Doctors, decisions and dollars: Why stewardship matters

Physicians alone can’t rein in U.S. health spending. However, what they can do is take cost into consideration when there are options for the best way to treat a patient.

Such is the key finding of a report by the American Medical Association Council on Ethical and Judicial Affairs, which declares that wise stewardship of limited health resources is an ethical obligation for physicians. The report, approved by delegates at the AMA Annual Meeting in June, was written and refined over three years to allow for careful consideration of what stewardship means, what it doesn’t mean, and what resources needs to be made available to physicians to fulfill that role.

Stewardship flows from physicians’ obligation to do what is best for the patient’s health, whatever the price tag. Yet there are factors away from the bedside, outside of doctors’ control, that impede their ability to be good stewards.

As the report noted, as of 2009, U.S. health care spending represented 17.6% of the gross domestic product, almost double that of other industrialized countries. The level of spending has become a burden to governments, businesses, families and individuals, and there are numerous efforts throughout the health system to find ways to relieve that financial pressure. Some of them — such as private insurers’ ham-handed attempts to reduce pay and restrict patient access to services —have drawn physician fire for being focused solely on cost at the expense of health, or for making cost-benefit analyses with little or no physician input.

Physicians recognize that they need to make fair, prudent, cost-conscious decisions for the good of their patients. More care, and more costly care, is not necessarily the best course of treatment. With that in mind, CEJA began working on its report to help give guidance on how all that can be done without compromising the health of their patients.

Stewardship is a process where a physician starts by asking: What is right for the patient? Stewardship certainly isn’t about cutting corners to save a few bucks. The doctor isn’t obligated to try some cheaper option if there is a clear indication, based on professional judgment, that a certain treatment is right.

However, there might be options available as the physician uses his or her knowledge of the efficacy of treatments, tests and procedures, and their costs — both short-term and long-term. Even a treatment that is more expensive up-front could save money and improve a patient’s health over time.

Physicians can involve patients and their families in the decision-making, laying out the case for a less expensive treatment that would be just as effective as one that costs more. Doctors already are under ethical obligation to avoid performing unnecessary tests and procedures, even if a patient demands them. Ultimately, it is transparency and clear communication between the physician and patient (and the patient’s family) that provides the best environment for a doctor to make the right treatment decision and make the wisest move as a steward of health care resources.

The report isn’t the AMA’s only effort in addressing the management of limited medical spending resources. It also supports the Choosing Wisely campaign, in which medical societies present their own lists of tests and procedures that “physicians and patients should question” before going ahead with them to ensure they are necessary

Physicians also should be able to look outside the profession for credible help. As the CEJA report points out, health care administrators and organizations need to make cost data transparent, including cost accounting methodologies, so physicians can exercise well-informed stewardship. In many cases, a physician’s decision on treatment will involve sending a patient to an outside lab, or a hospital, or another physician, or somewhere that doctors have limited control of costs. A doctor can’t be a steward if he or she doesn’t know what something costs. Along similar lines, the report says physicians and medical students need training to learn about health care costs and how their decision-making can affect overall health spending.

Finally, the report notes that there are systematic barriers that prevent physicians from being good stewards: a medical liability system that needs reform so that doctors aren’t compelled to practice defensive medicine. A June 2010 study in Archives of Internal Medicine said medicine’s cost to avoid medical lawsuits is about $60 billion a year.

For physicians to be the best stewards of health care, they need to know that their colleagues also are making the same effort, and that the health system is there to support them. CEJA’s guidance is focused on physicians but speaks to the whole health care sector on how high-quality care can be provided in ways that preserve resources to better meet the needs of all patients.