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Physicians and the Ethical Dilemma of Federal Cuts to Health Care
In about two weeks, we’ll know whether Congress’ 12-member bipartisan “Super Committee” has succeeded. If it can’t find $1.2 trillion in federal deficit reductions over the next decade, we face reductions of the same magnitude as across-the-board cuts.
Either way, we can expect federal funding cuts to impact value decisions at every level of health care decision-making. From individual patients deciding whether to seek care, to large purchasers such as Medicare and public-employee insurance boards determining which benefits to offer, people will ask with increased urgency: “What care is necessary, and what can we afford?”
Meanwhile, our nation’s physicians—who are primarily responsible for recommending “appropriate” care for individual patients in this increasingly cost-constrained environment—will find their work getting much tougher.
As Stanford University health economist Victor Fuchs recently wrote in the New England Journal of Medicine, “When escalating health care expenditures threaten the solvency of the federal government and the viability of the U.S. economy, physicians are forced to re-examine the choices they make in caring for patients.”
While his essay is sobering, his conclusion gives providers caring for patients in integrated group practices reason to take heart because these doctors have a defined and ethical way to control health costs. By contrast, he writes, it is harder for those serving patients in fee-for-service environments.
Fuchs points to the Physician Charter, which most of the nation’s leading medical societies endorsed around 2002. As part of the American College of Physicians group that worked on the Charter, I know it aimed to provide guidance during growing concern over escalating costs. But this was six years before our nation’s financial crisis began and nine years before today’s political stalemate over tax policy. Now physicians need a better compass to address today’s even greater pressure to control cost.
The Charter calls “patient welfare” the most important principle in health care, and states that it should not be compromised by “market forces, social pressures, and administrative exigencies.” It also says physicians must provide care based on “wise and cost-effective management of limited clinical resources.”
Here Fuchs zeroes in on the obvious conflict: “How can a commitment to cost-effective care be reconciled with a fundamental principle of primacy of patient welfare?”
Then he details how the dilemma plays out, including developing expensive technologies and drugs that benefit some (but not all) patients—but are used indiscriminately anyway. Third-party insurance also contributes, shielding patients and doctors from the costs of care. “If a physician is paid on a fee-for-service basis and the patient has open-ended insurance, the scales are tipped in favor of doing as much as possible and against limiting intervention to those that are cost-effective,” Fuchs writes. Who benefits from practicing more cost-effective medicine? In a setting like this, the answer may be obscured.
He contrasts this to practicing “in a setting that has accepted responsibility for the health of a defined population” where the organization receives an annual fee per enrollee. Here, he says, even though all patients are insured, physicians are more likely to practice cost-effective medicine. Ideally, their colleagues are practicing the same way. All told, the resources are used to benefit the defined population, including the physician’s patient. In other words, by coming together in community and facing the real-world limitations of health care resources, providers in such systems can work collectively to make the best decisions possible for individual patient care.
Research plays a major role in this equation. At integrated health plans such as Group Health, Kaiser Permanente, Geisinger Health Systems, HealthPartners, and elsewhere, teams of scientific investigators are collaborating with physicians and administrators to become what the Institute of Medicine calls “learning health care systems.” Here, such teams are evaluating the effectiveness, cost, and safety of various approaches to care, giving providers the evidence they need to serve the best interest of patients and entire populations.
Looking forward, our nation faces tremendous challenges for health care and the economy. Physicians throughout our country need to step forward, engage with researchers and all stakeholders to build more learning health care systems. Knowledge gained in such systems will prove useful for the nation as a whole.
Dr. Eric Larson is Vice President for Research, Group Health and Executive Director of the Group Health Research Institute. A graduate of Harvard Medical School, he trained in internal medicine at Beth Israel Hospital, in Boston, completed a Robert Wood Johnson Clinical Scholars and MPH program at the University of Washington, and then served as Chief Resident of University Hospital in Seattle. He served as Medical Director of University of Washington Medical Center and Associate Dean for Clinical Affairs from 1989-2002.
Dr. Larson’s research spans a range of general medicine topics and has focused on aging and dementia, including a long running study of aging and cognitive change set in Group Health Cooperative – The UW/Group Health Alzheimer’s Disease Patient Registry/Adult Changes in Thought Study. He has served as President of the Society of General Internal Medicine, Chair of the OTA/DHHS Advisory Panel on Alzheimer’s Disease and Related Disorders and was Chair of the Board of Regents (2004-05), American College of Physicians. He is an elected member of the National Academy of Sciences Institute of Medicine.
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