post by Paul Kelleher
Just by mentioning the importance of cost-effectiveness, the policy breaks important new ground. The cost problem is getting worse all the time. We’ve got to find a way to break that logjam.
It is, however, worth pointing out that this is actually not new ground for the American College of Physicians. In 2002, the the American College of Physicians–American Society of Internal Medicine (ACP–ASIM), the European Federation of Internal Medicine, and the American Board of Internal Medicine jointly released "A Physician Charter", which was intended a sort of new Hippocratic Oath. According to health economist Victor Fuchs, the Physician Charter "has been adopted by physicians’ organizations that include a majority of U.S. physicians."
The Physician Charter includes three Fundamental Principles and 10 Commitments. The three principles are: a Principle of Primacy of Patient Welfare, a Principle of Patient Autonomy, and a Principle of Social Justice. Among the commitments (and presumably justified by the Principle of Social Justice) is this one:
Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others.
A couple comments. First, notice that physicians are called upon to work with other stakeholders on the development of "guidelines for cost-effective care." My experience in talking with physicians (and physicians in training) is that they would rather be constrained by thoughtful, collaboratively developed treatment and diagnostic protocols than to be expected to "practice cost-effective medicine" in a discretionary manner at the bedside. Physicians would then not feel like they were "playing God," and would view themselves instead as providing "appropriate medical care" when they refuse to treat/screen/refer someone who does not fit a cost-effective protocol's indications.
Second, notice that what the charter does expect physicians themselves to do is to avoid the "provision of unnecessary services" through "scrupulous avoidance of superfluous tests and procedures." I have already suggested that this exhausts what the ACP meant when they encouraged physicians to practice "parsimonious care" in the Ethics Manual. (On "parsimonious," see Dr. Don Goldmann's comments in the round-up.) Again, the reflective view of physicians seems to be that while the doctor's job is to avoid providing harmful or unnecessary care, an understanding of what amounts to justified cost-effective care is more difficult to grasp, and should await a collaboration between different stakeholders with the power to shape cost-effective policy in a politically legitimate way.
A final theme in the round-up on ACP's Ethics Manual is that the Manual does not explain what it means to practice cost-effective medicine or how physicians are supposed to learn how to do it (this problem arises for the Physician Charter as well). Dr. Goldmann articulates what would surely be the first step envisioned by the Manual:
The true cost and effectiveness of a given treatment should be made available and utilized by clinicians as part of their decision making process. What I would love to see is increased pressure on the health care industry to be transparent about the true cost of what they’re making available to their providers and not make it so obscure that you can’t figure it out.
But history suggests that simply knowing the costs will not be enough. Here is Steven Schroeder:
During the administration of President Jimmy Carter, hospital cost containment became a prominent health policy initiative. In response, the hospital industry argued that it could achieve those goals on its own, without government interference. This “voluntary effort” featured physician education as a strategy to produce more rational spending patterns and thereby lower costs. We tested this hypothesis at UCSF, evaluating 3 different educational strategies on the medical and surgical services over a 2-year period. The educational efforts, which included teaching about costs and benefits of various services as well as a detailed cost audit of services ordered by individual residents, were well received. But there was no significant decline in hospital charges compared with control groups. We concluded that—absent major involvement by hospital authority figures or changes in incentives— voluntary cost containment would fail. Eisenberg and Williams, who conducted similar studies at the University of Pennsylvania, likened voluntary medical cost containment to the fox guarding the chicken coop. Predictably, after Carter lost his reelection to Ronald Reagan in 1980, the voluntary effort vanished.
All this suggests that there is great virtue in having cost-effectiveness be a property of policies and protocols, not discretionary physician behavior.