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Trying to Make Professionalism Real And Parsimonious
There has been a lot of both positive and negative reaction by physicians and others to the recently released American College of Physicians (ACP) Ethics Manual that states:
“Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”
Some have reacted to the notion of “parsimonious care” as it relates to cost effectiveness. Others have reacted to the idea of equitable availability of resources. The latter concept refers to a societal obligation to treat patients within a just system. ACP’s Manual describes the need to provide services to the uninsured and underinsured and not to deny care based on the inability to pay.
To address the issue of “cost-effectiveness,” I refer to the Physician Charter (co-authored by the ACP Foundation, ABIM Foundation and European Federation of Internal Medicine). The Physician Charter calls on the medical profession to “promote justice in health care, including the fair distribution of health care resources.” It goes on to suggest that physicians work “with other physicians, hospitals and payers to develop guidelines for cost-effective care.”
While ACP’s statement may not be introducing a new concept surrounding “parsimonious care,” it does suggest a welcome, increased dialogue on the issue of appropriate use and cost. But most importantly, how do we begin to introduce cost as a consideration in clinical decision-making without the dialogue dissolving into accusations that we are talking about “rationing” care?
The following are steps I recommended to get us from rhetoric to action:
1) Start having conversations about tests and procedures that do more harm than good. The Choosing Wisely campaign, an initiative of the ABIM Foundation, aims to engage nine specialty society partners in the identification of five tests or procedures physicians and patients should question. Patients and physicians will be given tools to engage in conversations about overuse and misuse. This gets us closer to spreading the word that more care is not always better care, and begins to inform and change the environment in which these conversations occur.
2) Engage patients, consumers, clinicians and payers/purchasers in conversations about what is meant by “cost-effective” – what it is, what it is not, its complexity and shortcomings. Multi-stakeholders need to converge to begin these in-depth conversations and education.
3) Develop language for communicating the attributes of cost-effectiveness to physicians and patients. Previously used language has caused fear-mongering about rationing of care. We need to find commonly agreed upon words and phrases if we are to have a meaningful conversation free of rhetoric designed to dismantle attempts at improvement.
4) Engage the public and policymakers in cost-effectiveness and how it might be introduced in clinical decision-making and possibly in decisions regarding coverage of new tests and procedures that have enormous costs but little value in improving the health.
5) Introduce cost-effectiveness and economics in the education and training of clinicians. Most often physicians-in-training are educated on what tests or procedures to order but nothing on their relative benefit or costs.
6) Align payment by third party payers with high value, cost-effective care. Payments are currently based on volume of services, not what impact they have on diagnosing a problem or how it restores or maintains health.
I applaud ACP and other specialty societies for raising the issue – it demonstrates real professionalism, courage and leadership. I look forward to going from rhetoric and debate (that often borders on hysteria) to implementation and action. Time is running out – the U.S. health care system is no longer economically sustainable. We must take the next step before it’s too late.
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