Are Primary Care Physicians Ready to Practice in a Consumer-Driven Environment? Results of a National Survey Giridhar Mallya, M.D. Robert Wood Johnson Clinical Scholars Program Leonard Davis Institute of Health Economics University of Pennsylvania

Why focus on primary care physicians? CDHP benefit design is complicated Many common primary care services are not exempt from deductible Cost and quality information are limited Clinical decision-making is difficult Primary care doctors are a source of guidance

Aims To assess primary care physicians’ Knowledge of CDHP cost-sharing and savings accounts Readiness to advise patients on costs and budgeting for medical needs Attitudes with regard to quality-of-care information To compare physicians with and without CDHP enrollees in their practices

Methods Mailed survey of 1500 nationally-representative primary care physicians May-June 2007 GPs, FPs, general internists $2 incentive with first mailing; 2 non-repsonse mailings 4-page questionnaire about CDHPs CDHP knowledge Brief description of plans Advice on costs, budgeting Attitudes regarding quality-of-care information

Methods 5-item response frames collapsed into 3 categories for analysis Descriptive statistics Multivariate regression for comparison of physicians with and without CDHP patients Adjusted for age, gender, specialty, board certification, practice size, academic affiliation, percent Medicaid, and geographic region

Results 49% adjusted response rate (528/1076) 124 not primary care physicians 300 with undeliverable or inaccurate addresses Respondents more likely to be: Female (32% vs. 27%, p=0.04) Board certified (86% vs. 81%, p=0.02) Family physicians/general practitioners (59% vs. 49%, p=0.002) No differences based on age or region

Experience with CDHPs 41% (210/528) of physicians had CDHP enrollees in their practices CDHP enrollees comprised a median of 5% of practice panels Interquartile range, 3%-7% Physicians with CDHP patients were less likely to care for a high percentage of Medicaid patients and less likely to be from the Northeast

Knowledge of CDHPs

Knowledge among physicians with CDHP patients More likely to have high knowledge of: CDHPs in general (5.31, ) Patient cost-sharing in CDHPs ( 3.34, ) How money is contributed to savings account (2.76, ) How money is spent from savings accounts (2.47, ) 21% with low knowledge of CDHPs in general 24% with low knowledge of cost-sharing 18% with low knowledge of MSA contributions

Readiness to advise patients on financial matters Ready or somewhat ready Readiness to discuss: Costs of medical care (in general)73 (69-77) Cost-effectiveness of medical care76 (73-80) Medical budgeting48 (43-52) Readiness to advise patients on the specific costs of: Office visits 85 (82-88) Medications79 (76-83) Laboratory tests67 (63-71) Radiologic studies54 (50-59) Specialist consultation38 (33-42) Hospital costs33 (29-37) Notes: Percentage and 95% CI

Readiness among physicians with CDHP patients More ready to discuss costs of Medical care in general (2.33, ) Medical budgeting (1.99, ) No more ready to advise patients on costs of 5/6 specific services Office visits, lab tests, radiologic studies, specialty consultation, and hospitalization More ready with regard to costs of medications (1.68, )

Role of quality-of-care information in patient decision-making Agree or strongly agree Quality-of-care information should factor into patients’ choice of: (%) Hospitals45 (41-49) Specialists41 (37-45) Patients can generally trust the quality-of-care information provided by: (%) Government websites21 (17-24) Insurer websites8 (6-10) Notes: Percentage and 95% CI

Role of quality-of-care information among physicians with CDHP patients No more likely to believe quality-of-care information should factor into patients’ choice of hospitals or specialists No more likely to trust quality-of-care information from government or insurer websites

Conclusions Physician knowledge of CDHP cost-sharing and savings accounts is limited Lesser but still significant extent among those with CDHP patients Generally ready to discuss issues of cost, but many not ready to advise patients on medical budgeting and the costs of certain common services Trust in quality-of-care information is very low and patients’ use of this information is not broadly supported

Implications Potential for poor decision-making Non-exempt services, non-guaranteed employer contributions Limited time, disjointed decisions Low-income enrollees Possible tension in doctor-patient relationship, confusion for patients Track knowledge, adherence, outcomes Develop educational interventions for physicians and patients Expand access to standardized, point-of-care cost info Encourage doctor-patient dialogue about quality information and physician involvement in development of quality metrics

Co-Investigators Craig Pollack, MD, MHS University of Pennsylvania, Robert Wood Johnson Clinical Scholars Program, Philadelphia VA Hospital, Leonard Davis Institute of Health Economics Dan Polsky, PhD University of Pennsylvania, Division of General Internal Medicine, Leonard Davis Institute of Health Economics

Limitations Response bias Board certification associated with higher knowledge Physician self-report rather than testing Patients have resources other than physicians Plan prevalence is still limited Skewed enrollment Physicians with CDHP enrollees: what’s the directionality? Physicians’ roles: agency vs. aspiration