Peter A Ubel

University of Stirling, Stirling, Scotland, United Kingdom

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Publications (323)2263.91 Total impact

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    ABSTRACT: Background: More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. Objective: We sought to determine how often patients and physicians discuss health care costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. Design: Retrospective analysis of dialogue from 1755 outpatient visits in community-based practices nationwide from 2010 to 2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. Results: Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median duration, 68 s). We identified 4 strategies to lower costs without changing the care plan. They were, in order of overall frequency: 1) changing logistics of care, 2) facilitating co-pay assistance, 3) providing free samples, and 4) changing/adding insurance plans. We also identified 4 strategies to reduce costs by changing the care plan: 1) switching to lower-cost alternative therapy/diagnostic, 2) switching from brand name to generic, 3) changing dosage/frequency, and 4) stopping/withholding interventions. Strategies were relatively consistent across health conditions, except for switching to a lower-cost alternative (more common in breast oncology) and providing free samples (more common in depression). Limitation: Focus on 3 conditions with potentially high out-of-pocket costs. Conclusions: Despite price opacity, physicians and patients discuss a variety of out-of-pocket cost reduction strategies during clinic visits. Almost half of cost discussions mention 1 or more cost-saving strategies, with more frequent mention of those not requiring care-plan changes.
    No preview · Article · Jan 2016 · Medical Decision Making
  • Peter A Ubel

    No preview · Article · Dec 2015 · JAMA The Journal of the American Medical Association
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    ABSTRACT: Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care.
    No preview · Article · Nov 2015 · Annals of internal medicine
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    ABSTRACT: Objectives: Patients with cancer can experience substantial financial burden. Little is known about patients' preferences for incorporating cost discussions into treatment decision making or about the ramifications of those discussions. The objective of this study was to determine patient preferences for and benefits of discussing costs with doctors. Study Design: Cross-sectional, survey study. Methods: We enrolled insured adults with solid tumors on anticancer therapy who were treated at a referral cancer center or an affiliated rural cancer clinic. Patients were surveyed at enrollment and again 3 months later about cost discussions with doctors, decision making, and financial burden. Medical records were abstracted for disease and treatment data. Logistic regression investigated characteristics associated with greater desire to discuss costs. Results: Of 300 patients (86% response rate), 52% expressed some desire to discuss treatment-related out-of-pocket costs with doctors and 51% wanted their doctor to take costs into account to some degree when making treatment decisions. However, only 19% had talked to their doctor about costs. Of those, 57% reported lower out-of-pocket costs as a result of cost discussions. In multivariable logistic regression, higher subjective financial distress was associated with greater likelihood to desire cost discussions (odds ratio [OR], 1.22; 95% CI, 1.10-1.36). Nonwhite race was associated with lower likelihood to desire cost discussions (OR, 0.53; 95% CI, 0.30-0.95). Conclusions: Patients with cancer varied in their desire to discuss costs with doctors, but most who discussed costs believed the conversations helped reduce their expenses. Patient-physician cost communication might reduce out-of-pocket costs even in oncology where treatment options are limited.
    No preview · Article · Sep 2015 · The American journal of managed care
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    ABSTRACT: Little is known about how physicians present diagnosis and treatment planning in routine practice in preference-sensitive treatment decisions. We evaluated completeness and quality of informed decision making in localized prostate cancer post biopsy encounters. We analyzed audio-recorded office visits of 252 men with presumed localized prostate cancer (Gleason 6 and Gleason 7 scores) who were seeing 45 physicians at 4 Veterans Affairs Medical Centers. Data were collected between September 2008 and May 2012 in a trial of 2 decision aids (DAs). Braddock's previously validated Informed Decision Making (IDM) system was used to measure quality. Latent variable models for ordinal data examined the relationship of IDM score to treatment received. Mean IDM score showed modest quality (7.61±2.45 out of 18) and high variability. Treatment choice and risks and benefits were discussed in approximately 95% of encounters. However, in more than one-third of encounters, physicians provided a partial set of treatment options and omitted surveillance as a choice. Informing quality was greater in patients treated with surveillance (β = 1.1, p = .04). Gleason score (7 vs 6) and lower age were often cited as reasons to exclude surveillance. Patient preferences were elicited in the majority of cases, but not used to guide treatment planning. Encounter time was modestly correlated with IDM score (r = 0.237, p = .01). DA type was not associated with IDM score. Physicians informed patients of options and risks and benefits, but infrequently engaged patients in core shared decision-making processes. Despite patients having received DAs, physicians rarely provided an opportunity for preference-driven decision making. More attention to the underused patient decision-making and engagement elements could result in improved shared decision making. © The Author(s) 2015.
    No preview · Article · Aug 2015 · Medical Decision Making
  • Steven K Dallas · Peggy J Liu · Peter A Ubel
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    ABSTRACT: The United States Food and Drug Administration recently announced that the serving sizes on the Nutrition Facts labels for many products will be increased, but the effect of these increases remains unclear. The present research examined consumers' interpretation of the meaning of serving size information (study 1) and tested whether exposing consumers to the increased serving sizes of the proposed Nutrition Facts label leads consumers to serve and purchase more food for themselves and others (studies 2-4). Study 1 (N = 101; 44.7% female) tested what consumers believe the serving sizes on Nutrition Facts labels refer to, and the majority of participants (over 78%) incorrectly believed that the serving sizes refer to how much food can or should be consumed in one sitting as part of a healthy diet. Study 2 (N = 51; 41.2% female) tested how exposure to the current versus proposed Nutrition Facts label influences the amount of food that consumers serve themselves, and studies 3 (N = 60; 46.7% female) and 4 (N = 61; 48.2% female) assessed how exposure to the current versus proposed label influences the amount of food that people serve and purchase for others. In studies 2-4, the proposed label (vs. the current label) led consumers to serve themselves 41% more cookies (study 2); serve 27% more cheese crackers to another person (study 3); and buy 43% more lasagnas for others and divide a lasagna into 22% larger slices (study 4). The results suggest that the proposed Nutrition Facts label's increased serving sizes may lead people who use this information as a reference to serve more food to themselves and others. Copyright © 2015 Elsevier Ltd. All rights reserved.
    No preview · Article · Aug 2015 · Appetite
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    Peter A Ubel

