Tuesday, September 29, 2009

Is it morally objectionable for physicians to consider cost in treatment decisions?

Yes, according to a majority of physicians in a recent poll. The survey, which was reported in the September 14 edition of the New England Journal of Medicine, found that 54% of surveyed physicians said that they had "moderate" (40%) to "strong" (14%) moral objections to using cost-effectiveness data to determine which treatments to offer to patients. 45% said they had no such moral objections.

A third of physicians had moderate to strong disagreement with limiting reimbursement for high cost procedures or drugs in order to help expand access to basic coverage to those who do not have it, while 67% favored such limitations to expand access for others. Primary care physicians were more likely than surgeons or procedural specialists to support limits on payments to help fund basic care for others.

The survey has some other surprising findings. While a large majority of physicians agreed that physicians are ethically obligated to care for the uninsured and underinsured, 27% moderately or strongly disagreed. Slightly more than one out of five physicians agreed that addressing societal health policy issues, as important as that might be, falls outside their professional obligations as physicians.

Like any poll, how a question is worded can produce a quite different result. I wonder, for instance, if fewer physicians would have moral objections to cost-effectiveness data if it was to "guide" or "inform" patient care decisions rather than "determine which treatments will be offered to patients" as stated in the survey. I can see why the notion that a treatment might not be even offered to patients, if it was determined not to be cost-effective, would raise moral objections. Comparative effectiveness research, at least the way ACP has envisioned it, should be used to engage patients in shared decision-making with their physicians on which course of treatment might work best for them, not to deny them this choice by taking the more expensive treatments off the table.

At the same time, the survey suggest to me that many physicians do not agree with concepts of social justice and fair allocation of resources as described the Physician's Charter on Professionalism, which has been endorsed by the ACP, the American Medical Association, the American Board of Internal Medicine, among others. The Charter's principle of social justice states that "The medical profession must promote justice in the health care system, including the fair distribution of health care resources." It also states that physicians must have a commitment to a just distribution of finite resources:

"While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."

Today's questions: Do you personally have a moral objection to using cost-effectiveness data to determine the treatments offered to patients? What about to guide and inform such treatments? Do you agree or disagree with the Charter's view that physicians must be committed to social justice and a fair distribution of finite resources?


Arvind said...

Bob, it is obvious that your thought process does not mirror that of practicing physicians. Hence, I believe you pose the question in this manner. I would like to dissect your theory a bit further.

First, there are more than one reason for physicians to offer the most appropriate care to a particular. Moral reason is only one of them.

Second, the ACP assumes that comparative effectiveness research findings/recommendations will be directly applicable to all patients under any condition/circumstance. If that is the case, we really don't need physicians at all. We can simply program in the research recommendations into computer databases and link it with diagnosis and let anybody make treatment decisions based on what the computer recommends.

Third, it is very difficult to determine whether a procedure is "high cost" unless you are a patient. To a patient with limited treatment options, no procedure is too pricey. We can only hope that we are not in that category!

Similarly, visits to specialists while deemed "excessive" by some, might actually save a lot of money and suffering. For example, my ER colleagues frequently lament that they hardly ever see my diabetic patients in their ERs - this is mainly because of how well we train them to manage their disease without resorting to ER visits. Such cost savings are very rarely accounted for - records will only show that these folks visited their Endocrinologist too many times in a year.

In reality, we make cost-considered treatment decisions on a daily basis. But these decisions are made by mutual agreement between patient and doctor, (not because some agency told us to do so) keeping in mind potential worsening of the treated condition. The principle responsibility of physicians in clinical practice is towards their patient. So the ACP would do well to stay away from any recommendation that would obligate its membership do anything else.

PCP said...

Don't talk to me about just allocation of resources, while the RUC through the RBRVU system decides physician payments.
Don't talk to me about the just allocation of resources while countless "non-physician providers" siphon off resources in the name of care. Don't talk to me about the just allocation of resources while PBMs, Hospital oligopolies, DME suppliers, Big Pharma, and Health Insurers skim billions off the top and are consistently enabled to do that.

Why is it that just physicians are expected to be burdened with the limited resources. Where for instance was the SGR for Medicare A, for Medicare D etc. in the last decade?

The irony is that those most equipped to make the rationing decisions ie Physicians are also those that have the largest moral dilemma in doing so. The Insurers have no such qualms. PBMs won't even deal with you. Pharmacies don't worry about unpaid bills, they simply don't deliver the goods and now apparently even with services(with minute clinics).

