Adoption of Cost Consciousness

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Adoption of cost consciousness: Attitudes, practices, and knowledge among Israeli

physicians

Wilf-Miron, Rachel; Uziel, Liad; Aviram, Alexander; Carmeli, Abraham; Shani, Mordechai; et al.

International Journal of Technology Assessment in Health Care 24.1 (Jan 2008): 45-51.

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Abstract

Objectives: In a resource-constrained reality, physicians are facing polar demands--those ofhealthcare managements to adopt cost-conscious behaviors and those of ethical standards

that obligate physicians to consider only their patients' best interests. In our study, we aimed

to determine the attitudes, practices, and knowledge of healthcare costs among Israeli

physicians.

Methods: A questionnaire was developed and mailed to a representative sample of

physicians in Israel. The overall response rate was 51 percent. The study reviewed self-

reported levels of cost consciousness in practice, attitudes, obstacles related to cost

containment, and knowledge of the costs of medical resources.

Results: Forty-two percent of the physicians reported high levels of cost consciousness in

their daily practice; 70 percent reported greater current cost consciousness in comparison to

5 years ago; 76 percent of the responses legitimized institutional demands for cost

containment. Although 83 percent of the physicians that responded expressed the belief that

economic thinking was inherently the role of management, only 39 percent thought it was

part of the physician's role. It was found that predominant predictors of agreement to cost

consciousness concepts were employment by a community health plan, a managerial

position, participation in health economics seminars, and male gender.

Conclusions: Cost consciousness among physicians is related to a broad array of

parameters. Interventions must emphasize the benefits of evidence-based medicine as an

anchor for both cost containment and quality care, as well as providing assistance to

physicians in accepting economic decision-making as part of their professional role.

[PUBLICATION ABSTRACT]

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Full Text

(ProQuest: ... denotes non-USASCII text omitted.)Health rationing due to budgetary constraints has raised seemingly unsolved issues

internationally (1 ). To promote cost containment, healthcare managements use various



measures directed toward increasing resources or reducing demand for service (1 ;11 ).

Implementation of these measures almost invariably involves physicians, who are

accountable for a large proportion of the total healthcare expenditures. Attempts to modify

physicians' conduct come in various forms, all well documented in the literature (3,14).

Intervention goals include changing physicians' attitudes and knowledge by educational

means, changing physicians' behavior by limiting utilization or enforcing second-opinion

procedures, and providing incentives to save through physician-targeted rewards or

sanctions. While some strategies have proven to be more efficient than others,

interdisciplinary approaches incorporating multiple strategies appear to be most effective in

creating prolonged behavioral change (7 ;16 ).

These transformations and the ensuing reactions have imposed unfamiliar strains on

physicians. Demands to economize are countered by consumer pressures for greater

accountability and better value for money. Cost consciousnesslikewise appears to contradict

traditional ethical standards that obligate physicians to consider only their patients' bestinterests; economic considerations thus appear to counter their primary mission and to

induce some physicians to violate what they consider to be management-imposed unethical

guidelines (16 ;22 ). In addition, the introduction of changes in medical practice by

nonphysician managers sometimes triggers antagonism among physicians sensitive to

issues of professional autonomy (4 ;12 ).

Given these escalating pressures and their effect on physicians' job satisfaction (5 ), it is

somewhat surprising to note the paucity of studies directed at profiling physicians' attitudes

regarding cost containment. One of the few large-scale surveys conducted demonstratedsubstantial objection to cost-cutting methods among U.S. physicians; respondents reported

that changes in the system had diminished their undivided loyalty to their patients while

reducing patients' trust in physicians (20 ). Israeli physicians and Israel's healthcare system--

respected throughout industrial countries (21 )--confront similar strains due to medicine's new

face. The study reported here attempted to explore the physicians' perceptions with respect

to these dilemmas and to identify the factors that affect physicians' cost consciousness. For

this purpose, a wide range of attitudes and behaviors were surveyed and their relationships

explored.

