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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Does Physician Decision Making Influence Outcomes?
Should the Problem List Include Insurance Type and Status?
The Real Answer
On the flipside
Exposing the Crazy Aunt in the Attic
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Jennifer E DeVoe, Portland Assistant Professor, Family Physician, Dept. of Family Medicine, Oregon Health & Science University
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As mentioned in the discussion letters, Dr. Meyers and his collaborators have begun an extremely valuable research endeavor examining the role insurance status plays to influence physician’s clinical decision making. Despite an increasing emphasis on evidence-based medicine, the authors of this paper eloquently discuss how insurance status plays a driving role in patient care—perhaps, the most important role. Decisions are often made based on the patient’s insurance (or lack of insurance) and not necessarily based on the best available evidence. The findings from this masterful research study should be alarming to family physicians given the plethora of evidence about the close link between insurance coverage and improved health outcomes. Family physicians need to continue to be leaders in advocating for health insurance coverage and access to healthcare services for all. It is essential that we continue to support studies such as this one. Dr. Meyers should continue this valuable work with studies that include a broader, more representative group of physicians. These future studies might include placing students or standardized patients in physicians’ offices to observe clinical decision-making, while keeping physicians and patients blinded to the particular area of study. In addition, a similar study could be conducted among a large cohort of patients. Another key area for exploration is to determine how this finding fits within the larger body of evidence about how uninsured and underinsured patients have worse outcomes. If the appropriate controls are in place to eliminate the effects of confounding demographic factors associated with both uninsurance and poor health outcomes, then are the poorer outcomes among uninsured populations largely a result of physicians altering their clinical decision making? Or patients altering their care seeking behavior? Or both? Competing interests: None declared |
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A. John Orzano, Somerset. USA Family Physician; Dept FM/Research Division, UMDNJ-RWJMS
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Meyers et all extend a line of practice-based inquiry into insurance effects on medical decision-making and patient care(1,2). Insurance status is a patient characteristic that relates not only to the absence or presence of any insurance in a particular patient but also limitations or variation of the scope of coverage even when present. In addition to exploring insurance status and other mediating factors in medical decision -making associated with the specific encounter, future work should consider the impact of these effects on a different patient in the next visit, and the impact on other practice members in relationship to care and office productivity. For example, might the effort of the practitioner to tailor a particular diagnostic or therapeutic intervention to a specific patient’s insurance limit the time or induce frustration that impacts the next encounter. Equally, might efforts of the office staff on the patient’s behalf divert their attention to providing services to other patients (e.g., education and screening) and/or maintain patient flow and other operational tasks. 1. Flocke S, Stange K, Zyzanski S. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract, 1997;45:129-135. 2. Flocke SA, Orzano AJ, Selinger HA, Werner JJ, Vorel L, Nutting PA, Stange KC. Does Managed Care Restrictiveness Affect the Delivery of Primary Care. J Fam Pract. 1999;48:762-768 1999. Competing interests: None declared |
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Robert M Pallay, Hillsborough, NJ, USA physician
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I commend the authors in undertaking a study about the effect of insurance status in clinical care. However, the conclusion of this study comes as no surprise to any of us who practice medicine today. Any physician who thinks that insurance status and type do not affect their decision-making is either delusional or working in a concierge type practice that doesn’t accept insurance anyway. Indeed, probably the number one complaint of today’s practicing primary care doctor is that insurance plays way too large a role in the decision paradigm. To me the much bigger and more important question is whether this effect of insurance leads to poorer quality care, worse outcomes, and, in the longer term, more expensive care for the health system. While we need to understand better the issues exposed in this study to better work within a system as it is today, what we really need to do is find a way to make insurance status and type not an issue at all. There is only one way to do that. We, as family physicians must be committed to bringing universal coverage to all Americans. Imagine a system where not only do we not need more studies to better care for people with no or different insurance, but also do not need to spend any time, money, or other energy factoring it into out decisions. Sooner or later all of us with any social conscience at all will see that it is our duty as family doctors, as Americans, as human beings to make this a reality. As a Director on the AAFP Board, we take very seriously the charge to find a way to deliver universal coverage for all in this country and our task force, headed by Dr. Mary Frank, past Board Chair, will continue work on this through the year and report to the Congress of Delegates in Chicago in 2007. Until then studies like this will open our eyes to what we need to do within our present system. However, I will continue to wait expectantly for the day these studies are not needed! Robert Pallay, M.D. Competing interests: None declared |
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kiran toor, United States Resident
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The authors need to be commended for bringing up an important new perspective into patient care. Another confounder in the study was years of practice of participating physicians. Over 50% were in practice under 3 years. Managed care as it is practiced today is a relatively new concept. On the flipside, the physician who does not give consideration to patients insurance status can end up delaying care, resulting in frustrations to both physician and patient involved. For example, ordering test/imaging which is unlikely to be done, ordering medication which is unlikely to be filled, results in delaying care, paperwork generation, long calls to providers etc which is not always practical. The physician's response to this issue is to understand up front what can be accomplished and at least get those things done. Rather, not giving due consideration to insurance issues can result in less efficient care in today's world. Competing interests: None declared |
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J.Michael Pontious, Enid, Oklahoma Academic Physician - Rural Oklahoma
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Dr. Meyers and his colleagues are to be congratulated for the publication of this pilot study. It exposes one of the things that affects clinical decision making in many clinical situations. I call it the "crazy aunt syndrome" or the "clinical ghost phenomena" and as clinicians we know it is there and we have done it so long that we do not even realize its implications in clinical care of our patients. You do what you can and you move on. As with any narrowly defined practice based research network there are significant biases that must be confessed. The authors deal with this somewhat in their discussion, but another bias that needs to be addressed by doing this study in other networks is the bias that these physicians were largely academic or working in Community Health Centers. This significantly limits the findings of this study, in that there is a selection bias that will make it difficult to apply to the practice settings in which most family physicians in this country spend the bulk of their time. Since this is a pilot study, I hope the authors will be aggressive about pushing the research question on to larger and more diverse practice based research networks. It is only then that a clearer picture of the effect of having no health insurance will be more fully elucidated. Competing interests: Member - AAFP NatNet Member - OKPRN |
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