Until people come to the realization that being a doctor is a social contract and that mutual respect and consideration is needed both at an individual level and at the legislative level, and we learn to entrust the Doctors with that stewardship of resources instead of pressuring them constantly in how they are doing it and disincentivizing those that try to do it wisely, we will continue to have all these middle men and all these debates.
Always, two can play this game. Sadly a few doctors do, further opening the chasm of distrust and continuing the vicious cycle.
I have always believed that doctors have a social contract. However a contract is a two way street. Lately however, it has become quite fashionable to criticize doctors as money craving, price gouging, uncaring individuals, starting, I might add at the very top, remember the "pediatricians that remove kids tonsils because it is profitable" jibe? This is a trend that will not culminate in anything good for society nor its doctors.
One would hope policy makers learn that the only way to control costs is to empower/enable/incent Doctors to do so. All other efforts are doomed to fail.
Take Tort reform for example. Why senselessly take that off the table for a desire to appease the Trial lawyer lobby? Why not reasonably consider the intrusion that DTC advertising has become in the Doctor-Patient relationship? Why focus so much of the attention instead on the marketing to Physicians?

There are many such questions that lead honest physicians who work very hard every day, to question whether we are in fact ready to bend the cost curve, whether we want to do anything serious, or we just like to talk the talk from time to time. Reform is not easy, but it will surely fail if the issues raised here are not addressed.

Jay Larson MD said...

Hear, Hear. Arvind and PCP are making excellent observations.

We apply population studies to management of individuals with the hope that the treatment works. Individuals, though, are just that individuals. What may benefit one person may cause harm to another.

It is through a good physician-patient relationship and experience of the physician that the best fitted treatment is used. As an endocrinologist, Arvid knows that the treatment of diabetes and associated conditions is so diverse that "protocols" are pretty much worthless. We are treating individuals, not populations.

Our social obligation is to keep our patients as healthy as possible. General internists have been so hammered by "prior-authorization" requests by insurance companies that cost effective medicine is the path of least resistance and the treatment of choice.

There are times, though, that more expensive treatments will need to be pursued as generic medications may not cut it. That's just the way it is.

The main moral dilemma is why are medications and treatments so darn expensive? The morality of treatment costs should fall onto the shoulders of CEOs and not on physicians.

The ACP's view that physicians must be committed to social justice and a fair distribution of finite resources is reasonable. The finite resources are not procedures or medications, but the number of physicians that can use them wisely

Rich Neubauer MD said...

Quoting from the introduction to the Physician Charter written by Hal Sox when it was published in the Annals: “Everyone who is involved with health care should read the charter and ponder its meaning.” Quoting from the first line of the Charter itself: “Physicians today are experiencing frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism.”

The authors of the Charter thus articulate that changes in society are driving rapid changes that are shaking the foundations of medical professionalism. In fact, the Charter has attracted attention not just in this country, but in many countries including China. Dr. Sox, in suggesting contemplation of the Charter, implicitly acknowledges that the words of the Charter are not the be all and end all of a new ethical/ professional structure, but rather a framework on which individual physicians may begin to build their personal professional ethos even as society is changing around them.

The three fundamental principles of the Charter are 1) Principle of primacy of patient welfare 2) Principle of patient autonomy and 3) Principle of social justice. To a certain extent, and I believe underlying some of the responses in regards to cost control you quote from the physician survey, physicians perceive that the first principle (primacy of patient welfare) collides with the third principle (social justice). To that extent, I would be cautious in drawing the conclusion you mention “the survey suggests to me that many physicians do not agree with concepts of social justice and fair allocation of resources as described the Physician's Charter on Professionalism.”

To me the most disturbing statistics were those regarding lack of perceived obligations to care for the un and underinsured and the lack of professional commitment to addressing societal health policy issues.

Caution is appropriate in using the survey to interpret the moral compass of the physician community. However, if anything, the survey results seem to validate that the Charter was timely and appropriate in its focus and should indeed be actively pondered by physicians.

Steve Lucas said...

From across the desk let me state what a wonderfully frank discussion this is about a very important topic.

I do wish to followup with a comment made by Arvind about ER visits. I know a number of diabetics and they are fortunate to see out local specialist. Instead of trying to make a square peg fit a round hole, he takes the time to look at their situation, forms a plan to reach a stable blood sugar level, thus eliminating crashes and the associated ER visits.

Having seen a number of peoples lives changed by this, I cannot stress the importance of relationships enough in medicine.

Steve Lucas