METHODS

Participants and Procedure

A sample of 1,545 physicians was randomly selected from the Ministry of Health's register of

all physicians under 65 (a total of 23,380 physicians). Before mailing the questionnaire, a

"refuse to participate" postcard was sent (143 physicians refused to participate). The

remainder received the questionnaire together with a prepaid, self-addressed return

envelope. Ten days later, a written reminder was mailed; 3 weeks later, the questionnaire

was resent to physicians who had failed to return their questionnaire by that date. Four

weeks later, the physicians received telephone reminders and were offered the option of

participating in a telephone interview or receiving another copy of the written questionnaire.

The whole process took place between November 2001 and March 2002.



At the procedure's conclusion, 456 physicians were eliminated (406 due to erroneous

addresses and phone numbers, 21 no longer practiced medicine, 22 were abroad, and 7 had

passed away) from the initial sample of 1,545 physicians, which was reduced to 1,089. (The

seemingly high proportion of erroneous addresses and phone numbers is not implausible in

light of our reliance on the Ministry of Health's register. The register relies on details supplied

by physicians close to receipt of their license to practice medicine. That the list is infrequently

updated is a barrier to research.) From this sample, 552 physicians (50.7 percent) ultimately

participated in the survey. Among the respondents in the final sample, 67 percent (370/552)

were men; average age was 46 (SD = 8.48), 85 percent (469/552) were 31-54 years of age;

the main countries of origin were Israel (39 percent [215/552] and the former Soviet Union

(31 percent [171/552]; Israel absorbed more than one million immigrants from the former

Soviet Union between the years 1989 and 1999. This group of immigrants, which represents

approximately a sixth of Israel's current population, included approximately 7,300 physicians

below 65 years of age [see reference 13]); 30 percent (166/552) were employed solely bycommunity-based health maintenance organization (HMOs), 30 percent (166/552) solely by

hospitals, 26 percent (144/552) by both, and 14 percent (77/552) by neither (the major place

of employment being private clinics); 69 percent (381/552) were specialists (including Family

Medicine), 14 percent (77/552) nonspecialist general practitioners, and 17 percent (94/552)

residents; 31 percent (171/552) of all respondents held a managerial position (i.e., they

exercised some degree of managerial responsibility usually combined with clinical

responsibilities).

To assess the sample's representativeness, we compared the sample's demographiccharacteristics with data on the entire population of Israel's physicians aspublished by Israel's

Ministry of Health (17 ). This comparison yielded close similarity for most variables (e.g.,

gender, age, and medical specialty), excluding two variables that are apparently related. The

first referred to country of origin: 39 percent (215/552) of the respondents were born in Israel

ascompared to 26 percent (6,188/23,800) in the general population of physicians. The

second difference was specialization: 69 percent (381/552) of the survey's respondents were

specialists, compared to 41 percent (9,758/23,800) in the general population of physicians.

This gap is largely attributed to the relatively high proportion 84 percent (14,794/17,612) of

nonspecialist general practitioners among immigrant physicians, whose relatively low

response rates may be explained by language difficulties. Apart from these differences, all

other comparisons yielded acceptable results. Another test performed compared the early

(i.e., physicians who responded on the first mailing; n = 349) and late (n = 203) respondents'

demographic characteristics and responses to major substantive items. The only significant

difference was related to country of origin. Immigrants were found again to be somewhat

underrepresented (56 percent of the early respondents were immigrants compared with 66

percent of the late respondents). However, no significant differences were found between the

early and late respondents with respect to the substantive questions. These results indicate

that the bias did not compromise the external validity of the attitudes, knowledge, and

conduct reported for the sample asa whole.



Questionnaire

The questionnaire consisted of 55 items, constructed on the basis of the literature in addition

to exploratory open-ended interviews conducted with physicians and managers in Israel's

healthcare system. Several pretests were conducted before completion of the final version,

which contained four sections: (i) extent of cost consciousnessin daily practice and

perception of locus of responsibility for economic decision making; (ii) general attitudes

toward cost containment(the respondents were asked to indicate how much they agreed with

statements such as, "economic considerations compromise patients' health" or "economic

considerations facilitate better utilization of resources"); (iii) familiarity with the costsof

medical resources (e.g., in-patient bed days, computed tomography [CT] scans and

prevalent antibiotic drugs); and (iv) selected demographic variables. Likert-type scale

responses were requested for the items in sections (1-3).

