Most physicians are often unaware of the cost of tests, drugs or scans that they order for their patients. If they were better informed, would there be any difference in the choices made?

Logically, this idea makes sense in theory; but, a recent study reveals that it does not seem to work in practice.

Involving almost 100,000 patients – more than 140,000 hospital admissions and a random distribution of laboratory tests – the study found that physicians do not consider cost at all. Some physicians even increased the number of tests they ordered after the cost was disclosed, according to a separate study.

During the electronic ordering process, half the tests were presented to doctors alongside fees and the other half of the tests were presented without such data.

The researchers suspected that in the group seeing the prices, there would be a significant decrease in the number of tests ordered each day per patient – and subsequently, reduce the spending on the tests.

Nonetheless, over the span of a year, there were no meaningful or consistent changes in test-ordering by the doctors.

A difference in primary care physicians and specialists

This is not the first study to prove that the disclosure of prices to doctors makes no difference. Earlier this year, a similar randomised controlled trial on paediatricians was conducted.

The doctors were randomised to one of three groups where the first group saw the median price of a test, the second saw two prices ̶ one obtained within the current health system and another outside it. The third saw no price at all. Again, no effect was observed. Adult-focused physicians actually ordered more tests when they saw the prices.

Last year a survey by CMI/Compas, a market research firm, looked at more than 800 doctors, and found that specialists were worse at taking cost into consideration. Only primary care physicians cited cost as among their most important considerations; but only 47% of them ranked the issue as a key concern.

Oncologists, cardiologists, neurologists, dermatologists and pulmonologists all ranked safety evidence of a drug to be more important than cost.

Different types of patients also play a part

The disparity can be explained.

“This is likely because of the nature of the visit with the primary care doctor and what that may entail,” explained a spokeswoman for the research firm. “Imagine you’re a primary care physician who needs to keep track of a huge range of potential diagnoses and cures. You have a patient complaining of persistent GI issues. Could it be a food allergy, constipation, Crohn’s disease? It’s likely you’d want to start by prescribing a lower-cost medication addressing the most likely culprit,” she elaborated.

The possibility of pushback from the patient who may feel concerned about cost is also high, compared to a patient with a chronic or life-threatening illness, the spokeswoman added.

A certain amount of speculation is reflected in her statement; however, the main takeaway from all the findings is that it places more of the onus on patients to talk to their doctors about affordability when reviewing treatment options.

Other factors affecting physicians' decisions

A variety of other factors could possibly explain the paradox such as keeping up with research literature, attending conferences, following medical news and staying abreast of clinical trials. These doctors may be tempted to try new drugs or devices that are usually pricier.

In 2007, a systematic review showed that doctors could be ignorant of the costs of prescription drugs as well ̶ underestimating prices of expensive drugs, overestimating the prices of inexpensive ones and not understanding the extent of price difference between cheap and pricey drugs.

The relationship with drug sales reps is also another factor. A study last month showed that doctors tended to order fewer promoted brand-name drugs, which tend to be pricier, and used more generic version instead when hospitals put pharmaceutical sales representatives on a shorter leash.

Experts suggest that doctors need to be educated to deliver "high-value, cost-conscious care" and to do it in a holistic method. Flashing one point of data most likely will not do the job, as knowledge transmission needs to be accompanied by "reflective practice and a supportive environment". Efforts to understand why physicians order tests regardless of cost needs to be put forward.

Value as defined by the quality and impact relative to the cost should instead be focused on – so that it makes more of a difference to physicians and their patients. MIMS

Read more:
Hospital-based doctors more likely to order unnecessary tests or referrals
What the pharmaceutical industry needs: Transparency and rigorous monitoring
Big Pharma found to influence guideline writers, patient advocacy groups and doctors