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November 13, 1981, Vol 246, No. 19 >
ARTICLE | November 13, 1981

Cost Containment and Changing Physicians' Practice Behavior: Title and subTitle BreakCan the Fox Learn to Guard the Chicken Coop? FREE

John M. Eisenberg, MD, MBA; Sankey V. Williams, MD
[+] Author Affiliations

Reprint requests to Silverstein Pavilion 3, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (Dr Eisenberg).


JAMA. 1981;246(19):2195-2201. doi:10.1001/jama.1981.03320190053032
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Article
References

The important role of physicians in the generation of medical care costs is evident, but methods of inducing physicians to participate in cost-containment efforts are not well developed. Efforts to change physicians' use of medical services have included education, peer review and feedback, administrative changes, participation, penalties, and rewards. Although educational programs have had mixed success, those using individualized instruction have been most effective. Several feedback and peer-review programs have demonstrated reductions in costs, as have administrative interventions. While penalties and direct rewards may be effective, alterations in the current reimbursement system could offer financial incentives to physicians who practice in a cost-effective manner.

(JAMA 1981;246:2195-2201)

REFERENCES

1 +
Expenditures for Health Care: Federal Programs and Their Effects. Congressional Budget Office, Government Printing Office, 1977.
2 +
Kovar MG:  Health of the elderly and use of health services . Public Health Rep 1977;;92:9-19.
3 +
Gibson R, Mueller M:  National health expenditures: Fiscal year 1976 . Soc Security Bull (April) 1977;;40:3-22.
4 +
Eisenberg JM, Rosoff AJ:  Physician responsibility for the cost of unnecessary medical services . N Engl J Med 1978;;299:76-80.
5 +
Roth JA:  The necessity and control of hospitalization . Soc Sci Med 1972;;6:425-446.
6 +
Hall FM:  Overutilization of radiological examinations . Radiology 1976;;120:443-448.
7 +
Kurylo LL:  Measuring inappropriate utilization . Hosp Health Serv Adm 1976;;21:73-89.
8 +
GMENAC (Graduate Medical Education National Advisory Committee): Supply and Distribution of Physicians and Physician Extenders . US Dept of Health, Education, and Welfare publication No. (HRA) 78-11, Bureau of Health Manpower, Division of Medicine, Manpower Supply and Utilization Branch, 1978;.
9 +
Somers AR, Somers HM:  A proposed framework for health and health care policies . Inquiry 1977;;14:115-170.
10 +
Skipper JK, Smith G, Mulligan JL, et al:  Physicians' knowledge of costs: The case of diagnostic tests . Inquiry 1976;;13:194-198.
11 +
Dresnick SJ, Roth WI, Linn BS, et al:  The physician's role in the cost-containment problem . JAMA 1979;;241:1606-1609.
12 +
Nagurney JT, Braham RL, Reader GG:  Physician awareness of economic factors in clinical decision-making . Med Care 1979;;17:727-736.
13 +
Roth RB:  How well do you spend your patients' dollars? Prism 1973;;1( (September) ):16-17.
14 +
Fineberg HV:  Clinical chemistries: The high cost of low cost technologies , in Altman S, Blendon R (eds): Medical Technology: The Culprit Behind Health Care Costs? Proceedings of the Sun Valley Forum on National Health . US Dept of Health, Education, and Welfare publication No. 79-3216, 1979;, pp 144-165.
15 +
Schroeder SA:  Variations in physician practice patterns: A review of medical cost implications , in Carels EJ, Neuhauser D, Stason WB (eds): The Physician and Cost Control . Cambridge, Mass, Oelgeschlager Gunn & Hain, Publishers Inc, 1980;, pp 23-50.
16 +
Hardison JE:  Sounding board: To be complete . N Engl J Med 1979;;300:193-194.
17 +
Hudson JI, Braslow JD:  Cost containment education efforts in the United States medical schools . J Med Educ 1979;;54:835-840.
18 +
Garg ML, Gliebe WA, Kleinberg WM:  Student peer review of diagnostic tests at the Medical College of Ohio . J Med Educ 1979;; 54:852-855.
19 +
