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Health Care Costs and Financing

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Most midcareer physicians object to cost-control arrangements that influence clinical decisionmaking

Managed care brought in its wake financial incentives to doctors to reduce the number of tests, treatments, and referrals they order for their patients. However, most midcareer physicians strongly object to this intrusion into the doctor-patient relationship and believe these cost-control arrangements are unethical, according to a study supported in part by the Agency for Healthcare Research and Quality (HS09196).

Researchers from St. Vincent's Hospital in New York, New York Medical College, and Georgetown University conducted the first national survey on this topic. They randomly surveyed 1,549 physicians 8 to 17 years past their medical residency. More than three-fourths of the doctors believed that personal financial incentives to doctors to encourage restraint in testing, treatment, or referrals were not ethically acceptable. About 80 percent said that professional commitment to the traditional medical ethic of undivided loyalty to patients had diminished during the past decade. More than half of surveyed doctors believed that their own patients' trust in them had weakened over the past 5 years.

Most doctors vehemently objected to so-called gag rules of health plans. For instance, 87 percent felt strongly that health care payers' efforts to discourage doctors from telling patients about coverage restrictions were ethically unacceptable. Also, 78 percent of them felt that it was highly unethical for health plans to discourage disclosure of physician financial incentives. Physicians who reported that the overall personal financial incentives in their practices encouraged them to reduce services were significantly more likely than other doctors to have ethical objections to such incentives and to believe that the ethic of undivided loyalty to patients had diminished. These findings clearly underscore the depth of physicians' concern about payers' efforts to control clinical costs.

More details are in "Physicians' ethical beliefs about cost-control arrangements," by Daniel P. Sulmasy, O.F.M., M.D., Ph.D., M. Gregg Bloche, M.D., J.D., Jean M. Mitchell, Ph.D., and Jack Hadley, Ph.D., in the March 13, 2000 Archives of Internal Medicine 160, pp. 649-657.

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