    Preview · Article · Jun 2015 · New England Journal of Medicine
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    Full-text · Article · Mar 2015 · Journal of Oncology Practice
  • Peter A Ubel
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    ABSTRACT: In the last few years, the U.S. health care system has seemingly been gripped by "back to the nineties" fever. But there is a notable change in professional debates about how to better control health care costs. Discussion of health care rationing, which was hotly debated in the nineties, has become much more muted. Is health care rationing passé? I contend that debates about health care rationing have waned not because the need to ration has dwindled nor because ethical debates about how or whether to ration have been resolved. They have declined because the word "rationing," and unrelated concepts such as cost-effectiveness analysis, have been replaced by terms-"parsimony," "value," and "CER"-that are not burdened by emotional and historical baggage. Sometimes the best way to promote healthy moral debate is to turn to new words that don't carry the burden of past debates. © 2015 The Hastings Center.
    No preview · Article · Mar 2015 · Hastings Center Report
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    Peter A Ubel · David A Comerford · Eric Johnson
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    ABSTRACT: One component of the Affordable Care Act (ACA) was to create an individual market for health insurance plans. The majority of these plans are offered as part of health insurance exchanges and purchased via Web sites. When designing health insurance exchange Web sites, states should be mindful of the effects of language, layout, organization, and other display details on consumers’ ability to choose the plan that best suited them. The authors of this article conducted various tests to determine how certain design and language factors changed the way people selected health care plans. The authors asked a group of people to choose between plans labeled “gold” and “bronze,” with the gold plan having higher monthly premiums and lower out-of-pocket costs than bronze in one group and reversing that assignment in another group. Both groups said they preferred gold plans despite the fact that the “gold” plans were on the opposite ends of the spectrum. Listing plans in a particular order, by premiums or other factors for example, could also influence the way consumers selected plan, as could identifying plans by weekly premiums rather than monthly. One study conducted by an author found that included educational definitions and calculators on exchange Web sites improved the decisions made by consumers. The article concluded that designers should work with researchers to investigate the design’s effect on decision making. It is not recommended that plans be labeled with terms such as “gold” or “bronze.” It is not advised to list an overwhelming amount of financial information in complex tables, but rather site designers should aim to help consumers approximate annual costs under best- and worst-case scenarios.
    Preview · Article · Feb 2015 · New England Journal of Medicine
  • Peter A Ubel · David A Asch
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    ABSTRACT: As hard as it may be for clinicians to adopt new practices, it is often harder for them to "de-innovate," or give up old practices, even when new evidence reveals that those practices offer little value. In this article we explore recent controversies over screening for breast and prostate cancer and testing for sleep disorders. We show that these controversies are not caused solely by a lack of clinical data on the harms and benefits of these tests but are also influenced by several psychological biases that make it difficult for clinicians to de-innovate. De-innovation could be fostered by making sure that advisory panels and guideline committees include experts who have competing biases; emphasizing evidence over clinical judgment; resisting "indication creep," or the premature extension of innovations into unproven areas; and encouraging clinicians to explicitly consider how their experiences bias their interpretations of clinical evidence. Project HOPE—The People-to-People Health Foundation, Inc.
    No preview · Article · Feb 2015 · Health Affairs
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    ABSTRACT: Editorial summary Failure to consider lessons from behavioral economics in the case of whole genome sequencing may cause us to run into the ‘last mile problem’ - the failure to integrate newly developed technology, on which billions of dollars have been invested, into society in a way that improves human behavior and decision-making.
    Full-text · Article · Jan 2015 · Genome Medicine
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    Peter A Ubel
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    ABSTRACT: While rule revisions to reduce geographic disparities in U.S. organ distribution are debated, some patients have taken it upon themselves to travel to areas where organs are more abundant, and some companies have been created to enable more patients to follow suit.
    Preview · Article · Dec 2014 · New England Journal of Medicine
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    ABSTRACT: Three laboratory experiments and a field experiment in a restaurant demonstrate that neither a price surcharge nor an unhealthy label is enough on its own to curtail the demand for unhealthy food. However, when the two are combined as an unhealthy label surcharge, they reduce demand for unhealthy food. The authors also show that the unhealthy label is as effective for women as the unhealthy label surcharge, whereas it backfires for men, who order more unhealthy food when there is an unhealthy label alone. The authors demonstrate that an unhealthy surcharge, which highlights both the financial disincentive and potential health costs, can significantly drive healthier consumption choices. From a policy and government perspective, if the goal is to reduce demand for unhealthy food, increasing the transparency of the health rationale for any financial disincentive is necessary to effectively lower unhealthy food consumption.
    Full-text · Article · Dec 2014 · Journal of Marketing Research
  • Wynn G Hunter · Peter A Ubel

