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'Rationing' Acts Reported by More Than Half of Physicians

More than half of the physicians in a national survey engaged in behaviors consistent with rationing, according to a study published online July 19 in the Journal of General Internal Medicine.

Marcia Frellick, Medscape, Aug 5, 2016

The study, led by Robert D. Sheeler, MD, from the Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, found that 1348 respondents (53.1%) reported having personally refrained within the past 6 months from using specific services that would have provided the best care because of health system cost.

The treatments or services most commonly rationed were prescription drugs (n = 1073 [48.3%]) and magnetic resonance imaging (MRI; n = 922 [44.5%]).

"[M]ajor limitations exist in the way questions were asked and the behavioral definition used to frame questions without directly asking about rationing," they write.

Future research should use the term "rationing" in questionnaires to avoid ambiguity, they said, adding that, "[I]t is imperative that questions have a solid theoretical basis and should address factors that influence decisions to ration care and preferences for implicit as opposed to explicit strategies."

Dr Sheeler and colleagues also acknowledge limitations, in that the American Medical Association Physician Masterfile database relies on self-reported specialty data. Also, they add, studying self-reported behavior does not directly address the motivations and intentions behind the behaviors.

How Survey Was Done

The researchers mailed the paper survey to 3872 physicians in the United States who were randomly selected from the American Medical Association Masterfile; 2541 responded (65.6%).

The survey asked respondents "to rate the frequency (never, less than monthly, monthly, weekly, daily, or not applicable) with which they 'personally refrained, because of cost to the health care system, from using' 10 listed interventions-laboratory tests, routine radiography, [MRI], screening tests, referral to a specialist, referral to an intensive care unit, prescription drugs, referral for surgery, referral for dialysis, and hospital admission-even when that intervention would have been the best intervention for the patient," according to the report.

The wording was important "to convey the concept of clinician-mediated rationing without using the term 'rationing,' in order to minimize any potential social desirability influence on responses," the authors write.

They note they believed it was the first study to focus on rationing behaviors, rather than attitudes, among US physicians.

Additional Results

Services other than prescription drugs and MRI "were rationed considerably less often (among physicians for whom the service was available), including referral to an intensive care unit (10.9 %), referral for surgery (20.2 %), and hospital admission (18.8 %)," the authors write.

Most physicians reported rationing behaviors less than monthly, but frequency varied widely.

In all but one category, fewer than 5% of physicians reported rationing behaviors daily; 13.5% reported they rationed prescription medications daily.

The authors write they were surprised to find that those in small practices were more likely to report rationing than those in government, health maintenance organizations, or group practices that emphasize cost-consciousness.

One possible explanation, they say, might be "rationing by proxy," when "physicians become rationing agents for insurance companies because of the paperwork burden and the excessive prior authorizations or out-of-pocket costs required by payers and pharmacy benefit managers."

Independent physicians with fewer resources may find it easier not to make the effort when they know their efforts will likely be in vain or will not be compensated, the authors write.

Reasons for the behaviors and their effect on medicine need further research, they add.

"We recognize that a variety of circumstances may cause physicians to choose a less costly service, such as the desire to reduce patient out-of-pocket expense, not all of which would fall under a narrow definition of rationing," they said. "Even with a conservative definition of what constitutes 'bedside rationing,' however, we found that a significant number of US physicians reported such behavior."

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