Zeleznik C, Gonnella JS:  Jefferson Medical College student model utilization review committee . J Med Educ 1979;;54:848-851.
20 +
Friedman E:  Changing the course of things: Costs enter medical education . Hospitals 1979;;54:82-85.
21 +
Lyle CB, Bianchi RF, Harris JH, et al:  Teaching cost containment to house officers at Charlotte Memorial Hospital . J Med Educ 1979;; 54:856-862.
22 +
Griner PF, Liptzin B:  Use of the laboratory in a teaching hospital . Ann Intern Med 1971;;75:157-163.
23 +
Eisenberg JM:  Educational program to modify laboratory use by housestaff . J Med Educ 1977;;52:578-581.
24 +
Rhyne RL, Gelbach SH:  Effects of an educational feedback strategy on physician utilization of thyroid function panels . J Fam Pract 1979;;8:1003-1007.
25 +
Griner PD and Medical Housestaff, Strong Memorial Hospital:  Use of laboratory tests in a teaching hospital: Long-term trends . Ann Intern Med 1979;;90:243-248.
26 +
Martin AR, Wolf MA, Thibodeau LA, et al:  A trial of two strategies to modify the test ordering behavior of medical residents . N Engl J Med 1980;;303:1330-1336.
27 +
Klein L, Charache P, Johannes R, et al:  Effect of physician tutorials on prescribing patterns and drug cost in ambulatory patients , abstracted. Clin Res 1980;;28:296.
28 +
Robertson WO:  Costs of diagnostic tests: Estimates by health professionals . Med Care 1980;;18:556-559.
29 +
Greenland P, Mushlin AI, Griner PF:  Discrepancies between knowledge and use of diagnostic studies in asymptomatic patients . J Med Educ 1979;;54:863-869.
30 +
Lawrence RS:  The role of physician education in cost containment . J Med Educ 1979;; 54:841-847.
31 +
Lawrence RS:  The role of physician education in cost control , in Carels EJ, Neuhauser D, Stason WB (eds): The Physician and Cost Control . Cambridge, Mass, Oelgeschlager Gunn & Haine Publishers Inc, 1980;, pp 151-159.
32 +
Bowers DG, Franklin JL: Survey-Guided Development 1: Data-Based Organizational Change . La Jolla, Calif, University Associates, 1977;.
33 +
Schroeder SA, Kenders K, Cooper JK, et al:  Use of laboratory tests and pharmaceuticals: Variation among physicians and effect of cost audit on subsequent use . JAMA 1973;;225:969-973.
34 +
Wennberg JE, Blowers L, Parker R, et al:  Changes in tonsillectomy rates associated with feedback and review . Pediatrics 1977;;59:821-826.
35 +
Dyck FJ, Murphy FA, Murphy JK, et al:  Effect of surveillance on the number of hysterectomies in the province of Saskatchewan . N Engl J Med 1977;;296:1326-1328.
36 +
Craig WA, Ulmar SJ, Shaw WR, et al:  Hospital use of antimicrobial control program . Ann Intern Med 1978;;89:793-795.
37 +
Counts GW:  Review and control of antimicrobial usage in hospitalized patients: A recommended collaborative approach . JAMA 1977;; 238:2170-2172.
38 +
Mitchell JH, Hardacre JM, Wenzel FJ, et al:  Cholecystectomy peer review: Measurement of four variables . Med Care 1975;;13:409-416.
39 +
Henderson D, D'Alessandri E, Westfall B, et al:  Hospital cost containment: A little knowledge helps , abstracted. Clin Res 1979;;27:279.
40 +
Eisenberg JM, Williams SV, Garner L, et al:  Computer-based audit to detect and correct overutilization of laboratory tests . Med Care 1977;;15:915-921.
41 +
Johns RJ, Blum BI:  The use of clinical information systems to control costs as well as improve care . Trans Am Clin Climatol Assoc 1978;;90:140-152.
42 +
Brook RH, Williams KN:  Effect of medical care review on the use of injections: A study of the New Mexico Experimental Medical Care Review Organization . Ann Intern Med 1976;; 85:509-515.
43 +
Lohr KN, Brook RH, Kaufman MA:  Quality of care in the New Mexico Medicaid Program . Med Care 1980;;18( (suppl) ):1-129.
44 +
The Effect of PSROs on Health Care Costs: Current Findings and Future Evaluations. Congressional Budget Office, Government Printing Office, 1979.
45 +
Dixon RH, Laszlo J:  Utilization of clinical chemistry services by medical housestaff . Arch Intern Med 1974;;134:1064-1067.
46 +
Dunn WN, Swierczek FW:  Planned organizational change; toward grounded theory . J Appl Behav Sci 1977;;13:135-137.
