PHYSICIAN RESPONSE TO PATIENT INSURANCE STATUS IN AMBULATORY CARE CLINICAL DECISION-MAKING - IMPLICATIONS FOR QUALITY OF CARE

OBJECTIVES. Individuals without health insurance in general receive fe wer health services and are more likely than insured patients to exper ience poor outcomes. The main goal of this research was to study wheth er physicians' clinical recommendations vary for insured and uninsured patients, implying that physicians' choices of care may mediate insur ance-related differences in health care use. METHODS. The authors desi gned clinical scenarios that describe routine decisions encountered by primary care physicians in ambulatory settings. Scenarios were design ed to include discretionary, nondiscretionary, preventive, and diagnos tic/therapeutic services. Insurance status of patients was indicated a s either insured or uninsured for the service under consideration. Sce narios were presented to a nationally representative sample of primary care physicians (n = 1182) as part of the American Medical Associatio n 1992 Socioeconomic Monitoring System Survey. Physicians were assigne d randomly to receive eight scenarios in which patients were either in sured or uninsured. For each scenario, physicians were asked to indica te the percentage of patients for whom they would recommend a given se rvice. RESULTS. After controlling for variables associated with nonres ponse, we found that physicians who were presented scenarios with insu red patients recommended services for 72% of patients, and physicians who were presented scenarios with uninsured patients recommended the s ame services for 67% of patients (P < 0.001). Physicians recommended b oth discretionary services (50% versus 42%; P < 0.001) and nondiscreti onary services more often for insured than uninsured patients (93% ver sus 91%; P < 0.05). CONCLUSIONS. In self-reports, physicians are more likely to recommend services for insured than for uninsured patients, and more so when services are discretionary. This provides evidence th at physicians' recommendations may be important mediators of insurance -related variation in the use of health-care services. Higher rates of use among the insured may not always reflect higher quality of care, particularly when the service is discretionary in nature.