The impact of consumer-directed health plans and patient socioeconomic status on physician recommendations for colorectal cancer screening

BACKGROUND: Consumer-directed health plans are increasingly common, yet little is known about their impact on physician decision-making and preventive service use. OBJECTIVE: To determine how patients' deductible levels and socioeconomic status may affect primary care physicians' recommendations for colorectal cancer screening. DESIGN, SETTING, AND PARTICIPANTS: Screening recommendations were elicited using hypothetical vignettes from a national sample of 1,500 primary care physicians. Physicians were randomized to one of four vignettes describing a patient with either low or high socioeconomic status (SES) and either low- or high-deductible plan. Bivariate and multivariate analyses were used to examine how recommendations varied as a function of SES and deductible. OUTCOME MEASURES: Rates of recommendation for home fecal occult blood testing, sigmoidoscopy, colonoscopy, and inappropriate screening, defined as no screening or office-based fecal occult blood testing. RESULTS: A total of 528 (49%) eligible physicians responded. Overall, 7.2% of physicians recommended inappropriate screening; 3.2% of patients with high SES in low-deductible plans received inappropriate screening recommendations and 11.4% of patients with low SES in high-deductible plans for an adjusted odds ratio of 0.22 (0.05-0.89). The odds of a colonoscopy recommendation were over ten times higher (AOR 11.46, 5.26-24.94) for patients with high SES in low-deductible plans compared to patients with low SES in high-deductible plans. Funds in medical savings accounts eliminated differences in inappropriate screening recommendations. CONCLUSIONS: Patient SES and deductible-level affect physician recommendations for preventive care. Coverage of preventive services and funds in medical savings accounts may help to mitigate the impact of high-deductibles and SES on inappropriate recommendations.