47 +
Weisbord MR, Stoelwinder JU:  Linking physicians, hospital management, cost containment and better medical care . Health Care Mgmt Rev 1979;;4:7-12.
48 +
Stoelwinder JU, Clayton PS:  Hospital organization development: Changing the focus from 'better management' to 'better patient care.' J Appl Behav Sci 1978;;14:400-414.
49 +
Morse JJ, Lorsch JW:  Beyond Theory Y , in Hampton DR, Summer CF, Webber RA (eds): Organizational Behavior and the Practice of Management . Glenview, Ill, Scott Foresman & Co, 1973;, pp 650-660.
50 +
Stross JK, Bole GG:  Evaluation of a continuing education program in rheumatoid arthritis . Arthritis Rheum 1980;;23:846-849.
51 +
Stross JK, Bole GG:  Continuing education in rheumatoid arthritis for the primary care physician . Arthritis Rheum 1979;;22:787-791.
52 +
Wang VL, Terry P, Flynn BS, et al:  Evaluation of continuing medical education for chronic obstructive pulmonary disease . J Med Educ 1979;;54:803-811.
53 +
Hampton DR, Summer LE, Webber RA (eds): Organizational Behavior and the Practice of Management . Glenview, Ill, Scott Foresman & Co, 1973;, pp 609-614.
54 +
Buck CR Jr, White KL:  Peer review: Impact of a system based on billing claims . N Engl J Med 1974;;291:877-883.
55 +
Paris M, McNamara J, Schwartz M:  Monitoring ambulatory care: Impact of a surveillance program on clinical practice patterns in New York City . Am J Public Health 1980;;70:783-788.
56 +
Jones E, Densen PM, Altman I, et al:  HIP incentive reimbursement experiment: Utilization and costs of medical care, 1969 and 1970 . Soc Security Bull 1974;;37:3-21.
57 +
Markel GA: Per case reimbursement for Medicaid services . National Center for Health Services Research Summary Series, NCHSR-US Dept of Health, Education, and Welfare publication No. PHS 79-3230, 1978;.
58 +
Hunt DD:  Effects of incentives on economic behavior and productivity of psychiatric residents . J Psych Educ 1980;;4:4-13.
59 +
Luft HS:  How do health-maintenance organizations achieve their 'savings'? N Engl J Med 1978;;298:1336-1343.
60 +
Moore S:  Cost containment through risk-sharing by primary care physicians . N Engl J Med 1979;;300:1359-1362.
61 +
Schroeder SA, Showstack JA:  Financial incentives to perform medical procedures and laboratory tests: Illustrative models of office practice . Med Care 1978;;16:289-298.
62 +
A Manpower Policy for Primary Health Care . Washington, DC, National Academy of Science, Institute of Medicine, 1978;.
63 +
Peterson ML:  The Institute of Medicine report 'A Manpower Policy for Primary Health Care': A commentary from the American College of Physicians . Ann Intern Med 1980;;92:843-851.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Expenditures for Health Care: Federal Programs and Their Effects. Congressional Budget Office, Government Printing Office, 1977.
2 +
Kovar MG:  Health of the elderly and use of health services . Public Health Rep 1977;;92:9-19.
3 +
Gibson R, Mueller M:  National health expenditures: Fiscal year 1976 . Soc Security Bull (April) 1977;;40:3-22.
4 +
Eisenberg JM, Rosoff AJ:  Physician responsibility for the cost of unnecessary medical services . N Engl J Med 1978;;299:76-80.
5 +
Roth JA:  The necessity and control of hospitalization . Soc Sci Med 1972;;6:425-446.
6 +
Hall FM:  Overutilization of radiological examinations . Radiology 1976;;120:443-448.
7 +
Kurylo LL:  Measuring inappropriate utilization . Hosp Health Serv Adm 1976;;21:73-89.
8 +
GMENAC (Graduate Medical Education National Advisory Committee): Supply and Distribution of Physicians and Physician Extenders . US Dept of Health, Education, and Welfare publication No. (HRA) 78-11, Bureau of Health Manpower, Division of Medicine, Manpower Supply and Utilization Branch, 1978;.
9 +
Somers AR, Somers HM:  A proposed framework for health and health care policies . Inquiry 1977;;14:115-170.
10 +
Skipper JK, Smith G, Mulligan JL, et al:  Physicians' knowledge of costs: The case of diagnostic tests . Inquiry 1976;;13:194-198.
11 +
