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. Craig Evan Pollack and Giridhar Mallya: The authors contributed equally to this publication.