November 28, 2011

Physicians and the ethical dilemma of federal cuts to health care

In less than three weeks, we’ll know whether Congress’ 12-member bipartisan “Super Committee” has succeeded. If it can’t find $1.2 trillion in federal deficit reductions over the next decade, we face reductions of the same magnitude as across-the-board cuts. 

Either way, we can expect federal funding cuts to impact value decisions at every level of health care decision-making. From individual patients deciding whether to seek care, to large purchasers such as Medicare and public-employee insurance boards determining which benefits to offer, people will ask with increased urgency: “What care is necessary, and what can we afford?”

Meanwhile, our nation’s physicians—who are primarily responsible for recommending “appropriate” care for individual patients in this increasingly cost-constrained environment—will find their work getting much tougher.

As Stanford University health economist Victor Fuchs recently wrote in the New England Journal of Medicine, “When escalating health care expenditures threaten the solvency of the federal government and the viability of the U.S. economy, physicians are forced to re-examine the choices they make in caring for patients.”

While his essay is sobering, his conclusion gives Group Health’s providers reason to take heart. Fuchs describes how caring for patients within an integrated group practice gives doctors a defined and ethical way to control health costs. By contrast, he writes, it is harder for those serving patients in fee-for-service environments.

Fuchs points to the “Physician Charter,” which most of the nation’s leading medical societies endorsed around 2002. As part of the American College of Physicians group that worked on the Charter, I know it aimed to provide guidance during growing concern over escalating costs. But this was six years before our nation’s financial crisis began and nine years before today’s political stalemate over tax policy. Now physicians need a better compass to address today’s even greater pressure to control cost.

The Charter calls “patient welfare” the most important principle in health care, and states that it should not be compromised by “market forces, social pressures, and administrative exigencies.” It also says physicians must provide care based on “wise and cost-effective management of limited clinical resources.”

Here Fuchs zeroes in on the obvious conflict: “How can a commitment to cost-effective care be reconciled with a fundamental principle of primacy of patient welfare?”

Then he details how the dilemma plays out, including developing expensive technologies and drugs that benefit some (but not all) patients—but are used indiscriminately anyway. Third-party insurance also contributes, shielding patients and doctors from the costs of care. “If a physician is paid on a fee-for-service basis and the patient has open-ended insurance, the scales are tipped in favor of doing as much as possible and against limiting intervention to those that are cost-effective,” Fuchs writes. Who benefits from practicing more cost-effective medicine? In a setting like this, the answer may be obscured.

He contrasts this to practicing “in a setting that has accepted responsibility for the health of a defined population” where the organization receives an annual fee per enrollee. Sounds like Group Health. Here, he says, even though all patients are insured, physicians are more likely to practice cost-effective medicine. Ideally, their colleagues are practicing the same way. All told, the resources are used to benefit the defined population, including the physician’s patient.

In other words, by coming together in community and facing the real-world limitations of health care resources, Group Health providers can work collectively to make the best decisions possible for individual patient care.

Research plays a major role in this equation. By evaluating the effectiveness, cost, and safety of various approaches, we in the Group Health learning health care system are giving providers the evidence they need to make the best choices for their patients and the Group Health membership. Looking forward, the challenges we face as a nation and as a health system may not be easy.  The model provided by Group Health’s integrated delivery system and commitment to caring for a defined population allows us to achieve our commitment to be aligned so we are truly capable of working in the best interest of our patients and the population we serve. Now it’s up to us to prove we can do it.

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