Money, Medicine and Ethics
The American College of Physicians has published their updated manual on ethics for physicians and the following passage is causing quite a stir:
Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.
On the right, American Enterprise Institute scholar Scott Gottlieb writes “Parsimonious, to me, implies an element of stinginess, and stinginess implies an element of subterfuge.” (Quote of the Day in American Health Line.)
On the left, Aaron Carroll writes:
I would fight tooth and nail to get anything — and I mean anything — to save [his own child]. I’d do it even if it cost a fortune and might not work. That’s why I don’t think you should leave these kinds of decisions up to the individual. Every single person feels the way I do about every single person they love, and no one will ever be able to say no. That’s human.
Similarly, I don’t think that it’s necessarily fair to make it a physician’s responsibility. I also want my child’s doctor to fight tooth and nail to get anything that might save my child. Many times, physicians have long-standing relationships with patients. Asking them to divorce themselves from the very human feelings that compel them to do anything that might help their patients is not something that I think will necessarily improve the practice of medicine. They also should be human.
So whose job is it? Well, mine for instance. That’s what I do as a health services researcher. That’s what policy makers should also do….
That’s a roundabout way of saying that only the government can ration care the right way. Here is Don Taylor’s (Incidental Economist) take on the subject.
My view: people in health care have become so completely immersed in the idea of third-party payment that they have completely lost sight of the whole idea of agency.
This game of life I play
Living and dying with the choices I made
Can you imagine a lawyer discussing the prospects of launching a lawsuit without bringing up the matter of cost? What about an architect submitting plans for a building but completely ignoring what it would cost to build it? Outside of medicine, can you imagine any professional anywhere discussing any project with a client and pretending that money doesn’t matter? Of course not.
Then what is so special about medicine? Answer: the field has been completely corrupted by the idea that (a) patients should never be in a position to choose between health benefits and monetary cost, (b) doctors shouldn’t have to think about such tradeoffs either, (c) in order to insulate the patient from having to choose between health care and other uses of money, third-party payers should pay all the medical bills and (d) since no one else is going to think about what anything costs, the third-party payer is the only entity left to decide which services are worthwhile and which ones aren’t.
To appreciate how doctors could do the same thing other professionals do in advising patients on how to spend their own money, take a look at the graphic below. These numbers are several years old and there may be more recent studies, but the graphic will serve our heuristic purpose. Armed with this information, what would a responsible doctor tell her patient about Pap smears and how often the patient should get them?
Source: Tammy O. Tengs et al., “Five Hundred Lifesaving Interventions and Their Cost-Effectiveness,” Risk Analysis, June 1995.
Note that getting a Pap smear every four years (versus never getting one) costs $12,000 per year of life saved, when averaged over the whole population. What the responsible doctor should say is, “In the risk avoidance business, this is a really good buy. Based on choices people like you make in other walks of life, this is a good decision. This type of risk reduction is well worth what it costs.”
What about getting the test every three years (versus every four) or every two years (versus every three)? Here the doctor should say, “Now we are moving toward the upper boundary of what most other people are willing to spend to avoid various kinds of risks. So at this point, serious thought needs to be given to whether the test is really worth what it cost.”
How about getting the test done every year (versus every two years)? Here the responsible doctor will say, “This is definitely a bad buy (unless there is some specific indication). The cost of an annual Pap smear in relation to the amount of risk reduction achieved is way outside the range of choices most people make with respect to other risks.”
Notice what is going on here. The responsible doctor, functioning as an agent of a patient who is not familiar with the medical literature and who is not skilled at evaluating risks or trading off risk reduction for other uses of money, advises her patient in these matters. She helps her patient manage both her health and her money — because both are important.
When Dr. Carroll says “I’d do it even if it cost a fortune and might not work,” I am sure he is being sincere. But I am equally sure that is not how he normally makes decisions. It is in fact easy to spend a fortune to avoid small-probability events. The EPA makes the private sector do it every day. But if an ordinary family tried that, they would end up spending their entire income avoiding trivial risks. And that is not what normal people do.
