All-member survey measures physician opinions on health care costs, transparency and payer issues
by Chet Seward, CMS Chief Strategy Officer
Featured in the November/December 2018 Colorado Medicine.
Concerns about rising health care costs, price transparency and payer issues continue to roil the Colorado health care system. Colorado Medical Society (CMS) physician members are actively engaged in and have numerous ideas about these issues, as evidenced in the results of an online poll conducted during July and August 2018.
Health care costs
Almost three-quarters (73 percent) of CMS physicians in active practice describe the current situation in Colorado regarding the cost of health care as a crisis that they hear about daily (23 percent) or a very serious problem (50 percent). Physicians in small towns or in rural settings are more likely than others to say this is a crisis.
Two-thirds of CMS members (66 percent) believe physicians can have an impact on reducing health care costs, with 30 percent saying they can have a great deal of impact, and another 36 percent saying they can have some impact. More than one-quarter (28 percent) say they do not have much impact and just 4 percent say they can have no impact.
Physicians are taking active steps to control cost. Significant percentages of CMS physicians are implementing (or have specific plans to implement) various technologies, systems or strategies to contain costs while ensuring quality. Results also show some uptake of various alternative payment models: almost half (46 percent) of primary care physicians and 22 percent of specialists have pay for performance programs, two-in-five (38 percent) of PCPs say they are part of an ACO (versus 15 percent of specialists), and 18 percent of specialists say they are using bundled payments.
Open-ended responses show a range of physician views about their role in controlling costs. Most, especially primary care physicians, say they are “stewards” of care. Others emphasize their duty to provide care that is appropriate, or report that they feel pressured to meet patient demands for extensive treatments or to practice defensive medicine. Some point to the fact that they have little ability to control the cost of their visits/services or of the treatments or drugs they must prescribe.
The survey underscores the belief by many physicians that as a group they have little impact relative to other stakeholders on the rising cost of care across the system. Specifically, insurers, medical liability, drug manufacturers, hospitals, tests/labs and technology are seen as contributing more to the problem than physicians. This concern is particularly strong among those who have seen flat or declining reimbursements in their own practice over the past 5-10 years, with skyrocketing overhead to meet the administrative requirements from government and commercial payers. In terms of relative power to affect health care costs, CMS members rank insurers, drug manufacturers and hospitals in that order as having the greatest ability to reduce costs.
The business community has become increasingly concerned about rising costs, witnessed by recent efforts by the Denver Chamber of Commerce (DMCC). The poll explored some DMCC proposals. Physicians support many ideas that would increase transparency for drug manufacturers and PBMs, as well as requiring physician disclosure of financial interests. At the same time, there is soft support – with concern about the details – for solutions such as having an independent database to help determine practice variances. Physicians want interventions grounded in evidence.
Two-thirds of CMS members (69 percent) believe that price transparency can have a positive impact on controlling the cost of care, with 28 percent saying a great deal of impact and 41 percent saying some impact.
That said, details about how to make enhanced price transparency work so that information is meaningful and actionable are points of concern for physicians. Two-thirds feel they do not have influence on the pricing charged for the services they provide in their practices (including 30 percent who say not much and 35 percent who say none), while 15 percent feel they have a lot of influence and 20 percent feel they have some influence.
Open-ended survey responses emphasize that physicians want more transparency in the entire health care system. They want efforts to focus on both quality and pricing, but they are concerned that patients will struggle to see the link between the two. Many are worried that small practices would be unduly burdened (from a cost perspective in complying on an ongoing basis, as well as from the point of view of negotiation with payers who now have access to their competitors’ rates). CMS physicians want transparency about the costs of tests, labs and drugs – for which the prices are out of the control of the physician – as well as for patient costs imposed by the insurers and hospitals.
CMS physicians continue to work in a climate where they struggle to meet the demands (and associated costs) placed on them by commercial payers and the government, while trying to balance their patients’ needs with the imperative to control health care costs.
Physicians agree that the high cost of health care is a crisis that affects their patients daily and needs to be addressed. Indeed, as stated previously, many already see themselves as stewards of care, responsible for prescribing and ordering what their patients need and can afford, while being mindful of the overall costs to the system and the need to avoid unnecessary or repetitive visits or procedures.
They help patients daily with ways to find less expensive treatments or medications, and they have invested in technologies, systems and initiatives for cost reduction and quality improvement. At the same time, many are concerned that their impact will be minimal relative to the impact hospitals, drug manufacturers, PBMs and insurers (as well as changes in patient expectations) can have.
Given this landscape, it is not surprising that physicians support ideas that would increase transparency for drug manufacturers and PBMs, and would require physician disclosure of financial interests. There is soft support – with concern about the details – for solutions such as having an independent database to help determine practice variances, or a requirement that physicians publish their fee schedules to their patients. Physicians are open to these ideas but want them grounded in evidence.
They want to see solutions that take into account the complexity of pricing in health care, the relative lack of influence individual physicians have on these prices, and the inability of patients to translate these prices into meaningful comparisons of cost/quality between providers. Interactions with commercial payers continue to worsen given lack of basic information about the criteria used to build networks and determine physician eligibility (particularly among smaller practices), ongoing administrative burdens related to prior authorization, and insufficient health plan provider-relations staffing and expertise.