressed as a continuous variable. ** p < 0.05

EXHIBIT 5. Association Between Physician Practice Intensity And Local Health Care Spending

SOURCE: Authors’ calculations using survey data and Medicare claims data. NOTES: Data are aggregated by decile of health care spending (End-of-Life Expenditure Index, or EOL-EI). Physician practice intensity represents the mean factor-derived summary intensity score for physicians in Hospital Referral Regions (HRRs) within each decile of EOL-EI. Data include only the 593 physicians who responded to all questions included in the factor analysis. Local health care spending represents mean local spending (EOL-EI) for physicians in HRRs within each decile of EOL-EI. r = 0.94.