Dresnick SJ, Roth WI, Linn BS, et al:  The physician's role in the cost-containment problem . JAMA 1979;;241:1606-1609.
12 +
Nagurney JT, Braham RL, Reader GG:  Physician awareness of economic factors in clinical decision-making . Med Care 1979;;17:727-736.
13 +
Roth RB:  How well do you spend your patients' dollars? Prism 1973;;1( (September) ):16-17.
14 +
Fineberg HV:  Clinical chemistries: The high cost of low cost technologies , in Altman S, Blendon R (eds): Medical Technology: The Culprit Behind Health Care Costs? Proceedings of the Sun Valley Forum on National Health . US Dept of Health, Education, and Welfare publication No. 79-3216, 1979;, pp 144-165.
15 +
Schroeder SA:  Variations in physician practice patterns: A review of medical cost implications , in Carels EJ, Neuhauser D, Stason WB (eds): The Physician and Cost Control . Cambridge, Mass, Oelgeschlager Gunn & Hain, Publishers Inc, 1980;, pp 23-50.
16 +
Hardison JE:  Sounding board: To be complete . N Engl J Med 1979;;300:193-194.
17 +
Hudson JI, Braslow JD:  Cost containment education efforts in the United States medical schools . J Med Educ 1979;;54:835-840.
18 +
Garg ML, Gliebe WA, Kleinberg WM:  Student peer review of diagnostic tests at the Medical College of Ohio . J Med Educ 1979;; 54:852-855.
19 +
Zeleznik C, Gonnella JS:  Jefferson Medical College student model utilization review committee . J Med Educ 1979;;54:848-851.
20 +
Friedman E:  Changing the course of things: Costs enter medical education . Hospitals 1979;;54:82-85.
21 +
Lyle CB, Bianchi RF, Harris JH, et al:  Teaching cost containment to house officers at Charlotte Memorial Hospital . J Med Educ 1979;; 54:856-862.
22 +
Griner PF, Liptzin B:  Use of the laboratory in a teaching hospital . Ann Intern Med 1971;;75:157-163.
23 +
Eisenberg JM:  Educational program to modify laboratory use by housestaff . J Med Educ 1977;;52:578-581.
24 +
Rhyne RL, Gelbach SH:  Effects of an educational feedback strategy on physician utilization of thyroid function panels . J Fam Pract 1979;;8:1003-1007.
25 +
Griner PD and Medical Housestaff, Strong Memorial Hospital:  Use of laboratory tests in a teaching hospital: Long-term trends . Ann Intern Med 1979;;90:243-248.
26 +
Martin AR, Wolf MA, Thibodeau LA, et al:  A trial of two strategies to modify the test ordering behavior of medical residents . N Engl J Med 1980;;303:1330-1336.
27 +
Klein L, Charache P, Johannes R, et al:  Effect of physician tutorials on prescribing patterns and drug cost in ambulatory patients , abstracted. Clin Res 1980;;28:296.
28 +
Robertson WO:  Costs of diagnostic tests: Estimates by health professionals . Med Care 1980;;18:556-559.
29 +
Greenland P, Mushlin AI, Griner PF:  Discrepancies between knowledge and use of diagnostic studies in asymptomatic patients . J Med Educ 1979;;54:863-869.
30 +
Lawrence RS:  The role of physician education in cost containment . J Med Educ 1979;; 54:841-847.
31 +
Lawrence RS:  The role of physician education in cost control , in Carels EJ, Neuhauser D, Stason WB (eds): The Physician and Cost Control . Cambridge, Mass, Oelgeschlager Gunn & Haine Publishers Inc, 1980;, pp 151-159.
32 +
Bowers DG, Franklin JL: Survey-Guided Development 1: Data-Based Organizational Change . La Jolla, Calif, University Associates, 1977;.
33 +
Schroeder SA, Kenders K, Cooper JK, et al:  Use of laboratory tests and pharmaceuticals: Variation among physicians and effect of cost audit on subsequent use . JAMA 1973;;225:969-973.
34 +
Wennberg JE, Blowers L, Parker R, et al:  Changes in tonsillectomy rates associated with feedback and review . Pediatrics 1977;;59:821-826.
35 +
Dyck FJ, Murphy FA, Murphy JK, et al:  Effect of surveillance on the number of hysterectomies in the province of Saskatchewan . N Engl J Med 1977;;296:1326-1328.
36 +
Craig WA, Ulmar SJ, Shaw WR, et al:  Hospital use of antimicrobial control program . Ann Intern Med 1978;;89:793-795.
37 +
Counts GW:  Review and control of antimicrobial usage in hospitalized patients: A recommended collaborative approach . JAMA 1977;; 238:2170-2172.
