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The Medical Professionalism Blog

The Necessity of Stewardship

This post was written by Dr. John Benson, Jr., President Emeritus, American Board of Internal Medicine and ABIM Foundation.

The prospect of health care consuming 20% of the GDP by 2020 is unconscionable so corrective actions have enormous urgency.  There are some initiatives underway that address this issue and still others that need to happen in order to bring stewardship to the forefront of individual physicians and organizations at-large.

Through its admirable Choosing Wisely® campaign, the ABIM Foundation has promulgated the concept of stewardship of limited resources—especially unnecessary, even harmful, costs—as a clinical competence to be stressed to trainees. None too soon, especially since only 36% of physicians polled in 2013 feel they are responsible for rising costs or their reduction. Obvious proof that there is so much more ground to cover in this area.

As a start:

  • Some teaching hospital administrators, who see Graduate Medical Education’s acolytes as a risk to their current modus operandi, must stop acting as competitors in a local technology arms race: pricing services without relationship to costs, skimping on nurse/inpatient ratios, counting outpatient clinics as losers and regarding premature readmissions as revenue.
  • ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC.
  • ACP could grade use of resources through MKSAP questions.
  • CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations.
  • Educators, if forced to adhere to stricter ACGME’s accreditation standards, can reward suitable ordering behavior by trainees or require meaningful interventions.

The time is well past exhortation. The issue has been recognized for decades. Hard choices and penalties must go beyond training the next generation. 2020 is closing in.

1 Comment to The Necessity of Stewardship

  • Howard c. Mandel MD FACOG's Gravatar Howard c. Mandel MD FACOG
    February 20, 2014 at 4:46 pm | Permalink

    I respectfully disagree. Why is 20% GDP bad? Would Dr. Benson prefer that America spends more of its GDP making missiles, bombs and other devices that wound and kill? Would he prefer, that we spend it on unnecessary consumer products? Bigger cars that burn fuel? Coke, Pepsi and other high caloric beverages? What is important is that America is healthy. What is important is the Americans are free and have liberty. People should be free to spend their money as they see fit. If they want to spend it on health, so be it. Paternalistic one sized fits all approaches are not the way to go. “Corrective actions?”—sounds more like President Putin or Chairman Mao than America. Doctors have responsibilities to their individual patients; they have a fiduciary responsibility to educate regarding pros/cons and costs and benefits. Money should never be wasted but remember much of the health care GDP goes back into the economy creating jobs and stabilizing local economies. If it improves a patient’s life and helps the economy it is better than bridges to nowhere and other ways our government wastes billions of dollars. Does California really need a high speed rail to Modesto?

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