Despite professional consensus, guidelines, and national campaigns, physicians continue to provide many low-value services. These services are defined as having little to no benefit, little benefit relative to their cost, or outsized potential harm compared to their benefit. Policies have tried to promote high-value care by altering physician compensation, but have had limited success in part because they are rarely based on theories of physician behavior. An emerging policy solution is to financially penalize the physicians who deliver low-value care, but physician support for these policies is largely unknown.

In an LDI-funded pilot project, lead author and LDI Senior Fellow Joshua Liao, and LDI colleagues Amol Navathe, Marilyn Schapira, Nandita Mitra, and David Asch, studied physician support for financial penalties in the case of three low-value services: placing, and leaving in, urinary catheters for urine output monitoring in non-critically ill patients; ordering continuous telemetry monitoring for non-intensive care unit patients without a protocol governing continuation; and prescribing stress ulcer prophylaxis for medical patients who are not at high risk for gastrointestinal complications. This project was a novel attempt to leverage professional values to inform the design of value-based incentives.

Liao and colleagues conducted a randomized, web-based survey of 484 physicians and residents practicing hospital medicine, which yielded 187 responses. They reported their findings in two recent Journal of Hospital Medicine articles.

The first report evaluated physician beliefs regarding who benefits from the money saved by reducing low-value services. Despite efforts to highlight the benefits to patients of reducing low-value care, the surveyed physicians did not believe that most of the savings would actually benefit patients. The researchers found that physicians are more likely to support financial penalty policies if they believed that any money saved go to patients. Physicians were less likely to support such policies if they believed that the savings would accrue to the health system or insurance companies, as shown below.

The second report evaluated physician support for financial penalty policies based on how the harms of low-value care were framed: either as a cost to patients, health care institutions, or society. Respondents answered one of three versions of the survey question:

Overall, the physicians surveyed agreed that financial incentives were an effective means to influence behavior and that physicians should consider the impact of a service on society when making clinical decisions. The researchers found that physician support for such policies was 39.6% overall and highest when the harms of low-value care were framed as costs to society (48.4%). Support from respondents was 36.9% when low-value care was framed as an institutional harm, dropping to 33.3% when framed as an patient harm. Although the comparatively low support in the “patient harm” version was somewhat surprising, the researchers noted that it may reflect whether the service qualified as low value because of its high cost relative to its benefit, or because of its potential to cause clinical harm. For example, physicians were more likely to support reducing unnecessary stress ulcer prophylaxis, which has been shown to result in nosocomial infections and adverse drug reactions, than to reduce unnecessary telemetry, for which high cost relative to benefit is the primary concern rather than potential clinical harms to the patient.

The findings potentially reflect physicians’ alignment with the principles of health care justice, in which they were more likely to support policies that benefit their patients and society as a whole, rather than health institutions or insurers. The authors conclude that effective physician penalties will communicate that patients stand to benefit from reducing costs more than health systems and insurers. In addition, framing low-value care in part based on its burden on society could increase the support for financial penalties.