38 +
Mitchell JH, Hardacre JM, Wenzel FJ, et al:  Cholecystectomy peer review: Measurement of four variables . Med Care 1975;;13:409-416.
39 +
Henderson D, D'Alessandri E, Westfall B, et al:  Hospital cost containment: A little knowledge helps , abstracted. Clin Res 1979;;27:279.
40 +
Eisenberg JM, Williams SV, Garner L, et al:  Computer-based audit to detect and correct overutilization of laboratory tests . Med Care 1977;;15:915-921.
41 +
Johns RJ, Blum BI:  The use of clinical information systems to control costs as well as improve care . Trans Am Clin Climatol Assoc 1978;;90:140-152.
42 +
Brook RH, Williams KN:  Effect of medical care review on the use of injections: A study of the New Mexico Experimental Medical Care Review Organization . Ann Intern Med 1976;; 85:509-515.
43 +
Lohr KN, Brook RH, Kaufman MA:  Quality of care in the New Mexico Medicaid Program . Med Care 1980;;18( (suppl) ):1-129.
44 +
The Effect of PSROs on Health Care Costs: Current Findings and Future Evaluations. Congressional Budget Office, Government Printing Office, 1979.
45 +
Dixon RH, Laszlo J:  Utilization of clinical chemistry services by medical housestaff . Arch Intern Med 1974;;134:1064-1067.
46 +
Dunn WN, Swierczek FW:  Planned organizational change; toward grounded theory . J Appl Behav Sci 1977;;13:135-137.
47 +
Weisbord MR, Stoelwinder JU:  Linking physicians, hospital management, cost containment and better medical care . Health Care Mgmt Rev 1979;;4:7-12.
48 +
Stoelwinder JU, Clayton PS:  Hospital organization development: Changing the focus from 'better management' to 'better patient care.' J Appl Behav Sci 1978;;14:400-414.
49 +
Morse JJ, Lorsch JW:  Beyond Theory Y , in Hampton DR, Summer CF, Webber RA (eds): Organizational Behavior and the Practice of Management . Glenview, Ill, Scott Foresman & Co, 1973;, pp 650-660.
50 +
Stross JK, Bole GG:  Evaluation of a continuing education program in rheumatoid arthritis . Arthritis Rheum 1980;;23:846-849.
51 +
Stross JK, Bole GG:  Continuing education in rheumatoid arthritis for the primary care physician . Arthritis Rheum 1979;;22:787-791.
52 +
Wang VL, Terry P, Flynn BS, et al:  Evaluation of continuing medical education for chronic obstructive pulmonary disease . J Med Educ 1979;;54:803-811.
53 +
Hampton DR, Summer LE, Webber RA (eds): Organizational Behavior and the Practice of Management . Glenview, Ill, Scott Foresman & Co, 1973;, pp 609-614.
54 +
Buck CR Jr, White KL:  Peer review: Impact of a system based on billing claims . N Engl J Med 1974;;291:877-883.
55 +
Paris M, McNamara J, Schwartz M:  Monitoring ambulatory care: Impact of a surveillance program on clinical practice patterns in New York City . Am J Public Health 1980;;70:783-788.
56 +
Jones E, Densen PM, Altman I, et al:  HIP incentive reimbursement experiment: Utilization and costs of medical care, 1969 and 1970 . Soc Security Bull 1974;;37:3-21.
57 +
Markel GA: Per case reimbursement for Medicaid services . National Center for Health Services Research Summary Series, NCHSR-US Dept of Health, Education, and Welfare publication No. PHS 79-3230, 1978;.
58 +
Hunt DD:  Effects of incentives on economic behavior and productivity of psychiatric residents . J Psych Educ 1980;;4:4-13.
59 +
Luft HS:  How do health-maintenance organizations achieve their 'savings'? N Engl J Med 1978;;298:1336-1343.
60 +
Moore S:  Cost containment through risk-sharing by primary care physicians . N Engl J Med 1979;;300:1359-1362.
61 +
Schroeder SA, Showstack JA:  Financial incentives to perform medical procedures and laboratory tests: Illustrative models of office practice . Med Care 1978;;16:289-298.
62 +
A Manpower Policy for Primary Health Care . Washington, DC, National Academy of Science, Institute of Medicine, 1978;.
63 +
Peterson ML:  The Institute of Medicine report 'A Manpower Policy for Primary Health Care': A commentary from the American College of Physicians . Ann Intern Med 1980;;92:843-851.

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