New ethics guidelines from the American College of Physicians calling for physicians to practice “parsimonious care” have reignited a debate about the role and responsibility of physicians in dealing with health care costs.  In a perspective published this week in the New England Journal of Medicine,  I argue that the debate reflects the larger struggle in the United States over how to deal with — and talk about — health care costs.
U.S. political leaders are generally at pains to assure Americans that proposed health care reforms will not reduce their benefits nor curtail their choices. The problem is that no one in charge seems willing to acknowledge that getting a handle on cost growth will also involve uncomfortable trade-offs. Providing better-quality care, though vital, won’t change that reality.
Including the term “patient-centered” in the name of the Patient Centered Outcomes Research Institute (PCORI) underscores the issue. PCORI has embraced “stakeholder engagement,” which, like patient-centeredness, acknowledges the importance of giving a voice to affected parties and assuring that clinical studies answer relevant questions. While focusing on patients and stakeholders has benefits, changing the conversation in this fashion also has downsides. Focusing on patients’ own preferences to the exclusion of considerations of societal resources will only compound our cost problems. Engaging stakeholders is undoubtedly important, but one person’s stakeholder is another person’s interest group.
The resulting conversation allows little space for cost concerns. It ignores resource constraints and has an unreal, wishful quality. Rarely is there mention that we will have to face hard choices and in some cases make do with less: patients with fewer services, more cost sharing, and restricted alternatives; physicians and hospitals with less revenue.
The challenge is how to have a more honest conversation. A candid discussion could set expectations, inform policy debates, and help the country prioritize its resources. That is why the new ACP guidelines are so valuable. Their focus on responsibility, their direct acknowledgement of the need to consider constraints, their recognition that less care may be better care, and their call for individual physicians to use resources wisely are rare and welcome.
Peter J. Neumann, Sc.D.
1. American College of Physicians Ethics Manual: Sixth Edition, 2012. Ann Intern Med 2012; 156:73-104
2. Neumann PJ. What we talk about when we talk about health costs. N Engl J Med. 2012;366(7):585-86. Available here