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Towards an Ethic of Physician Responsibility

By Arvind Suguness

By now we are all familiar with the statistics: the United States spends a disproportionate amount of money on health care for results that are, at best, comparable to countries that spend far less. Whatever your diagnosis of this problem, whether it is a result of misaligned incentives, under-investment in primary care, or government interference, and whatever your prescribed treatment – Accountable Care Organizations, increasing access or unleashing the free market – there is one inescapable common denominator. If any reform is to be successful, physicians must have more knowledge of and be more responsible for costs in our health care system.

Physicians in the United States have historically been granted a substantial degree of autonomy. We were slow to develop a system of private insurance, largely because physicians saw private insurers as a threat to their independence. Likewise, the United States was, until recently, one of the few developed nations without a national health policy providing universal coverage, in large part due to opposition from physician's groups. Even the Affordable Care Act avoids the overt government involvement of a single payer plan, instead preferring a lighter touch that defers to doctors and hospitals

This deference to the autonomy of physicians gives the medical community a moral obligation to address the challenges that face our industry. As a profession, physicians cannot stand idly by while costs in the health care system – costs which are largely under their control – grow to consume an ever larger share of economic output, pricing ever more people out of the system. Whether you believe in the power of free markets or the necessity of government intervention, the case for practicing more efficient and less wasteful medicine is clear.

Of course, nearly any physician you ask will acknowledge the importance of this goal. After all, who stands for wasteful spending? And yet, at an absolute minimum, in excess of twenty percent of our health care dollars are wasted. The question then is not whether physicians should commit themselves to eliminating waste, but rather what are the obstacles standing in the way of this commitment?

The primary obstacle is one of education. A recent study showed that physicians don't understand basic cancer screening statistics. They mistakenly valued less important indicators like increased early detection and improved survival times over more definitive indicators, such as reduced mortality, when evaluating whether a screening test was worthwhile. Another study looked at oncologist's readiness to assess the cost-effectiveness of various treatments and found them unprepared. They were inconsistent in how they weighed the cost of expensive new therapies against the benefits they provided in additional months of life, first saying a treatment adding one year to a patient's life would be worth $100,000, and then later, when presented with a hypothetical patient, endorsing much higher levels of spending.

Many would pause here claiming that it is not the physician's role to assess the cost effectiveness of the tests and interventions they provide. They argue that physicians ought to do whatever their patients wish, regardless of the costs incurred. Wasteful spending in one area, however, leads inevitably to higher insurance premiums and higher taxes, and the costs we incur therefore fall upon society as a whole. For this reason, physicians should work to reduce these costs not only as stewards of our patient's overall well-being, seeking to provide the highest quality care that we can for our patient's dollars, but also as citizens of our nation, attempting to utilize limited resources in the most efficient way possible.

The other major barrier to the practice of cost-effective medicine is the problem of misaligned incentives. Because doctors and hospitals are mostly paid on a fee-for-service basis, rather than for entire episodes of care, they are rewarded for performing more tests and procedures instead of for providing quality care efficiently. This means that even if doctors are well informed about cost-effectiveness research it will be difficult to translate this knowledge into practice without damaging their own bottom lines.

We are beginning to solve this latter problem. With the Affordable Care Act's move towards Accountable Care Organizations and reimbursing physicians for the quality of care they provide rather than the quantity, the fee for service model will hopefully soon be a thing of the past.

Equipping physicians with the knowledge needed to make this transition is a more difficult matter. The recent list of overused medical tests compiled by a group of medical societies led by the American Board of Internal Medicine Foundation was a good first step. The move by organizations like Costs of Care  to bring price transparency to health care will aid physicians in making these cost-conscious decisions. Increasing the emphasis on cost-effectiveness in the education of medical students like myself will also be an important change. In the end, this transition will require the acknowledgment of physicians as a whole that understanding the costs of the care they provide is as integral to being a high-quality clinician as understanding the benefits.

Transforming the American health care system will not be easy. But no matter what your political persuasion, no matter what reforms you think are necessary, no reform can succeed unless physicians are ready and willing to eliminate wasteful spending and perform their jobs more efficiently. It is the single change upon which all others ultimately rest.

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