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November 3, 1999

Physicians' Duties in an Era of Cost Containment: Advocacy or Betrayal?

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JAMA. 1999;282(17):1675. doi:10.1001/jama.282.17.1675-JMS1103-3-1

The explosion of medical technology in the late 20th century has forced physicians to think seriously about cost containment. When my father first practiced medicine in the 1950s, his pharmaceutical armamentarium included a handful of antibiotics and 2 or 3 antihypertensives. The most expensive diagnostic tests were plain film radiographs. It was easier to give patients the best health care money could buy, because there was not as much health care to buy.

Now, however, physicians can order $2000 magnetic resonance imaging (MRI) scans that may have little chance of finding anything clinically relevant. Screening women annually for cervical cancer by Papanicolaou smear costs over $1 million per life saved.1 Screening people a sixth time for colon cancer with fecal occult blood testing costs over $26 million per life saved.2 In short, today we can offer our patients many interventions that bring small benefits at great financial cost. From my perspective as a physician who did not begin practicing medicine until the late 1980s, the cost of health care has always been an issue to consider.

Pressure to contain health care costs places physicians and other health care practitioners in difficult positions. If we pursue our patients' best interests without regard to costs, we will accelerate health care inflation, a serious concern in an era in which governments throughout the industrialized world are struggling to offer health care to their populations. But if we forsake patients' best interests in favor of society's pocketbook, we risk alienating our patients, who expect that we will be their untiring advocates.

Most contemporary medical ethicists argue that physicians should pursue patients' best interests regardless of cost. According to this view, health care rationing should be done at higher levels than the patient-physician encounter,3,4 such as by formulary committees, which limit the medications available to clinicians, and by utilization reviewers, who tell us when insurers will stop paying for extra hospital days. It is my position, however, that physicians need to relax their advocacy duties in order to control health care costs.5

Debates about the moral status of bedside rationing do not often recognize its already pervasive presence in clinical medicine. Suppose, for example, that a physician who believes that she should not ration care from her patients is faced with a formulary committee that restricts the use of proton pump inhibitors to patients with severe gastroesophageal reflux. Should she advocate for her patients' best interests by liberalizing her interpretation of what qualifies as "severe reflux"? If not, she is participating in the rationing of care. When should this physician accede to and participate in third-party rationing mechanisms, and when should she fight them, even to the point of misrepresenting patients' conditions to get them what is in their best interests?

Often, an extra hospital day is only mildly beneficial, or a new medication is only 1% better than an older, less expensive one. At the same time, health insurance in the United States is so expensive that many employers no longer offer health benefits to their employees, thereby swelling the ranks of the uninsured. In times like ours, physicians need to be willing to forego small benefits for their patients by acceding to reasonable third-party payer rationing mechanisms.

Each physician must decide what constitutes a "small benefit" and a "reasonable rationing mechanism." When very important health care resources are being withheld from our patients, we need to fight third-party payers aggressively to obtain the resources. But other times, when the resources being withheld are only slightly better than available resources, we need to take third-party payer restrictions as a reminder that not all benefits are worth pursuing, given the great importance of controlling health care costs.

It is, of course, often possible to bend third-party payer rules without technically breaking them. The difference between moderate and severe gastroesophageal reflux, for example, is a judgment call. A physician who has a low threshold for classifying reflux as "severe" is not necessarily breaking a rule. In fact, most third-party payer rules leave generous room for interpretation.6 Ultimately, though, deliberate bending of the rules amounts to a deliberate misinterpretation of their spirit.

Physicians need to think hard about the societal and personal consequences of such rule-bending. The societal consequences are clear: frequent rule-bending will fuel continued health care inflation. The personal consequences, however, can be even more dramatic. A physician who always errs on the side of providing additional resources will be unpopular with third-party payers, who may refuse to contract with him or her in the future. In interpreting third-party payer reimbursement rules, we need to remember that such rules exist because society wants us to control health care costs. If physicians bend too many rules, the health care system is bound to break.

Funding/Support: Dr Ubel is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar and a recipient of career development awards in health services research from the Department of Veterans Affairs.
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