Here is another example of a money-is-no-object-no-matter-how-improbable-the-prospects-if-life-and-death-are-at-sake choice. This is Zeke Emanuel, writing in The New York Times the other day:
Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it. But the machines are tremendously expensive, requiring a particle accelerator encased in a football-field-size building with concrete walls. As a result, Medicare will pay around $50,000 for proton beam therapy for a patient with prostate cancer, roughly twice as much as it would if the patient received another type of radiation.
Emanuel claims there is no evidence the treatment works for prostate cancer — so the therapy is a waste of $25,000. Is he right? I don’t know. If you’re paying the extra $25,000 out of your own pocket, listen to what the doctors at Mayo have to say (in favor of its use) and then listen to what Emanuel has to say and make up your own mind.
Bottom line: helping patients manage their health dollars as well as their health care should be what doctoring is all about.
Good song pairing.
Wonderful case, John, for moral agency. The principle behind this is, of course, autonomy. Bravo.
So the role of the state should be to “fairly” redistribute money to citizens’ health accounts and let them decide how to use it for health care only. And let them pass anything left to their estate.
Great post.
These are the moral, ethical and monetary dilemnas that are faced with in health care. They are no doubt difficult decisions and trade offs — that frankly no one, but the patient should be making for themselves. The issue is that the information available to patients is all too often either unavailable/unknown, beyond their level of comprehension, or they are not in a frame of mind due to their condition to be able to process the information and make rational choices.
A fine mess you have gotten us into Ollie.
The American College of Physicians, with this statement, have completely undermined the doctor-patient relationship, and abandoned medical professionalism. Why would anyone trust a physician who may well short-change him or her, perhaps without discussing the situation? Is the physician an advocate for the patient or the insurance company or government? And what patient would turn down treatment that someone else e.g., third pary, is paying for? Generally, the patient is not making his or her decisions with their current dollars, but figuring that they are paying premiums (or having them paid for them by an employer, etc., ostensibly, but that is just coming out of the individuals overall compenstation for their labor), and want to get his or her money’s worth of healthcare. So the entire transaction is distorted.
This statement iluustrates the old dictum: A physician cannot serve two masters, both the patient (to whom the physician’s professional obligation is directed) and the insurer. If the patient were directly paying the bill, the physician would automatically include risk benefit information in a far more cogent and accurate way in to the recommendations, and the patient would want to know. Currently, the patient has little incentive to want to discuss costs, and the physician has a perverse financial incentive not to. Physicians are no longer professionals, and they have a divided loyalty.
I periodically check Vitamin B12 serum levels in patients taking Metformin. Metformin can deplete Vitamin B12 levels, potentially leading to dementia, neuropathy, anemia. Medicare is loathe to pay for such therapeutic monitoring, and if I don’t code just right, the bill will not be paid. This is a relatively inexpensive test. No one has any idea how cost effective it is. I have picked up a lot of patients with B12 deficiency on Metformin, and advised B12 supplementation (sublingual tablet treatment is a good approach), but this also has costs. With current strictures becoming progressively tight, I suspect B12 levels won’t be allowed unless the patient has full blown symptoms of disease, at which point it may be too late to correct the damage.
On a daily basis, I’m am blocked from providing adequate care, particularly for diabetes, both by Medicare, more severly by Medicaid, and also by private insurers who increasingly follow Medicare’s lead. My decisions on patient care are all but dictated from Washington. The ACP is now saying that I am unprofessional if I do not kow-tow to government edicts on patient management. I contend that my management decisions, in the long run, are more cost effective than are the dictates of insurers, or Medicare, who have a very short term view of costs,although I can’t prove it. If I request a continuous glucose monitor for home use for a patient with brittle type 1 diabetes and recurrent hypoglycemia with hypoglycemic unawareness, and with this device avoid one emergency room visit for severe hypoglycemia over a period of a couple of years, I have saved everyone money, despite the rather steep costs of such devices. If I prevent a fatal motor vehicle accident, I believe I have done a service even beyond treating the patient. Keeping a patient under good control, and staving off such things as blindness, foot ulcers, infections, amputations, renal failure and dialysis, cardiac disease, and painful and incapacitating neuropathy, is not just cost effective, it is humane and highly beneficial to society generally. Such things are not figured in to insurance costs.