RESULTS

Cost Consciousnessin Daily PracticeThe physicians were asked to what extent they take economic criteria into consideration in

their daily practice. Forty-two percent (230/548) reported a large to a great extent and

another 45 percent (247/548) reported a moderate level of economic decision making; only 1

percent (5/548) stated that they completely ignore economic considerations.

Univariate analyses of the responses revealed several significant differences between the

sample's subgroups (Table 1 ). The most noticeable differences appeared between age

groups, HMO physicians and hospital physicians, physicians holding a managerial position

and those who do not, and physicians who participated in health economics (HE) seminarsasopposed to those who did not.

A simultaneous multiple regression analysis was performed to ascertain the relative

contribution of the demographic variables to physicians' cost consciousness. Asseen in Table

2 , four variables were found to contribute significantly to cost consciousness, which we list in

descending order of their contribution: employment by an HMO, holding a managerial

position, participation in HE seminars, and gender, with male physicians reporting greater

cost consciousnessthan female physicians.

Table 1.

Demographic Variables Associated with Physicians' Cost Consciousness

Note.Values are numbers, percentages, and 95% confidence intervals (CI) of physicians

reporting large to great extent of cost consciousness. Some respondents did not answer all

questions. The subscripts a and b indicate a difference significant at p < .01.

HMO = health maintenance organization; HE = health economics.

Table 2.

Simultaneous Multiple Regression Analysis of Factors Affecting Physicians' Cost

Consciousness

Note. R 2=.15, p < .01.a

Versus physicians working in hospitals, hospitals and HMOs, and other.



bp < .01.

cVersus general practitioners and residents.

dVersus immigrant physicians.

HMO, health maintenance organization; HE, health economics.

The participants in the survey were also asked to compare the level of their current cost

consciousnessrelative to 5 years ago. Seventy percent (374/520) reported an increase in

cost consciousnesscompared to the past, whereas only 1 percent (5/520) reported a

decrease in that level.

Perception of the Locus of Responsibility for Economic Decision Making

The physicians were asked about the degree to which they perceive economic decision-

making asan element of their roles. Among the respondents, 39 percent (203/521) agreed

that economic decision making was within the framework of the physician's role to a large or

great extent; an additional 44 percent (229/521) agreed to a moderate extent. A minority (5

percent [26/521]) indicated that such issues were completely foreign to a physician's dutiesand rejected the idea. When asked about the degree to which economic decision making

was inherent in management's role, 83 percent (432/523) expressed a large or great extent

of agreement.

Attitudes Toward Cost Containment

The physicians were presented with a series of statements regarding various aspects and

implications of cost containment. (The reported percentages in this and in the next section

refer to physicians who indicated a large or great extent of agreement with the associated

statement.) Eighty-one percent (445/547) of the respondents indicated that integration ofcost containmentmeasures into the healthcare system would facilitate better utilization of

resources. Seventy-six percent (418/551) acknowledged the legitimacy of institutional

demands that physicians contain costs. Furthermore, 60 percent (330/547) agreed that

oversight of physicians' work would promote saving. On the other hand, only one-third (33

percent [183/552]) of the respondents indicated that it was legitimate to offer financial

incentives to physicians to encourage saving. A large majority (85 percent (467/548) agreed

with the statement that the best way to increase saving was to practice "right" medicine.

("Right" medicine is a recently formulated concept, used in the Israeli healthcare system to

define the role of the individual physician regarding cost-containmentpractices. It is based on

the paradigm modeling right medicine, ie, the wisdom to render a compassionate, patient-

oriented medical care, based on scientific evidence and in accord with desired clinical

routines, asbeing inevitably economical by markedly reducing inappropriate utilization of

resources.) Only 11 percent (59/547) indicated that expensive medicine necessarily meant

better medicine.

Obstacles to Achievement of Cost Containment

To achieve cost containment, impediments must be confronted. Based on the literature and

the interviews conducted, we formulated a series of statements regarding possible obstacles

to application of cost containmentmeasures. The physicians were asked to respond

accordingly.



