Stewardship of health care more than mere juggling act

A message to all physicians from Ardis Dee Hoven, MD, chair of the AMA Board of Trustees.

By — Posted March 21, 2011.

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As physicians, we have an ethical responsibility to manage wisely the health care resources with which we are entrusted.

Being a good steward has never been simple. It requires dedication, knowledge and constant awareness to make the right decisions at any given time under varying circumstances.

It is no easy task to do this in a way that treats everyone fairly and provides the best possible medical care, given disparities in insurance coverage, access to care, technology and many other issues. And while responsibility to individual patients should be paramount as we consider the use of resources, we also have an obligation to patients in general.

Today, with U.S. health care spending almost double that of other industrialized countries and more than 16% of our own gross domestic product, stewardship has become even more of a juggling act.

Granted, the advent of the Patient Protection and Affordable Care Act and the budget debates across the nation make staying on top of the system a moving target. However, that is the milieu in which we practice medicine and do business. And since physician orders and recommendations play a significant role in determining what services and how many services patients receive, these decisions affect the cost of health care -- and ultimately access to care.

At the same time, individual physicians have no control over many of the other factors that drive health care costs. Patient expectations and demands affect costs. The high prices of devices, drugs and hospital and professional services are also significant factors in overall costs. Medical liability costs, which we hope will be brought under control by pending legislation in this Congress, are also a major contributor.

Additionally, population trends -- things like the epidemics of obesity, diabetes and our rapidly aging populace -- all place their own demands on the resource pool.

And when the provisions of the health reform law kick in in 2014, millions more Americans will have access to health insurance, and the challenge to practicing physicians will be enormous.

Because stewardship is such a significant issue today, the AMA Council on Ethical and Judicial Affairs is developing guidance to support physicians in making fair, prudent, cost-conscious decisions that meet the needs of individual patients and help to ensure availability of health care for others.

In the meantime, as we make our way through the daily minefield of expectations, resources, finances, judgments and time, here are some things to keep in mind:

  • First, we must always ensure that treatment recommendations are based on medical need. Physicians should not order, recommend or participate in care that does not offer reasonable likelihood of medical benefit.
  • We need to be sure that we recommend only interventions or services that in the physician's best professional judgment will substantially benefit the patient without placing undue burdens on health care resources.
  • Existing guidelines are a good place to start in making a professional judgment about whether the benefit of a proposed intervention justifies the cost.
  • When probable outcomes are substantially similar, the prudent course is to give preferences to lower cost treatment options over higher cost treatment options.
  • Listen to your patients and work with them to identify their goals for care. Help patients and their families form realistic expectations about whether a particular intervention is likely to achieve their goals.
  • Remember that communication is an important aspect of medical care. Be transparent about alternatives, including disclosing when resource constraints play a role in decision-making.
  • If it becomes an issue, make reasonable efforts to resolve persistent disagreement about whether a costly intervention is worthwhile. This may include consulting with a colleague, ethics committee or other appropriate resource.

This is not to say that anyone should practice unrealistic or one-size-fits-all medicine. Patients are always individual, and judgment is always a part of the mix. Physicians have a responsibility for the course of care they deem most appropriate for their individual patients based on patients' unique clinical circumstances -- including forgoing interventions dictated by guidelines when the patient's situation warrants.

Beyond physicians' individual decisions made on a day-to-day basis, medicine as a profession must play a stewardship role in managing the rising cost of health care in America.

As an example, overall medical culture should be such that a physician can be confident that the colleague to whom a patient is referred also will be judicious in making recommendations about that patient's care.

So important is it that today's physicians be knowledgeable about health care costs and how their own behavior can affect overall health care spending, the University of Michigan's medical school, for one, now offers an elective class on our health care system -- and the class is always filled.

Likewise, any understanding of the system should be buoyed by increased transparency. Health care administrators and organizations must make a practice of making accounting costs transparent so that physicians can exercise well-informed stewardship.

Good stewardship has never been simple. And as we go forward, how we manage those resources entrusted to us will become even more difficult -- and ever more important -- as we serve the medical needs of a growing American population.

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