    No preview · Article · Dec 2014
  • J S Blumenthal-Barby · Amy L McGuire · Peter A Ubel

    No preview · Article · Oct 2014 · Annals of internal medicine
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    ABSTRACT: Purpose: Even when patients are educated about their treatment choices, they are often not activated or able to engage with their physicians regarding their treatment values, goals, or preferences. This study tested whether a DVD that taught and modeled shared decision techniques making to prostate cancer patients would improve their self-efficacy for communicating effectively with their physicians (urologists and radiation oncologists) and their report of whether they engaged in shared decision making. Methods: 564 men undergoing a prostate biopsy were recruited and randomized to receive either a decision aid booklet only or a decision aid booklet + DVD. The DVD follows a patient going through a typical prostate cancer diagnosis visit and modeled shared decision making strategies such as how to better ask questions, question physician recommendations (against active surveillance) and express their values and treatment preferences. Participants who were diagnosed with localized prostate cancer (N=200) completed surveys at recruitment, before learning their diagnosis, and then following their treatment discussion with their medical team. Primary outcome variables included perceived and actual ability to: ask questions, ask for a second opinion, ask for a referral to a radiation oncologist, bring questions, take notes, and participate in shared decision making. Results: Participants who received the DVD reported stronger intentions to: ask questions (p=0.001), ask for second opinions from another urologist (p=0.001), ask for a referral to see a radiation oncologist (p=0.006), take notes (p=0.001), and to participate in shared decision making (p=0.006). However, when surveyed after meeting with their physicians there were no differences in patients’ perceptions of performing these behaviors with either their urologist or their radiation oncologist (measured separately) during their clinic visit(s). Conclusions: Even when patients intend and feel confident about engaging in shared decision making, it is often difficult for them to feel they have succeeded in doing so. It is crucial that we explore methods to better help patients participate in shared decision making at the level they desire.
    No preview · Conference Paper · Oct 2014
  • Peter A Ubel