Approximately two-thirds (65 percent (361/552) of the physicians reported that apprehension

regarding malpractice lawsuits was restraining their cost containmentefforts. Approximately

half (51 percent [283/551]) indicated that economic considerations would reduce patient

satisfaction with care received whereas 45 percent (246/551) indicated that they might harm

patient health, albeit only 18 percent (99/547) indicated that physicians should approve every

patient request regardless of the economic implications.

Apart from apprehensions related to the physician-patient relationship, other barriers were

mentioned aswell. Approximately two-thirds (64 percent [351/546]) of the respondents

indicated that physicians lack sufficient awarenessof economic issues. Half (51 percent

[280/547]) perceived a contradiction between their professional autonomy and their

organization policies guided by economic considerations. Finally, 38 percent (203/540)

indicated that cost containmentwould compromise their earnings.

Attitudinal Correlates

In an attempt to identify the attitudes that endorse cost-containmentbehavior, we calculatedthe correlation between the attitudes expressed by the respondents and the level of cost

consciousnessreported. Asseen in Table 3 , economic considerations were strongly

correlated with the attitude that economic decision making was part of the physician's role,

and that cost containmentmeasures facilitate better utilization of existing resources. Asfar as

implementation is concerned, economic decision making was correlated with the perceived

legitimacy of institutional demands for cost containmentand weaker objections to financial

incentives asmotivations for saving. Perceived potential hazards to patient health appear to

be inversely correlated with endorsement of cost consciousness.Table 3.

Correlations between Physicians' Attitudes and Self-Reported Level of Cost Consciousness

Note.The table presents only absolute correlations equal to or above .20 (all significant at p <

.001).

CI, confidence interval.

Knowledge of Costs

One manifestation of economic decision making is knowledge of resource costs. To explore

this issue, the survey's participants were asked whether they were familiar with the costto

their organization of nine frequently used medical resources (responses were given on a

three-point scale: full knowledge of exact cost, approximate knowledge of cost, and no

knowledge of cost. The list items: cardiac isotopic scans, laboratory exams, X-rays, CT

scans, and magnetic resonance imaging scans, frequently prescribed drugs, frequently

prescribed antibiotics, expert referrals, emergency room [ER] visits, and in-patient bed

days.). The physicians were quite familiar with the costsof in-patient bed days and ER visits

(56 percent [291/519] reported full knowledge for both items). In contrast, relatively little

awarenessof the costof expert referrals, laboratory tests, and cardiac scans was reported (full

knowledge of the costsof these items ranged between 17 percent and 28 percent (88-

145/519). The respondents reported knowing the exact costof 2.72 resources on average,

yet 58 percent (301/519) knew the costof no more than two resources. Knowledge of costs



was positively correlated with the level of cost consciousnessexercised in daily practice ( r s

(518) = .30; p < .001).

Univariate analyses were performed to identify the demographic characteristics associated

with knowledge of exact costs. The results (Table 4 ) indicated a significant effect for

physicians' organizational affiliation: HMO physicians (m = 3.14) reported knowing the costs

of more resources than did hospital physicians (m = 2.08). Physicians holding a managerial

position (m = 3.37) reported greater knowledge when compared with physicians in

nonmanagerial positions (m = 2.38), and physicians who participated in health economics

seminars (m = 3.53) reported greater knowledge when compared with physicians who had

not participated in such seminars (m = 2.36).

Table 4.

Variables Associated with Physicians' Knowledge of Resource Costs

Note.Values are mean number of resources, and 95% confidence interval. The superscripts

a and b indicate a difference significant at p < .01. Some respondents did not answer allquestions.

HMO, health maintenance organization; HE, health economics; CI, confidence interval; ns,

not significant.

DISCUSSION

This study revealed a rather pragmatic approach toward cost containmentamong Israeli

physicians. Most reported increasing levels of cost consciousnessin their practice over recent

years, legitimized management demands for cost containment, and believed it could improve

resource utilization. It appears that the traditional association of economic measures withsuboptimal medicine is no longer considered straightforward and that an alternative "right" or

evidence-based medicine can combine cost-effectiveness with excellence.

