title: Do Health Reforms Impact Cost Consciousness of Health Care Professionals? Results from a Nation-Wide Survey in the Balkans.
abstract: BACKGROUND
  Serbia, as the largest market of the Western Balkans, has entered socioeconomic transition with substantial delay compared to most of Eastern Europe. Its health system reform efforts were bold during the past 15 years, but their results were inconsistent in various areas. The two waves of global recession that hit Balkan economies ultimately reflected to the financial situation of healthcare. Serious difficulties in providing accessible medical care to the citizens became a reality. A large part of the unbearable expenses actually belongs to the overt prescription of pharmaceuticals and various laboratory and imaging diagnostic procedures requested by physicians. Therefore, a broad national survey was conducted at all levels of the healthcare system hierarchy to distinguish the ability of cost containment strategies to reshape clinician's mindsets and decision-making in practice.
  
  
  OBJECTIVE
  Assessment of healthcare professionals' judgment on economic consequences of prescribed medical interventions and evaluation of responsiveness of healthcare professionals to policy measures targeted at increasing cost-consciousness.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  A nationwide cross-sectional survey was conducted through a hierarchy of medical facilities across diverse geographical regions before and after policy action, from January 2010 to April 2013. In the middle of the observed period, the National Health Insurance Fund (RFZO) adopted severe cost-containment measures. Independently, pharmacoeconomic guidelines targeted at prescribers were disseminated. Administration in large hospitals and community pharmacies was forced to restrict access to high budget-impact medical care. Economic Awareness of Healthcare Professionals Questionnaire-29 (EAHPQ-29), developed in Serbian language, was used in face-to-face interviews. The questionnaire documented clinician's attitudes on: Clinical-Decision-Making-between-Alternative-Interventions (CDMAI), Quality-of-Health-Care (QHC), and Cost-Containment-Policy (CCP). The authors randomly and anonymously recruited 2000 healthcare experts, with a total of 1487 responding; after eliminating incomplete surveys, 649 participants were considered before and 651 after policy intervention.
  
  
  RESULTS
  Dentists (1.195±0.560) had a higher mean CDMAI score compared to physicians (1.017±0.453). The surgical group compared to the internist group had a higher total EAHPQ-29 score, CCP score and CDMAI score. Policy intervention had a statistically significant negative impact on the QHC score (F=4.958; df=1; p=0.027). There was no substantial impact of policy interventions on professional behavior and judgment with regard to the CDMAI, CCP, and total EAHPQ-29 scores.
  
  
  CONCLUSIONS
  Although cost savings were forcibly imposed in practice, the effects on clinical decision-making were modest. Clinicians' perceptions of quality of medical care were explained in a less effective manner due to the severely constrained resources allocated to the providers. This pioneering effort in the Balkans exposes the inefficiency of current policies to expand clinicians' cost consciousness.
authors.affiliation: Health Economics and Pharmacoeconomics, University of Kragujevac, Faculty of Medical Sciences, Kragujevac, Serbia.
authors.forename: Mihajlo
authors.initials: M
authors.lastname: Jakovljevic
authors.affiliation: Department of Quality Assurance, Health Centre, Valjevo, Serbia.
authors.forename: Mira
authors.initials: M
authors.lastname: Vukovic
authors.affiliation: Department of Epidemiology & Community Health, New York Medical College, School of Health Sciences & Practice, New York, USA.
authors.forename: Chia-Ching
authors.initials: CC
authors.lastname: Chen
authors.affiliation: Institute of Pharmacy, Military Medical Academy, Belgrade, Serbia.
authors.forename: Mirjana
authors.initials: M
authors.lastname: Antunovic
authors.affiliation: Centre for Clinical Pharmacology, Military Medical Academy, Belgrade, Serbia.
authors.forename: Viktorija
authors.initials: V
authors.lastname: Dragojevic-Simic
authors.affiliation: Department of Pharmacy, Nis University Faculty of Medicine, Nis, Serbia.
authors.forename: Radmila
authors.initials: R
authors.lastname: Velickovic-Radovanovic
authors.affiliation: Psychiatric Clinic, University Clinical Center Vojvodina, Novi Sad, Serbia.
authors.forename: Mladenovic Siladji
authors.initials: MS
authors.lastname: Djendji
authors.affiliation: Department of Statistics, University of Kragujevac Faculty of Medical Sciences, Kragujevac, Serbia.
authors.forename: Nikola
authors.initials: N
authors.lastname: Jankovic
authors.affiliation: Diagnostic Radiology Service, University Clinical Center Kragujevac, Kragujevac, Serbia.
authors.forename: Ana
authors.initials: A
authors.lastname: Rankovic
authors.affiliation: Centre for Clinical Pharmacology, Military Medical Academy, Belgrade, Serbia.
authors.forename: Aleksandra
authors.initials: A
authors.lastname: Kovacevic
authors.affiliation: Institute of Pharmacy, Military Medical Academy, Belgrade, Serbia.
authors.forename: Marko
authors.initials: M
authors.lastname: Antunovic
authors.affiliation: Department of Pharmacy, University of Kragujevac Faculty of Medical Sciences, Kragujevac, Serbia.
authors.forename: Olivera
authors.initials: O
authors.lastname: Milovanovic
authors.affiliation: Department of Pharmacy, University of Kragujevac Faculty of Medical Sciences, Kragujevac, Serbia.
authors.forename: Veroljub
authors.initials: V
authors.lastname: Markovic
authors.affiliation: Department of Economics, Rutgers University, the State University of New Jersey, New Jersey, USA.
authors.forename: Babu N S
authors.initials: BN
authors.lastname: Dasari
authors.affiliation: Department of Economics, Rutgers University, the State University of New Jersey, Center for Children and Childhood Studies, New Jersey, USA.
authors.forename: Tetsuji
authors.initials: T
authors.lastname: Yamada
keywords: Awareness; I180 Health; cost control; economics; government; health care reform; hospital costs; medical; physicians; policy; practice patterns