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

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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 JAMA “Physician 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.”

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[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

What is the ethical role for physicians in the "business" of health care?

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Health care is a complex business. “Business” in the sense of “a human endeavor”, but also as “an organization seeking to make a profit.” Over the last several decades we have seen increases in the portion of health care delivery services that are formally organized as “for profit”. Hospitals, especially, have undergone such changes, joining the ranks of long-term care facilities, pharmaceutical companies, device makers, home health agencies, and insurance companies that have always been primarily “for profit”. Indeed, most physician practices, whether solo, small-group, or large group, are for-profit, organized into “professional” or “limited liability” corporations.

“For profit”, however, means that these organizations pay taxes, but because an organization is “not-for-profit” does not mean it behaves significantly differently. Not-for-profits are granted this status because a significant part of their activity is providing a public good, and their income-over-expenses (profit, which we can call “margin” to be less confusing) is not owned by shareholders but is rather intended to be re-invested to further enhance that public good. But not-for-profit hospitals generally follow very similar business practices to for-profit. They have to “compete for market share”. While they may have a mission, they often cite the mantra “no margin, no mission” as they invest in high-margin product lines (heart disease, cancer, neurosurgery) to attract more paying customers. Rather than, say, spending that money providing their wonderful care for free or at great discounts to the poor and uninsured. Or expanding their provision of high-need but low-margin services (primary care, obstetrics, pediatrics, psychiatry). The salaries paid to management of not-for-profit hospitals and professional personnel are often as high as those paid by for-profits (who, after all, have to maximize profit to please their shareholders, so want to keep costs, largely salaries, down).

So what is reasonable profit in health care, for companies that are for-profit? Should there be any? Does competition with for-profits distort the behavior of non-profits or would they act in the same ways if they had to compete only with other non-profits? Is competition good or bad? And what about doctors? Do they behave differently in their practice if they are salaried or have an incentive to make profit? Is this a good thing or a bad thing? So many questions!

In their commentary “Physician stewardship of health care in an era of finite resources” (JAMA 27Jul2011; 306(4):430-1), David B. Reuben and Christine K. Cassel address some of these issues. They start by noting that “Although there are varying opinions about the quality of health care in the United States, there is consensus that it costs too much.” I would guess that this is probably true, but may be as far as it goes. I suspect that each individual player or industry dependent upon health care dollars is unlikely to think it is their part that costs too much. It’s those other guys!

Reuben and Cassel focus on physicians. Not on how much physicians earn (salary or profit), but how they choose to spend health care dollars, because “Health care costs are directly related to decisions made in clinical practice”.  They go on to say that “These decisions are difficult to influence because they are made in the context of individuals who are often sick and vulnerable, with little understanding of the potential benefits and risks of diagnostic and therapeutic options. Patients seek help from physicians and physicians chose careers to provide this help, or at least the hope of it. Because of this relationship, it is futile to expect that changing physicians' behavior through evidence and shared decision making alone will solve the problem of high health care costs. Alternative approaches will be necessary.”

Cassel, the President and CEO of the American Board of Internal Medicine (ABIM, the organization that certifies internists; not to be confused with the American College of Physicians, ACP, the internal medicine professional organization), is both a geriatrician and a medical ethicist. I have heard her discuss physician stewardship in individual cases, arguing that the use of resources ordered by an individual physician for an individual patient should not be based on issues other than the benefit and risk for that patient, since the physician and patient have no control over what money “saved” might be used for. (My patient and I cannot decide to not do expensive interventions and instead use the money for housing the homeless or feeding the hungry – unless s/he is that rare person paying all the costs out of pocket --  all we can decide is whether to do those interventions or not.) Savings have to be looked at on a more global level, with a shared understanding of what those “saved” dollars will be used for.

The contribution that Reuben and Cassel make in this piece is to provide something of a taxonomy of physician stewardship, examining the various levels at which it can occur beyond that of individual patient decisions. These include the “highest” level, of national and state policy where spending decisions (initially, one presumes, via Medicare and Medicaid) should be based on evidence of benefit and consistency with national policy objectives (such as, I imagine, Healthy People 2020). The second level is that of payers (insurers) who would choose to pay for interventions that are shown to be beneficial (and presumably cost effective) rather than those that are ineffective or marginal. They suggest that rather than charging high deductibles and co-pays for services that are known to be beneficial and cost-effective, they simply do not pay for those that are not. This makes sense; why should insurers pay even a significant portion of procedures that are of little or no benefit while excluding such things as hearing aids that are of great benefit and (relatively) inexpensive?

The third level that they address is the practice level, where groups of physicians can use evidence to guide their group decision making and decrease inappropriate variation in physician practice. An example of this would be the use of a limited drug formulary emphasizing generic medications (this could also occur at the insurer level). Finally, there is the individual patient level; while making cost-effective decisions at this level can be more complex, it can certainly be done. While it is certainly unfair to ask a sick person to decide upon the choice of having, or not having, a medical intervention that they can scarcely understand so that saved dollars may possibly benefit some unnamed person more, it is quite a different thing to educate people about the impact of their health decisions, especially before they become critically ill. Advance directives, such as living wills, are one method, but there are many others.

What is clearly unethical and unacceptable is for physicians to encourage patients, sick or well, to undergo a diagnostic or therapeutic intervention because the physician stands to gain financially from doing it. Unfortunately, this happens. Sometimes it is done consciously, but often it is because the physician who does the procedure (and will happen, coincidentally, to benefit financially from doing it) truly believes it is of benefit. To not believe it would, in fact, be cognitive dissonance. Although there are increasing numbers of procedures being called into question for everyone, there are far more that are of benefit to some people but not to others. It is the ability of physicians to distinguish between these people and present recommendations honestly and free of financial bias that will make the biggest difference. The fact that there are still many physician-owned for-profit hospital and “surgi-centers” in which the doctors benefit financially not only as the providers but as owners of the facility from more procedures being done argues that we have a long way to go. (See also my commentary in an earlier post,  Greed, corruption and medical procedures: ignoring or suppressing the evidence?, August 12, 2011.)

The greed of human beings is not going to be wished away, whether they are physicians or lay corporate executives; whether of for-profit or not-for-profit companies. The taxonomy of Reuben and Cassel is useful for thinking about these issues, but it is only comprehensive – and thoughtful and balanced – regulation that can be sufficient impetus to make these changes happen.

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