There are a lot of people and companies out there who are making, or seeking to make, a profit on delivering health care. I have written about this often. However, it is in fact physicians who control many of the expenditures, and thus the cost; they are the ones who order the tests, prescribe the medicines, use the devices, refer to each other, advise their patients regarding the most appropriate treatment. To the extent that physicians (and other providers who have this power) exert it wisely, judiciously, and appropriately, the cost of care might begin to be controlled. Yes, there will still be tensions between cost and benefit, between benefit to a single person vs. benefit to the whole population, between what the goals of care are, and the degree to which physician choices are limited, but cost consciousness among physicians would go a long way.
It was, therefore, disappointing to read the results of a survey of US physicians recently published in JAMA. In “Views of US Physicians About Controlling Health Care Costs”, Jon C. Tilburt and colleagues randomly surveyed 2665 physicians (a 65% response rate, pretty good) about a variety of issues regarding cost control in health care. Most of those surveyed did not believe that physicians had any major responsibility for controlling health care costs; it was “the other guys”:
‘Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.”’
Whether 50-60% of doctors believing something can be considered “most” is open to question, but there is no doubt that when only 36% of doctors believe that they have a major responsibility, most do not. This is, of course, as I have noted above, incorrect. Do they really believe it? If so, this would imply that they believe that they, and other doctors, are doing all they can already, within the limits of their ethical responsibilities to their patients. However, their responses to other questions in the survey cast doubt on whether they actually are, or even think that they are. While ‘More than 90% of physicians expressed some or strong enthusiasm for -improving conditions for evidence-based decisions, including “expanding access to quality and safety data,” “promoting head-to-head trials of competing treatments,” and “limiting corporate influence on physician behavior,”’, only 51% were strongly enthusiastic about “limiting access to expensive treatments with little net benefit”. Since another 38% were “somewhat enthusiastic”, the article’s contention that it was “relatively strong support” is justifiable; still, it is pretty scary to think that half of doctors are not strongly enthusiastic about this issue.
When it comes to physician reimbursement, it is unsurprising that doctors are very chary of any new models, since most have been doing pretty well with the old ones. Thus, only 7% supported elimination of “fee-for-service” (FFS), in which doctors get paid for what they do (and, as we have often discussed, get paid more for doing more, whether necessary or not, and a lot more for doing procedures) rather than getting a global fee for caring for patients (which, in full disclosure, I have advocated). It is also not surprising that those physicians who were paid salary only or salary-plus-bonus were more than three times as likely to support elimination of FFS. Self-interest is a powerful motivator.
In an accompanying editorial, “Will physicians lead on controlling health costs?”, the ubiquitous Ezekiel Emanuel (former Obama health advisor and now apparently the “go-to” guy on health policy for JAMA and the New England Journal) and Andrew Steinmetz, come to the unavoidable conclusion that, at least for now, the answer is no. This disturbs them, and they spend a lot of time showing why these doctors are wrong. They note that “Not unlike the public, physicians embraced reforms that are sufficiently vague that they may offer only modest improvements but certainly will not transform the health care system,” which seems to be true; if this survey indeed reflects physician opinion, they don’t want transformation of the system. After all, Emanuel and Steinmetz concede, “Change is hard,” but they are very clear that it needs to happen, and the editorial (which I agree with a lot of) tends to get more shrill as it goes on. They take heart in faint positives:
“…not all the results are discouraging. Physicians do seem to recognize that health care costs are important. For instance, 51% strongly disagreed that the cost of a test or medication is only important if the patient has to pay for out of pocket; 85% strongly or moderately agreed that trying to contain costs is the responsibility of every physician; and 66% disagreed that there is too much emphasis on costs of tests and procedures.”
How much hope does it give you that half of doctors do not strongly disagree that cost of medication is only an issue if it is coming directly out of a patient’s pocket? I imagine it gives pharmaceutical companies a great deal. They note that 70% support continuity of care (a good thing, why not?) but add that it is “…another reform not proven to reduce costs or reengineer the system,” losing sight of the fact that those are not the only two goals; providing better care to people is another!
Physicians often don’t want to do the hard work of having to make difficult decisions of what is the best treatment for individuals even considering risk/benefit to the individual, not to mention harder to measure (and more controversial) work of balancing of benefit to the individual vs. the whole society. It is much easier for someone else to make those decisions, allowing you to be free to criticize them and tell your patients “it’s not my fault”. But it is disingenuous. With authority comes responsibility. If physicians want to continue to have significant autonomy in the decisions that they make, they need to take on responsibility for the impact. Saying “I just made this decision because it was best for my patient and I can’t be responsible for overall health costs” is a little like saying that the candy bar wrapper you just chucked out the window of your car isn’t responsible for the garbage all over our roads. More important, and concerning, is the finding that there is little sense of responsibility for choosing the right treatment – not the newest, or most expensive – for the individual.
In a recent JAMA “Viewpoint”, the same issue is addressed by Christopher Moriates and colleagues in “First, Do No (Financial) Harm”. They argue that, in this context, physicians have 4 responsibilities. The first two are innovative and good ideas:
· Screen for financial harm, i.e., what will it cost this person out of pocket and can they afford it?;
· Adopt a universal approach, i.e., do with everyone. As with HIV screening, or asking about risk behaviors, don’t assume you can “tell” who is at risk; doing it with everyone means those you ask are not being “singled out”;
The last two are less innovative but equally important, and address what I have discussed above:
· Understand financial ramifications and value of recommendations, and
· Optimize care plans for individual patients.
The authors provide a nice “box” showing how this might work for the problem of back pain.
Actually, if one looks at past health reforms, physicians as a group have never been in the lead. AMA shot down both President Truman’s national health insurance proposal and strongly opposed Medicare and in 1965. Change is hard, and it is particularly hard when there is good chance that change will not be beneficial for your pocketbook. But change is necessary. Not necessarily in, or only in, the areas that Ezekiel and Steinmetz focus on (reducing costs and “re-engineering the system”) but certainly in ensuring money is not wasted, quality of care is high, people have trust in their providers, and that the ethical principle of justice – that EVERYONE with the same conditions has access to the same diagnostic and treatment options – is adhered to.
We certainly don’t have the latter, and it is perhaps the most important. People -- doctors, patients and others -- cannot let that concern be lost as we “re-engineer”.
 Moriates C, Shah NT, Arora VM, “First, Do No (Financial) Harm”, JAMA. 2013;310(6):577-578. doi:10.1001/jama.2013.7516.