Perspective
What We Talk about When We Talk about Health Care Costs
N Engl J Med 2012; 366:585-586February 16, 2012
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open through February 22, 2012
- Article
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.
— American College of Physicians Ethics Manual: Sixth Edition, 20121New ethics guidelines from the American College of Physicians (ACP) calling for physicians to practice “parsimonious care” have reignited a debate about the role and responsibility of physicians in addressing the country's problems with health care costs.1 The ACP argues that the guidelines will help physicians to consider more carefully the tests and treatments they order and prescribe for patients and to think on a higher level about the well-being of the community at large.2 Others have balked at the term “parsimonious,” viewing it as implying that care should be withheld and that society should be stingy about how resources are allocated for health care.2
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. Health care costs are a major problem, they admit, but the way out of our dilemma is to deliver more efficient, more effective, and safer care and to reduce waste.3
There is a sturdy logic to these arguments, beyond their obvious political advantages. Research has revealed nonadherence to clinical guidelines, variations in practice patterns, preventable errors, and unnecessary hospitalizations. There is an overwhelming case for being smarter about how we finance and deliver care.
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. We cannot as a society provide patients with unlimited access and unlimited choice. Providing better-quality care, though it is vital, won't change that reality.
The language of the Affordable Care Act highlights the dilemma. The law states, for example, that the newly created Independent Payment Advisory Board, established to recommend spending reductions for Medicare, cannot change benefits, shift costs to patients, or ration care. The law created a Patient-Centered Outcomes Research Institute (PCORI) to conduct comparative-effectiveness research but specifies that the secretary of health and human services cannot use it as the sole basis for denying coverage for items or services. The Affordable Care Act forbids the PCORI and the Department of Health and Human Services from using cost-effectiveness thresholds.
The inclusion of “patient-centered” in the name of the PCORI underscores the issue. On the one hand, the focus on patients has clear benefits, apart from its inspired branding. As PCORI Executive Director Joseph Selby recently observed, “The notion that patients could be at the center of a research enterprise is pretty different from the way research has rolled out over the past century.”4 The idea is to concentrate on outcomes that patients view as important. The PCORI website lists questions of consequence to patients (e.g., “What can I do to improve the outcomes that are most important to me?”) and stresses that individual patients value different outcomes differently. The PCORI has also embraced “stakeholder engagement,” which, like patient-centeredness, acknowledges the importance of giving a voice to affected parties and ensuring that clinical studies answer relevant questions.
However, changing the conversation to emphasize patients and stakeholders also has unhelpful consequences that few are willing to acknowledge. 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. Moreover, the only stakeholders seemingly not at the table are future taxpayers (our children and grandchildren).
The resulting conversation allows little space for cost concerns. It ignores resource constraints and has an unreal, wishful quality to it, as though skydivers could defy gravity by cleverly talking their way around it. Rarely is there any 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 and physicians and hospitals with less revenue.
Even the move toward accountable care organizations (ACOs), for all its promise, will not eliminate the need to confront trade-offs. With their focus on integrating systems, rewarding performance, coordinating care, and reducing spending growth, ACOs should bring much-needed change. However, they will also decentralize choices, not remove them. Indeed, because they will put providers at financial risk and tie together payments for a continuum of care, ACOs may represent the ideal model for delivering parsimonious care, though that terminology is rarely employed.
The challenge is how to have a more honest conversation. A candid discussion could set expectations, inform policy debates, and help the country prioritize uses for resources within and outside the health care sector. There seems to be little evidence, however, that such a conversation will take place, at least in the public sphere. There is no political advantage in talking realistically about our problems. The election-year rhetoric will continue to emphasize prevention, quality, and health information technology. On the campaign trail, the speechifying will be about fraud and abuse, the evils of rationing, and the need to improve our way to sustainability.
That is why the new ACP guidelines are so valuable. Their focus on responsibility, their direct acknowledgment 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. The ACP should be applauded for its engagement of costs. Is “parsimonious” the right word? Perhaps there are better ones, but “frugal,” “prudent,” “thrifty,” “cost-conscious,” and others would also raise objections. Whatever we call this necessary quality, the conversation could use a dose of reality. Calling it parsimonious is a reasonable start.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
Source Information
From the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, and the Tufts University School of Medicine — both in Boston.