Yet, the emerging picture is still characterized by considerable physician reluctance to

perceive economic decision making asvital to fulfilling their responsibilities. This attitude's

high correlation with application of economic decision making in practice calls for special

attention. Only a minority perceived economic decision making asan aspect of the

physician's role, compared with more than 80 percent who attributed such thinking to

management. This position might result from the physicians' sense of helplessness regarding

their ability to affect healthcare costs, aswas expressed by primary care trainees in the

United States (19 ). Still, a more plausible explanation appears rooted in the physicians'

perception of the boundaries of their profession, which they view asconfined to purely clinical

activities. The increasing salience of economic considerations in shaping contemporary

medicine may nevertheless prove this "encapsulation strategy" to be a double-edged sword.

Recent studies have shown that the general population perceives physicians to be the most

suitable advocates for their patients in the conflict between clinical practice and economic

constraints (18 ). Therefore, because refusal to incorporate economic decision-making within

the physician's role not only "invites" greater nonmedical intervention on the micro aswell as

macro level, and hence decline the physician's advocacy capacities, patient trust in their own

physicians and the public healthcare system asa whole may ultimately be undermined.



Some of the other apprehensions mentioned add to our understanding of the physicians'

attitudes. Approximately half saw a contradiction between their professional autonomy and

cost-cutting healthcare policies, and approximately two-thirds expressed concern about

malpractice suits. These attitudes appear to reflect physicians' anxieties that proponents of

economic medicine are compelling them to implement a policy that undermines their

professional status while depriving them of the formal backing needed to contend with some

of the potential consequences.

In light of these considerations, we conclude that an additional aspect of the identified

predictors of cost consciousness(e.g., employment in an HMO or participation in HE

seminars) points to the weight of organizational culture in shaping physicians' on-the-job

behavior. Previous studies have demonstrated the relative success of interdisciplinary

approaches in creating effective intervention strategies (16 ;22 ). The current study's added

value thus lies in stressing the need for congruence among the messages conveyed to

physicians by their myriad work circles (managers and colleagues in the work setting,instructors in professional seminars, government, media, patient organizations, and so on).

Such agreement may positively impact on the ability to devise a compact between physicians

and their environments that is more appropriate to the current exigencies. In the process, it

may help physicians regain satisfaction with the practice of their calling (5 ).

In contrast to this elaborate approach, some organizations rely on financial incentives asthe

sole (and often blatant) measure to promote saving, resulting in strong physician antagonism

(2;10;13;15;20). Our findings corroborate the prevalence of this response. We conclude that

extreme caution is required when introducing any intervention containing such incentives.Despite that knowledge of costswas self-reported in the present study, the findings agree

with those of previous studies (which relied on objective measures) in demonstrating

relatively low levels of cost-related knowledge among physicians (6 ;8 ). Two-thirds of the

respondents in our study agreed with the statement that physicians lack sufficient awareness

of economic issues. It thus appears that physicians are not overly confident about their

knowledge of healthcare costsand wish to be better informed on the issue. In light of the

relationship between attitudes, knowledge, and behavior, educational interventions meant to

elaborate physicians' understanding of health economy issues are required and wanted (9 ).

The current study has several shortcomings that should be acknowledged. First, our sample

was characterized by under-representation of newly immigrant physicians, a group

constituting a substantial minority of Israel's practitioners. Although the literature indicates

that immigrants eventually assimilate pervasive attitudes, our current results are somewhat

less applicable to this population and invite further study. Another shortcoming rests on the

limitations of self-reported data, which affect the validity of the results regarding cost

containmentbehavior and knowledge of costs. Notwithstanding this caveat, the findings do

provide information about the physician's idiosyncratic approach to cost containment, input

that is crucial for preintervention purposes when strategies of intervention need to be

formulated.



CONCLUSION

Inducing change in healthcare systems is not a trivial task. This study focused on one aspect

of this complex endeavor and demonstrated--above all--the wide range of factors shaping

physicians' behavior. The participants in the study expressed pragmatic faith in the feasibility

of combining cost consciousnesswith quality through "right" medicine alongside fears and

reluctance to adopt economic decision making in daily practice. In addition to the attitudes

expressed, we were able to confirm the salience of several other variables that we had

hypothesized ascontributing to cost consciousness, such asknowledge of costs, managerial

status, and organizational setting, with the last two especially viewed asrepresenting the

influence of organizational culture. The myriad of variables suggests that, to achieve on-

going change, a comprehensive approach is mandatory.

