Doctors strongly oppose giving up fee-for-service payments, JAMA survey shows

Many physicians recognize the need to control health costs, but they're not eager to change how physicians are paid as a means of achieving cost control, according to a new survey of physicians' attitudes about health cost containment published in JAMA.

Cost-containment strategies that would cut direct payments to physicians in some form were particularly unpopular: 70% of doctors reported they weren't enthusiastic about eliminating the fee-for-service payment model, while 94% weren't enthusiastic about allowing Medicare payment cuts to physicians to take effect, according to a report on the survey.

Not surprisingly, salaried physicians were "significantly more likely" than those with a billing-only compensation model to express enthusiasm for eliminating fee-for-service, the report says.

Other strategies for changing for how physicians get paid were similarly opposed. Sixty-five percent of physicians aren't enthusiastic about bundled payments, and 59% aren't enthusiastic about penalizing providers for avoidable readmissions.

"Changing how physicians get paid is very unpopular in the profession," the report states. "Efforts to implement such changes, like the recent National Commission on Physician Payment Reform’s recommendations to eliminate fee-for-service reimbursement, could face stiff opposition from within the profession."

In a strongly worded editorial accompanying the report, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz call the survey's results "somewhat discouraging."

"The survey of 2,556 physicians suggests that in the face of this new and uncertain moment in the reform of the healthcare system, physicians are lapsing into the well-known, cautious instinctual approaches humans adopt whenever confronted by uncertainty: blame others and persevere with 'business as usual,'" Emanuel and Steinmetz say.

Specifically, Emanuel and Steinmetz seize on one question that asked physicians to rate whether various healthcare stakeholders have "major," "some" or "no" responsibility in reducing healthcare costs. Just 36% of physicians said that individual practicing physicians bear major responsibility. Physicians pointed to many other groups at much higher rates as having major responsibility for controlling costs, such as trial lawyers (60%), health insurance companies (59%), pharmaceutical and device manufacturers (56%), hospitals (56%), patients (52%) and government (44%).

As Emanuel and Steinmetz wryly observe: "Physicians report that almost everyone but physicians bear responsibility for controlling healthcare costs."

The editorial castigated physicians for "denial of responsibility" and failing to embrace the "all-hands-on-deck" approach that Emanuel and Steinmetz say is need to reduce excessive health costs in the U.S.

"Physician autonomy and leadership can only be affirmed if accompanied by acceptance of responsibility and accountability," they write. "Unless physicians want to be marginalized-unless they are willing to become just another deckhand- they must accept and affirm that they are responsible for controlling healthcare costs."

But Emanuel and Steinmetz didn't find all of the survey's results discouraging. On the positive side, physicians recognize that health costs are important and embraced three specific reforms that could take a bite out of health costs: using cost-effectiveness data to determine the availability of services, limiting access to expensive treatments that have little net benefit and including decision-support tools in electronic health records that show possible costs of tests and treatments, they note.

In physicians' defense, many of their responses to the survey reflect a difficult balancing act faced by nearly all doctors - the "inherent tensions" in physicians' professional role of serving both patients individually and society as a whole, the report's authors write.

For example, 78% of physicians surveyed agreed that they should be solely devoted to their patients' best interests, even if that's expensive, while 85% agreed that trying to contain costs is the responsibility of every physician. The study's authors gently label those somewhat contradictory views as "nuanced."

That difficult juggling act of trying to serve two masters is likely one that physicians will continue to struggle with for the near future.

The JAMA study, called "Views of Physicians About Controlling Heatlhcare Costs," featured John Tilburt, MD, MPH, of Mayo Clinic as lead author. The authors obtained data by sending an eight-page survey to physicians elected at random from American Medical Association's Physician Masterfile. Respondents represented all specialties, according to the report.

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