My position, for 30 years, has been that a first party payor system, with healthcare treated as any other commodity or service, not privileged as is currently done, is the most effective way to preserve quality, control costs, and keep physicians professional.
Always remember, physicians and hospitals originated the third party payor system for healthcare financing, to their financial advantage. Since the advent of third party health insurance, medical inflation has far outstripped general inflation (by roughly a factor of 3) and nothing has restrained that inflation. The healthcare financing system is gradually sinking under its own weight and threatens to induce insolvency nationally (with Medicare, and now Obamacare tacked on), coupled with declines in quality (as evidenced by abandonment of professionalism by the ACP), and ever-increasing costs. Further, medical innovation is curtailled, care delivery is inhibited artificially, and a free market in medical care does not exist (except in certain areas of medicine, such as ophthalmology and plastic surgery). Why do medical costs not bear any resemblance to, say, IT costs, which improve by leaps and bounds with rapidly declining costs and massive innovation? Our healthcare financing system is completely unsustainable, and often harms patients to boot. The only long term solution is a return to a first party payor (market) system.
One can look at coronary artery bypass surgery as a case in point over the last 50 years. The surgery is palliative only, except for a small subset of patients with severe multivessel disease who have not already had a heart attack. Yet it is virtually always presented as “life-saving” and insurance has reimbursed it without question. Adequate studies to show the comparative benefit of aggressive, optimal medical treatment vs surgical treatment have not been done. Fortunately, surgery is becoming less frequent, done mostly for “acute coronary syndrome” when stenting is not appropriate. Yet for almost half a century, Medicare and private insurers have covered this essentially without question, at enormous cost to society. Yet outcomes of coronary disease management are hardly affected, with very little benefit for enormous cost. The stats of similar populations (Canada and US) without and with fast and virtually unlimited access to bypass surgery, are hardly different. In one case, patients are simply denied. In the other case, sanctions are threatened against physicians who doesn’t send the patient for bypass. Studies like those of Dean Ornish that showed regression of coronary disease and disappearnce of symptoms with radical lifestyle changes only are ignored.
The only good answer is to return control of decisions and resources to individual patients.
That, of course, is an approach that no one would ever consider.
The American College of Physicians, with this statement, has completely undermined the doctor-patient relationship, and abandoned medical professionalism. Why would anyone trust a physician who may well short-change him or her, perhaps without discussing the situation? Is the physician an advocate for the patient or the insurance company or government? And what patient would turn down treatment that someone else e.g., third pary, is paying for? Generally, the patient is not making his or her decisions with their current dollars, but figuring that they are paying premiums (or having them paid for them by an employer, etc., ostensibly, but that is just coming out of the individuals overall compenstation for their labor), and want to get his or her money’s worth of healthcare. So the entire transaction is distorted.
This statement iluustrates the old dictum: A physician cannot serve two masters, both the patient (to whom the physician’s professional obligation is directed) and the insurer. If the patient were directly paying the bill, the physician would automatically include risk benefit information in a far more cogent and accurate way in to the recommendations, and the patient would want to know. Currently, the patient has little incentive to want to discuss costs, and the physician has a perverse financial incentive not to. Physicians are no longer professionals, and they have a divided loyalty.
I periodically check Vitamin B12 serum levels in patients taking Metformin. Metformin can deplete Vitamin B12 levels, potentially leading to dementia, neuropathy, anemia. Medicare is loathe to pay for such therapeutic monitoring, and if I don’t code just right, the bill will not be paid. This is a relatively inexpensive test. No one has any idea how cost effective it is. I have picked up a lot of patients with B12 deficiency on Metformin, and advised B12 supplementation (sublingual tablet treatment is a good approach), but this also has costs. With current strictures becoming progressively tight, I suspect B12 levels won’t be allowed unless the patient has full blown symptoms of disease, at which point it may be too late to correct the damage.
