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MarketWatch Discretionary Decision Making By Primary Care

Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians’ clinical judgment in discretionary settings. [Health Affairs 27, no. 3 (2008): 813–823; 10.1377/hlthaff.27.3.813] H e a lt h c a r e s p e n d i n g in the United States is the highest in the world and continues to grow at a rate of 7 percent per year.1 Such liberal health care spending fails, however, to provide the country with the best health in the world.2 Even within the United States—where per capita spending varies more than twofold between the lowestand highest-spending regions— higher spending appears to result, if anything, in slightly lower quality and worse outcomes.3 U.S. regions with the highest spending levels do not achieve lower mortality, nor do they show greater improvements in mortality over time.4 Higher spending is also not associated with better access to care, patient satisfaction, or physicians’ ability to provide high-quality care.5 These findings underscore the serious problem of wasteful—and possibly harmful—overuse within the U.S. health