- References
References
1
American College of Physicians Ethics Manual: Sixth Edition. Ann Intern Med 2012;156:73-104
Medline2
Stein R. Should doctors be `parsimonious' about health care? Washington, DC: NPR Health Blog, January 3, 2012 (http://www.npr.org/blogs/health/2011/12/30/144485098/should-doctors-be-parsimonious-about-health-care).
3
Dr. Donald Berwick addresses Catholic health leaders. Washington, DC: Catholic Health Association of the United States, June 6, 2011 (http://www.chausa.org/Pages/Newsroom/Releases/2011/Dr__Donald_Berwick_Addresses_Catholic_Health_Leaders/).
4
Dentzer S . The researcher-in-chief at the Patient-Centered Outcomes Research Institute. Health Aff (Millwood) 2011;30:2252-2258
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- Comments (5)
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5 Reader's Comments
JAMES RICKERT, MD | Physician | Disclosure: NoneBLOOMINGTON INFebruary 20, 2012ACOs and Patient Centered Care
Cost effective patient centered care can be delivered by ACOs while maintaining high patient satisfaction rates.
DAVID RIVERA, MD | Physician | Disclosure: NoneLOMBARD ILFebruary 18, 2012The Elephant in the Room
Cutting our annual health care expenditures depends on doing less and/or paying less. Who gives in first? Hospitals? Patients? Physicians? Pharmaceutical companies? Technology and device companies? Insurance companies? I’ll work for less money in exchange for getting the plaintiffs’ attorneys off my back, better working conditions and being able to talk to my recalcitrant patients like Judge Judy instead of Marcus Welby.
As an obstetrician, I often do more than I think is necessary. I don’t give a damn about any “quality metrics” and “chronic disease guidelines” because my patients don’t care. If there is a bad outcome and the patient’s perception is that I didn’t do everything possible, I’m likely to be sued. Witness the recent furor over the USPSTF breast cancer screening guidelines.
Customer service is the patients’ proxy for quality and competence. Americans believe “more” care is “better” care, a perception freely exploited by hospitals and drug companies. If you really want to change health care, patients need to be part of a public debate on how everyone contributes to health care costs, instead of being seen as hapless victims.ilaboo lener | Other | Disclosure: NoneFebruary 16, 2012what are you talking about?
I go to pharmacy to get new medication--it costs me $40.00 for 30 tablets. Person next to me on Medicaid pays nothing for hers. I need not tell you what my wife's cataract post surgery medications cost. The entire waiting room was full of patients on Medicaid and this system has the nerve to tell me to open my wallet while others don't. Some one is hallucinating. The American people right now I doubt has any idea whatsoever what changes are going to impact on their costs. The people on Medicaid are the only one who won in this scenario . I am a retired Physician Assistant with 30 years of experience throughout the country.
STEPHEN KARDOS, DO CEO | Physician | Disclosure: NoneRUMSON NJFebruary 16, 2012Parsimonious Health: A Rogue Wave
Choosing more socially acceptable terms to describe economic models to reduce health expense perpetuate a rogue wave in America's thought that an economic solution is the way to reform health care. For those of us who examine the relationship between Value, Cost, and quality in health, the use of quality metrics, not economic metrics, are required to bend the trend and reduce the medical expense burden patients and doctors suffer from. Examination of many population studies from private and public sponsors of health care highlight poor compliance to basic preventive health and chronic disease guidelines from the American Cancer Society, the American Diabetes Association, The American Heart Association, and the American Academy of Pediatrics. The following equation Quality = Outcome/Cost should guide America's discussion on health reform. Outcome is defined by compliance to preventive guidelines for preventive health and chronic disease management. Patients, their care givers, and health plan sponsors must be made aware individually and collectively about what the actual quality of care rendered and received is. Parsimonious health will do nothing to insure quality and lower cost of care.
Putting the Cart Before the Horse again.
At what cost?
When the body, mind and soul of the employee is unhealthy, there is a cost to the employer and to everyone involved.
Health literacy on what is meaningful first needs to be established before the cost cutting conversations begin.