On a daily basis, I’m am blocked from providing adequate care, particularly for diabetes, both by Medicare, more severly by Medicaid, and also by private insurers who increasingly follow Medicare’s lead. My decisions on patient care are all but dictated from Washington. The ACP is now saying that I am unprofessional if I do not kow-tow to government edicts on patient management. I contend that my management decisions, in the long run, are more cost effective than are the dictates of insurers, or Medicare, who have a very short term view of costs,although I can’t prove it. If I request a continuous glucose monitor for home use for a patient with brittle type 1 diabetes and recurrent hypoglycemia with hypoglycemic unawareness, and with this device avoid one emergency room visit for severe hypoglycemia over a period of a couple of years, I have saved everyone money, despite the rather steep costs of such devices. If I prevent a fatal motor vehicle accident, I believe I have done a service even beyond treating the patient. Keeping a patient under good control, and staving off such things as blindness, foot ulcers, infections, amputations, renal failure and dialysis, cardiac disease, and painful and incapacitating neuropathy, is not just cost effective, it is humane and highly beneficial to society generally. Such things are not figured in to insurance costs.
My position, for 30 years, has been that a first party payor system, with healthcare treated as any other commodity or service, not privileged as is currently done, is the most effective way to preserve quality, control costs, and keep physicians professional.
Always remember, physicians and hospitals originated the third party payor system for healthcare financing, to their financial advantage. Since the advent of third party health insurance, medical inflation has far outstripped general inflation (by roughly a factor of 3) and nothing has restrained that inflation. The healthcare financing system is gradually sinking under its own weight and threatens to induce insolvency nationally (with Medicare, and now Obamacare tacked on), coupled with declines in quality (as evidenced by abandonment of professionalism by the ACP), and ever-increasing costs. Further, medical innovation is curtailled, care delivery is inhibited artificially, and a free market in medical care does not exist (except in certain areas of medicine, such as ophthalmology and plastic surgery). Why do medical costs not bear any resemblance to, say, IT costs, which improve by leaps and bounds with rapidly declining costs and massive innovation? Our healthcare financing system is completely unsustainable, and often harms patients to boot. The only long term solution is a return to a first party payor (market) system.
One can look at coronary artery bypass surgery as a case in point over the last 50 years. The surgery is palliative only, except for a small subset of patients with severe multivessel disease who have not already had a heart attack. Yet it is virtually always presented as “life-saving” and insurance has reimbursed it without question. Adequate studies to show the comparative benefit of aggressive, optimal medical treatment vs surgical treatment have not been done. Fortunately, surgery is becoming less frequent, done mostly for “acute coronary syndrome” when stenting is not appropriate. Yet for almost half a century, Medicare and private insurers have covered this essentially without question, at enormous cost to society. Yet outcomes of coronary disease management are hardly affected, with very little benefit for enormous cost. The stats of similar populations (Canada and US) without and with fast and virtually unlimited access to bypass surgery, are hardly different. In one case, patients are simply denied. In the other case, sanctions are threatened against physicians who doesn’t send the patient for bypass. Studies like those of Dean Ornish that showed regression of coronary disease and disappearnce of symptoms with radical lifestyle changes only are ignored.
The only good answer is to return control of decisions and resources to individual patients.
That, of course, is an approach that no one would ever consider.
Empowering people with facts to make the choices effecting their most important personal decisions…what a novel idea!
Insightful post.
@Larry: Who’s Ollie?
At best, the choice of words by the ACP was unfortunate. It certainly does not give due credit to the basic ethical and moral priorities governing the professional character of nearly all physicians. The cost of our nation’s healthcare industry is a heavy burden for our nation’s economy. Suggesting that it is the duty of physicians to solve this burden reflects a lack of understanding of what it means to be a physician.
I would suggest that carefully considered health care planned in conjunction with each person’s values is the best means to achieve high quality healthcare that is also very efficient. In effect this level of health care also implies responsive accessibility with any change in the person’s health. It also implies a need for a regularly scheduled reassessment of any treatment plan in conjunction with the applicable personal preferences of the person. For the physician, it should always be about a relationship with the person, an understanding of their priorities and an empathic willingness to discuss any futility and benefits associated with those priorities.
