To the Editor: The article on the obligation of physicians to provide high-quality, cost-effective medicine even in the setting of patient requests for nonbeneficial interventions1 was thoughtful, but a number of points warrant more discussion. First, how does the fact that patients do not pay for interventions at the point of service figure into their requests? In the example of the patient who wanted a magnetic resonance imaging (MRI) scan, Drs Brett and McCullough asserted that the physician should not order the scan even if the patient offered to pay out of pocket. However, it seems unlikely the patient would have been as curious if he had had to write a check for several thousand dollars at the time of the scan. But because he has already paid thousands of dollars for health insurance, why not allocate a few thousand of those “to see what's going on”? This is one example of how the very structure of the current health care insurance and reimbursement system drives costs upward. The system—and the article—put the onus of holding the line on unnecessary spending solely on the physician.
Laws A. Patient Requests for Nonbeneficial Care. JAMA. 2012;307(17):1797–1798. doi:10.1001/jama.307.17.1797-b
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