CONTACT INFORMATION

Rachel Wilf-Miron, MD, MPH ([email protected]), Director, Quality Management,

Maccabi Healthcare Services, 27 Hamered Street, Tel-Aviv 68125, Israel; School of PublicHealth, Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv 69978, Israel

Liad Uziel, PhD (

[email protected]

), Graduate Student, School of Business Administration, The Hebrew University of

Jerusalem, Mt. Scopus, Jerusalem 91905, Israel

Alexander Aviram, MD (

[email protected]

), Clinical Associate Professor (Ret.), Faculty of Medicine, Tel-Aviv University, Tel-Aviv69978, Israel; Scientific Director, Israel National Institute for Health Policy Research, Sheba

Medical Center, Tel- Hashomer 62521, Israel

Abraham Carmeli, PhD (

[email protected]

), Chief, Department of Research &Evaluation, Pilat Management Consulting, 9 Habarzel

Street, Tel-Aviv 69710, Israel

Mordechai Shani, MD (

[email protected]

), Full Professor &Director, School of Public Health, Tel-Aviv University, Ramat-Aviv P.O.B

39040, Tel-Aviv 69978, Israel; Director, Israeli Center for Health Technology, Sackler School

of Medicine, Assessment in Health Care (ICTAHC), The Gertner Institute for Epidemiology

and Health Policy Research, Sheba Medical Center, Tel-Hashomer 52621, Israel

Joshua Shemer, MD (

[email protected]

), Full Professor, Department of Internal Medicine, Tel-Aviv University, Ramat Aviv 69978,

Israel; Director, Sackler Faculty of Medicine, Israeli Center for Health Technology,

Assessment in Health Care (ICTAHC), The Gertner Institute for Epidemiology and Health

Policy Research, Sheba Medical Center, Tel-Hashomer 52621, Israel



The authors thank Mrs. Nina Hakak, Information Specialist, for her tremendous assistance in

the search for research tools and other relevant information. This study was supported by a

grant from the Israel National Institute for Health Policy and Health Services Research. Grant

number 1998/001/A. The funding source had no role in the writing of the manuscript or the

decision to submit it for publication. None of the authors has been or will be paid to write this

article by any company or agency.

References

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AuthorAffiliation

Maccabi Healthcare Services and Tel-Aviv University

The Hebrew University of Jerusalem

Tel-Aviv University and Sheba Medical Center

Pilat Management Consulting

Tel-Aviv University and Sheba Medical Center

_______________________________________________________________

Indexing (details)

Subject Job satisfaction;

Immigration;

Behavior;

Health maintenance organizations--HMOs;

Cost reduction;

Medicine;Physicians;

Studies;

Health services;

Family physicians

MeSH Adult, Aged, Female, Humans, Israel, Male, Middle Aged,

Questionnaires, Attitude of Health Personnel (major), Cost Control

(major), Diffusion of Innovation (major), Physicians -- psychology

(major)

Title Adoption of cost consciousness: Attitudes, practices, and knowledgeamong Israeli physicians

Author Wilf-Miron, Rachel; Uziel, Liad; Aviram, Alexander; Carmeli, Abraham;

Shani, Mordechai; Shemer, Joshua

Publication title International Journal of Technology Assessment in Health Care

Volume 24

Issue 1

Pages 45-51

Number of pages 7

Publication year 2008

Publication date Jan 2008

Year 2008



Publisher Cambridge

Publisher Cambridge University Press

Place of publication Cambridge

Country of publication United Kingdom

Journal subject Medical Sciences--Experimental Medicine, Laboratory Technique

ISSN 02664623

Source type Scholarly Journals

Language of publication English

Document type Journal Article

Subfile Studies, Family physicians, Behavior, Physicians, Medicine, Job

satisfaction, Immigration, Health services, Health maintenance

organizations--HMOs, Cost reduction

DOI 10.1017/S0266462307080063

Accession number 18218168ProQuest document ID 210379122

Document URL http://search.proquest.com/docview/210379122?accountid=17242

Copyright Cambridge University Press

Last updated 2012-02-22

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