first – I’m not happy with the title of this post. That’s not really the point here, but if someone else can come up with something witty/creative, much appreciated. second – this post is long and hopefully isnt completely flight of ideas. bear with me, it should be good.
There is a time honored tradition in medicine known as the physician’s fiduciary duty to the patient. For the record, I didn’t know what fiduciary meant for longer than I’d like to admit. For those who don’t know, a fiduciary duty is a legal or ethical relationship of confidence or trust between two or more parties. In medicine, it works like this: Patient X walks into Doctor Y’s office with symptoms Z. Once Doctor Y agrees to accept Patient X as his or her patient, the fiduciary duty begins. Patient X accepts Doctor Y as his/her doctor, and Doctor Y agrees to treat Patient X for symptoms Z to the best of his/her ability while maintaining privacy and confidentiality. At the end of the encounter, Patient X pays Doctor Y for his/her services.
It sounds simple, and truly for awhile it was. When the scope of medicine was small, the availability of treatments was limited, and the cost of service was negligible, the doctor-patient interaction was straightforward. For better or for worse, we no longer live in that world. We now operate in a system with vast scope, myriad available treatment options, and high prices and costs. In fact, the one phrase (in various iterations) that seems to dominate health care these days is “cut costs.” More and more, patients, payers, and hospitals have an eye on the healthcare dollar, constantly hearing that the costs of health care are rapidly rising and bankrupting the nation. The real question is – to what extent do physicians need to keep an eye on costs?
In her NYTimes blog (as an aside, one of my favorite columns – I HIGHLY recommend following her articles), Dr Pauline Chen recounts a story from her training about the costs of care:
One doctor-in-training proposed blood work. A fellow student suggested a urine test. Another classmate asked for abdominal X-rays. My hand shot up. “A CAT scan,” I crowed with confidence. “I’d get a CAT scan!” The senior doctor coughed. “That’s an awfully expensive test,” he said, a grimace appearing on his face. Another student asked him just how much a CT scan cost, and he shifted uncomfortably in his seat and shrugged. “I don’t really know,” he said, “but I do know that we can’t just think about the patient anymore.” He took a deep breath before continuing, “We are now being forced to consider costs.”
Chen’s experience occurred over 20 years ago during the managed care experiments of the 80’s and 90’s. However, the cost chatter hasnt changed much and has only become louder and stronger. There is a growing commentary that more than anyone, physicians need to focus on the cost of care.
The reasoning seems to make sense: while actual spending on physician services only accounted for 19.8% of the roughly $2.6 trillion of National Health Expenditures in 2010, physicians make the decisions that account for the most of the remaining 80%. As has been pointed out by many in the fields of public health and health economics, physicians are the gatekeepers of the medical world. Physicians are the ones ordering labs and radiologic imaging, referring patients to specialty providers, deciding who and when to admit to what hospital, and deciding when patients are stable for discharge to home, rehab, or skilled nursing facilities. With the advent of electronic medical records, ordering tests and studies is even easier; unfortunately, electronic ordering systems do not note the associated price tags for services ordered. Physicians remain in the dark about the costs. The simple click of a button can add hundreds if not thousands of dollars to a patient’s bill.
I have certainly heard during my surgical residency that we need to be aware of the costs of care, that health care is becoming too expensive. And a few of my attendings have definitely demonstrated behavior aimed at reducing the cost of hospitalizations in constructive ways – for example, not ordering routine labs daily on inpatients or avoiding unnecessary CT scans for certain diseases like small bowel obstruction, pancreatitis, and appendicitis… in the right clinical setting of course. I can remember instances on the wards in medical school of attendings quoting the price of a complete blood count and a chemistry panel (around $300) or other tests. To be sure, there is a very small but growing sentiment in medical education to teach cost-conscious care. As Chen also points out in her article, this can be a monumental task for several reasons, including the lack of knowledge around cost and charges (many do not know that there is a difference between these two) but also the secrecy and varying costs and payments between regions, hospitals, and physicians.
But controlling costs becomes tricky when physicians must choose to forgo delivering high quality and ethical care for their own individual patients in the name of saving money for the system as a whole. The physician’s fiduciary duty requires treating the patient with appropriate quality care at the highest ethical standards. Nowhere should it be understood that the duty is subject to cost containment. Keeping an eye on costs is certainly important, and the “fat” should be trimmed where possible, but more importantly where clinically relevant. The price of care should never figure into clinical decision solely for the purpose of saving money, especially if denying care due to cost considerations hinders quality or violates the principles of medical ethics.