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Bioethics Corner: Who is responsible for lowering healthcare costs?

By SAAD ANJUM | October 31, 2013

The Journal of the American Medical Association published an article by Jon C. Tilburt et al., a former Greenwall Fellow at the Berman Institute, entitled “Views of US Physicians About Controlling Health Care Costs.” I sat down with Matthew DeCamp, MD, PhD, an Assistant Professor at the Hopkins Berman Institute of Bioethics, to talk about the results of the survey.

Saad: As both a bioethicist and a physician, what are your initial thoughts on the results of this survey? Do you think that physicians should bear responsibility for controlling healthcare costs? If so, to what extent?

Dr. DeCamp: I agree with the authors that physician views on controlling health care costs are complex. The physicians surveyed attribute major responsibility to others named in the survey while also acknowledging their own responsibility. In addition, physicians reported being well aware of the costs of health care and the need to reduce costs while also remaining firmly attached to the idea of patient’s best interest.

Saad: Do you think that physicians are well-placed to confront challenges related to costs should they bear the responsibility?

Dr. DeCamp: On the one hand, physicians hold the final pen that writes the prescription, or, increasingly, the final keystroke — in the era of electronic medical records — to hit the “order” button. So to that extent, physicians will play a role in cost control efforts.

Saad: That’s interesting; the survey states that 56 percent of physicians attribute a major responsibility to pharmaceutical and device manufacturers. How do you think prescriptions would relate to that?

Dr. DeCamp: As the authors point out, one intervention that could help assist physicians in cost control efforts would be clinical decision support systems. These point-of-care tools can help physicians — who are already trained in assessing the risks and benefits of particular interventions — make better choices by providing the right information at the right time.  To that extent, we also need high quality comparative effectiveness research and clinical decision support tools for physicians to confront cost challenges.

Saad: Do you think that there’s a possibility that resistance from doctors would prevent any successful efforts to control costs?

Dr. DeCamp: It really depends on the details of the cost control strategies. Taking the findings of the survey seriously, I think, leads you to believe that physicians will be resistant to interventions that they perceive hinder their obligations of beneficence to their own patients’ best interests.

Saad: What about physicians with market shares in the devices and procedures they use? For example, a group managing surgery centers presents their ‘focus’ as “Generate maximum revenue, profitability, and market share for surgeons through the development and management of successful ambulatory surgery centers” help explain some of the survey’s findings?

Dr. DeCamp: I don’t really know enough details to comment on that case in particular. At the end of the day, health care here exists in a competitive market place. Cost and profit matter. Other researchers have found that physician ownership of facilities like ambulatory service centers seem to be associated with increased volume, but what we don’t know is whether that increased volume represents increased inappropriate care.

Saad: That idea of cost and profit and maximizing profit through the market shares — do you think that would be a strong obstacle to reducing healthcare costs?

Dr. DeCamp: I think it really depends on the details of what happens when market shares increase. One could imagine increased market share leading to increased cost, or to better care coordination and integration, or something else. The details matter.

Saad: That’s fair. Switching gears, do the findings from Tilburt, et al seem consistent with your experiences as a clinician?

Dr. DeCamp: I think we as clinicians recognize this increasing concern over cost. So the tension the authors interpreted between physicians’ role in cost containment strategies and their obligation to their own particular patients is a very real one. And it comes up, in some sense, daily in clinical practice whenever you’re choosing an intervention for a particular patient. That tension definitely resonates.

Saad: Furthermore, as far as opinions go, in an editorial that was also published in The Journal of the American Medical Association, Dr. Ezekiel J. Emanuel and researcher Andrew Steinmetz state that controlling costs is a fundamental domestic policy challenge, and that confronting the complex challenges represents an ‘all hands on deck’ moment. They further suggest that physicians must take the lead, as captains of the healthcare ship, in a multimodal approach to reducing health care costs. Do you think that this analysis is correct? Is this an all-hands-on-deck moment? Why or why not?

Dr. DeCamp: The editorial and the article are right to point out that a number of players or stakeholders need to be involved in controlling healthcare costs. Many people think that including physicians in positions of leadership, or engaging clinicians in the process of developing cost controlling strategies, represents one way to mitigate the risk of infringing obligations of beneficence. To that extent, physicians will obviously play a role in developing and implementing cost control strategies.

Saad: Do you think that physicians should take lead and set an example for the other aspects of the healthcare market on reducing costs?

Dr. DeCamp: Physicians should definitely play a role on leadership teams that make these kinds of decisions. Most leadership occurs in teams, and as one important stakeholder, physicians should be on such teams.

Saad: Is there a potential cost-reducing system you as a physician and bioethicist would approve?

Dr. DeCamp: As a physician and bioethicist, I’m most interested in cost-reducing systems that do not infringe upon physicians’ obligations of beneficence and their relationships with patients. The survey notes that physicians understand the need to reduce costs and to reduce unnecessary care. But they want to do so in a way that preserves their fiduciary obligations to patients. A system that maintains physicians as fiduciary advocates is one that many physicians would probably endorse.

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