Thursday, September 8, 2011

"The Doctor's Dilemma": Balancing needs of individual patients and responsible stewardship of health resources

On August 25, 2011, in What is the ethical role for physicians in the "business" of health care?, I cited the commentary of Reuben and Cassel in JAMAPhysician stewardship of health care in an era of finite resources”. They identify the various levels at which physicians, physician groups, payers, and government can act to influence the cost/benefit of health care decisions. A similar issue is addressed recently by Victor Fuchs in the New England Journal of Medicine The doctor’s dilemma – what is appropriate care?[1] He notes that:
“…organizations representing more than half of all U.S. physicians have endorsed a ‘Physician Charter’ that commits doctors to ‘medical professionalism in the new millennium.’ The charter states three fundamental principles, the first of which is the “primacy of patient welfare.” It also sets out 10 ‘commitments,’ one of which states that ‘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.’ How can a commitment to cost-effective care be reconciled with a fundamental principle of primacy of patient welfare?”

He goes on to point out that some very expensive technologies benefit people while some do not or even cause harm, and many can benefit some people but are used too widely. He notes that, for example, “U.S. patients, on average, get almost three times as many magnetic resonance imaging  [MRI] scans as Canadian patients; there is no evidence that this large differential can be explained by national differences in the medical condition of patients or that it results in significant national differences in health outcomes.” This doesn’t mean that your MRI was not indicated, nor that there may be Canadians who did not get MRIs that were indicated, but it does mean that on balance we in the US are doing too many for the degree of benefit received.

Fuchs also addresses health insurance. He notes that, as many policy critics have observed, it is often not the patient but a third-party insurer who pays the bills (with the obvious, and glaring, and unconscionable, exception of the uninsured). Therefore, there is much less incentive on the part of the physician to not order expensive tests than if the patient were paying. I know this to be true. With underinsured or uninsured patients, especially in the free clinic I volunteer in, we minimize the use of unnecessary laboratory tests and maximize the use of generic medications on the “$4 list”. These practices are – or should be --  standard care in all patients. Working in the free clinic setting helps teach our volunteer physicians, as well as our volunteer learners, how to practice more cost-effective medicine. But it is not in itself enough. The free clinic still has major problems getting patients the care they need when they do need an MRI or CT, or a medication that is not available generically, or a specialist evaluation, or an expensive test (and for uninsured people virtually all procedures are expensive!), or a hospitalization.

So I also know that Fuch’s next point, criticizing those “policy experts [who]  think that if patients had “more skin in the game” — that is, had less insurance — the problem would be solved. It would not,” is correct as well.  He points out that even those who advocate this position agree there must be a cap on how much a patient should be liable for out-of-pocket (what? $5000?), but that “the extreme skew in annual health care expenditures, with 5% of individuals accounting for 50% of spending in any given year, means that many health care decisions, and especially those involving big-ticket interventions, will be made by and for patients whose costs have exceeded the cap.” The greatest expenditures are for people who need the greatest expenditures, and will be above any acceptable cap. Most people will not be, but most health dollars are not spent on the care of most people; they are spent on this small minority (which, as I have pointed out in Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009, any of us could join at any time!).

In a similar vein, policy pundits, many of the same ones who talk of “skin in the game”, talk about “freedom of choice” and allowing people to choose the kind of insurance that best meets their needs. Right. In Social Determinants, Personal Responsibility, and Health System Outcomes (September 12, 2010), I observe that all of those making such suggestions (the “Four Ps”: pundits, policymakers, politicians, and professionals) are not likely to be ever in the uninsured group. However, even they, even the doctors, have a difficult time figuring out insurance options. So imagine how it is for others, for most people? As highlighted by Lauri Martin and Ruth Parker in JAMA (“Insurance expansion and health literacy”)[2], for those who are less educated, for the 90 million Americans who have limited health literacy, choosing the “right” plan will be virtually impossible, a total crap-shoot.

What this means is that while large-scale comparisons, like MRIs between the US and Canada, can tell us there is something wrong, they cannot solve the problem. Nor can average expenditures of insurance companies, though again they can tell us a lot. But we must realize that we cannot solve the problem by limiting the individual access of individual people rather than attending to medically-appropriate guidelines that apply to all people. We need more fences, and fewer reins[3].

Ultimately, the contradiction between the commitment to the “primacy of patient welfare” and limiting the use of expensive technology is real, and the ability of physician organizations to put them into the same document without helping to explain how to resolve this “dilemma” is sloppy policy, and unfortunately often characteristic of them. Not just of physician organizations; indeed, given the scope of fine-words-with-no-action (or negative action) prevalent in the political sector, these physician groups are to be commended for calling for action. In “Dr. King weeps from his grave”, NY Times, August 26, 2011, Cornel West observes the same distinction between the actions called for and undertaken by the Rev. Martin Luther King, Jr., and the words spoken by those who have built his memorial. “King weeps from his grave. He never confused substance with symbolism. He never conflated a flesh and blood sacrifice with a stone and mortar edifice.”

The conclusions of Dr. Fuchs, and of Drs. Reuben and Cassel, are not very different. We do not need words, or proclamations, we need system change. In Fuchs’ words: “…when physicians are collectively caring for a defined population within a fixed annual budget, it is easier for the individual physician to resolve the dilemma in favor of cost-effective medicine. That becomes ‘appropriate’ care. And it is an ethical choice… because if all physicians act the same way, all patients benefit.”

[1] Fuchs V, “The doctor’s dilemma – what is appropriate care”, N Engl J Med 18Aug2011;365(7):585-7.
[2] Martin LT, Parker RM, “Insurance expansion and health literacy”, JAMA 24/31Aug2011;306(8):874-5.
[3] Grumbach K, Bodenheimer T, “Reins or fences: a physician’s view of cost containment”. Health Aff (Millwood). 1990 Winter;9(4):120-6

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