The underlying theme of the ACP probably reflects a recurrent theme of “downloading.” I would suggest a litmus test for the ACP before any new policy statement is finalized: does it promote collaboration, transparency and trust?
Thank you. This is the most frightening development yet. I appreciate you informing me about this.
Sam
THE EXAMPLE OF pap smears brings to mind my experience as a medical student going to a GYN clinic for frozen pelvises of women of all ages who had a cancerous frozen pelvis. There were many lined up for examination by medical students, all doomed to die an agonizing death. It was mentioned at the time that the Pap smear was just coming in and could detect this problem earlier. It was an awful clinic. As a physician it would be very difficult to minimize the risks of not performing a pelvic exam and Pap smear on a regular basis.
Several years later, as an officer of a medical association, I was invited to the headquarters of an insurance company. It
was a recruitment event to get medical leaders to recommend doctors to accept insurance patients of this large company. In the questions and answers period the question was raised about that particular company denied coverage for pap smears which resulted in a law suit and judgment about that particular publicized case. The explanation was that it was a “business decision.” In other words, denying this test resulted in an actuarial adverse cost, which could be corrected by either raising premiums, allowing the testing in the future; neither or both. It was a wakeup call for me, when I realized the insurance company was in business to make profits and the risk would be transferred to another party. That was their business, not to protect every individual. I learned from that experience about insurance. At the end of the day ,it may not protect you, you don’t know until you process a claim at which point they are protected, but not necessarily the insured. Its like the political promise “You can still see your doctor under this plan” if the plan exists, or if the doctor still exists.
A great article and it brought back memories of my education about insurance.
The position of the American College of Physicians could probably best be summed up as wishful thinking. Proclaiming that an ethical physician watches the dollar is unlikely to have an impact on a given physician’s practice style. A physician could make a valid argument against considering costs by claiming that withholding care is equally (if not more) unethical if there could be some therapeutic benefit.
Thanks, John.
The ACP forgot to mention that they mean being “parsimonious” for profit–the ObamaCare ACO cost control scheme for doctor gatekeepers to benefit corporate-government “payer” profits-“savings”…or go broke.
Too bad that transferring the gatekeepr role from managed care “payers” to clinician “management” at the bedside creates double agent doctors playing the dual roles of care-giver and “payer” underwriting agents–and it will fail like all other managed care “cures” have failed for decades. Why? Clinicians have no control from the bedside over tax-subsidized national medical demand inflation, population quality satistics driven primarily by socio-economic-demographics, or over blunt regulatory policy maker schemes to control costs by price-fixing and managed care policing.
Bob
Parsimonious is the wrong word to use. The best care is when the physician utilizes all of his knowledge, training and experience to arrive at a diagnosis using those three “diagnostic tools”. With our health care providers fear and greed, and the system not allowing for taking the time to utilize all our thought processes, this leads to overuse of expensive and unnecessary testing and diagnostic tools because the system (and the doctors) are scared of litigation and we are no longer reimbursed for our due diligence and thinking. The practice of medicine I was taught was to 1)Take a thorough history, 2)do a thorough physical, and 3)utilize the lab or other studies to validate your clinical opinion. For the last 50 years, this has been the most rewarding and exciting aspect of health care. Unfortunately, today’s health care system causes physicians to order tests they may suspect will aid in a diagnosis, rather than the other way of making a diagnosis by expensive testing, creating a huge escalation of cost, when a little thoughtful approach would be not only the utilization of thoughtful deliberation to use the knowledge we received in our education and training.
Do you ever think that we will be able to return to those sacred values, or is our system so corrupted that the cost will escalate more, and the need for all that learning will be for naught. One does not need medical school, residency and subspecialty training to be a “test orderer”. It almost obviates the need for the primary care physician.
Dr Bob Kramer
The use of the word is fine. It’s first definition in the Oxford English Dictionary is “The careful or sparing use of money or other material resources; economy; thriftiness; frugality.” It does not mean being penny wise and pound foolish. In the sense that it is being used, it simply means don’t do more tests and treatment than what is necessary.
The paragraph has been in the ethics manual unchanged for well over a decade. The statement has nothing to do health insurance, the making business decisions, or rationing of care.