Doctors Consider the Cost of Effective, Appropriate Health Care

Somewhere between scary false terms such as “death panel,” voiced by opponents of the Obama administration’s health care reform (the Affordable Care Act, or ACA), and the truly scary increase in the cost of health care lies a reasoned, enlightened conversation about what is appropriate care, and what it costs.

Often, the last people to endeavor to defuse the rhetoric and reality of medical care in America are the people who provide it. After all, consumers and insurers want and expect doctors and other caregivers to be, first and foremost, scientist-artists who can diagnose individual problems and treat them. We don’t expect them to be actuarial types, who perform cost-benefit analyses, and make treatment decisions based on numbers.

Do we?

Kinda. But not because we want to. We have to, because everyone is affected when people needing health care go without, when subsidizers pay too much and when the corruption in publicly funded programs gobbles up taxpayer resources.

So the American College of Physicians recently took the no-win bull by the horns and weighed in on whether doctors should consider cost when making decisions on how to treat patients. In its latest edition of ethical guidelines, published in the Annals of Internal Medicine, the ACP said, yes they should.

As recounted in a story on National Public Radio, topics that once were deemed unseemly for a caregiver to consider are an important part of health-care reform. Topics such as:

* Is a breast cancer drug worth its $100,000 cost if it adds only a few months to a woman’s life?

* Should certain tests, such as those for prostate cancer and mammograms, be routine for everyone if they’ve been shown to cause more suffering for a lot of people than the woe they’re trying to prevent?

These thorny issues are hardly news, and we’ve written about them many times-here and here, for example. But when a major medical group not only chews them over but also codifies them in its ethical guidelines, that’s a provocative act. That means that the discussion no longer is a polarized screed between clearly defined camps. It means these issues transcend political expedience and must become public health policy.

The ACP represents 132,000 internists. Their president, Virginia Hood, told NPR, “The cost of health care in the United States is twice that of every other industrialized country. We’re not providing care to as many people as they do in other places and we don’t even have as good outcomes.”

One way to promote better outcomes, she said, is for doctors to think harder about the tests they order and the treatments they prescribe. “Every time you prescribe something for a patient or subject them to some kind of investigation,” Hood said, “there’s a risk of harm, so the concept of doing less is actually a really good concept.”

One bioethicist told NPR that as soon as “cost” becomes a part of “care,” the notion of rationing enters the picture. And no one’s comfortable with that. Which makes some people wonder how many individual doctors will follow the ethics manual’s guidance-they already make the tough decisions that become only more difficult when patients demand an extra test or drug, patients who might be desperate for something, anything, that will restore their health or save their lives.

In that circumstance, yes, it is difficult to concentrate on an individual patient’s needs and simultaneously consider the well-being of the community at large. It’s difficult to remember that the whole is greater than the sum of its parts.

Which makes the ACP’s new guidelines so remarkable.