    No preview · Article · Sep 2014 · The American Journal of Bioethics
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    ABSTRACT: BACKGROUND Resources, including space, equipment, funding, personnel, and protected time, are essential in academic medical careers. Negotiation often plays a key role in the distribution of these resources. OBJECTIVE This study explored gender differences in resources, negotiation behaviors, and negotiation outcomes in a sample of career development awardees. DESIGN Postal survey of a cohort of 1,708 clinician-researchers with responses from 1,275 (75 % response rate). PARTICIPANTS Researchers who received NIH K08 or K23 awards between 2006 and 2009. MAIN MEASURES We analyzed gender differences in resources, negotiation behaviors, and negotiation outcomes, using regression models adjusted for race, K award type, K award year, degree, academic rank, specialty, and institutional funding. KEY RESULTS Over one-fifth of respondents reported inadequate access to research space and one-third had asked for increased space or equipment. Perceived adequacy of these physical resources did not differ significantly by gender, but a higher proportion of women reported inadequate access to grants administrators (34.8 %) and statistical support (49.9 %) than men (26.9 %; p = 0.002 and 43.4 %; p = 0.025, respectively). Women were more likely to have asked for reduction in clinical hours (24.1 % vs. 19.3 %; p = 0.02) and to have raised concerns about unfair treatment (50.2 % vs. 38.2 %; p p = 0.09), and among those who had asked for increased resources, the likelihood that the request was granted did not differ significantly by gender. CONCLUSION Many career development award recipients report resource needs and negotiate for increased resources. Gender differences in perceived access to research support personnel exist even in this select cohort of K awardees. Institutions should provide appropriate training in negotiation and ensure adequate and equitable distribution of resources to promote academic success.
    No preview · Article · Aug 2014 · Journal of General Internal Medicine
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    Kevin R. Riggs · Peter A Ubel
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    ABSTRACT: New technology is a major driver of health care inflation. One contributor to this inflation is indication creep, the diffusion of interventions that have been proven beneficial in specific patient populations into untested broader populations who may be less likely to benefit. Professional societies sometimes promote indication creep, as we illustrate with the case of therapeutic hypothermia after cardiac arrest. Professional societies are in a unique position to limit indication creep. We propose that, at a minimum, professional societies should refrain from recommending new diagnostic and therapeutic technologies in their guidelines until they have been proven beneficial in the targeted populations. In some circumstances, professional societies could be more active in combatting indication creep, either recommending against expanded use of clinical interventions when evidence is lacking, or coordinating efforts to collect data in these broader populations.
    Preview · Article · Aug 2014 · Journal of General Internal Medicine

Publication Stats

9k Citations
2,263.91 Total Impact Points


  • 2015
    • University of Stirling
      Stirling, Scotland, United Kingdom
  • 2004-2015
    • Duke University
      • Fuqua School of Business
      Durham, North Carolina, United States
    • University of Toledo
      • Department of Psychology
      Toledo, Ohio, United States
  • 2014
    • University of North Carolina at Chapel Hill
      North Carolina, United States
    • Duke University Medical Center
      Durham, North Carolina, United States
  • 1998-2011
    • University of Michigan
      • • Medical School
      • • Division of General Medicine
      • • Department of Psychology
      Ann Arbor, Michigan, United States
  • 2010
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2008
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
  • 2001-2008
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 2007
    • Northwestern University
      Evanston, Illinois, United States
    • National Institutes of Health
      • Division of Cancer Control and Population Sciences
      Bethesda, MD, United States
  • 2006
    • Icahn School of Medicine at Mount Sinai
      Borough of Manhattan, New York, United States
  • 1997-2006
    • Carnegie Mellon University
      • • Department of Social and Decision Sciences
      • • Department of Psychology
      • • Department of Engineering and Public Policy
      Pittsburgh, Pennsylvania, United States
    • University of Maryland, Baltimore
      • Department of Pediatrics
      Baltimore, MD, United States
  • 1995-2005
    • University of Pennsylvania
      • • Center for Clinical Epidemiology and Biostatistics
      • • Department of Medicine
      • • "Leonard Davis" Institute of Health Economics
      • • Division of General Internal Medicine
      Philadelphia, Pennsylvania, United States
  • 2003
    • University of Chicago
      Chicago, Illinois, United States
  • 1998-2003
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2002
    • The Children's Hospital of Philadelphia
      • Center for Outcomes Research
      Filadelfia, Pennsylvania, United States
  • 2000
    • Queen Elizabeth Hospital Birmingham
      Birmingham, England, United Kingdom
  • 1997-2000
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 1995-2000
    • United States Department of Veterans Affairs
      Бедфорд, Massachusetts, United States
  • 1999
    • University Pompeu Fabra
      Barcino, Catalonia, Spain
  • 1996
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States
    • Hospital of the University of Pennsylvania
      • Division of Infectious Diseases
      Philadelphia, Pennsylvania, United States
  • 1993
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States