AMA House of Delegates

AAFP President Glen Stream, MD: "It's simply a reality of practice." Photo by Ted Grudzinski / AMA

Doctors advised to consider costs in care choices

The AMA's new ethics policy advises physicians to manage scarce medical resources wisely.

By Kevin B. O’Reilly — Posted July 2, 2012

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Physicians have an obligation to recommend the less expensive option when the available medical alternatives offer a “similar likelihood” of patient benefit, according to ethics policy adopted at the AMA Annual Meeting.

Doctors ought to be “prudent stewards of the shared societal resources with which they are entrusted,” says the ethical opinion. The Council on Ethical and Judicial Affairs report overcame objections that it could wrongly limit physicians’ ability to advocate for the interests of individual patients when those conflict with the need to constrain health care costs. Medical spending consumes nearly 18% of the U.S. gross domestic product.

Glen Stream, MD, president of the American Academy of Family Physicians, spoke on the House of Delegates floor on behalf of the academy in support of the report, which had been considered at several previous meetings.

“We acknowledge that this is a controversial issue, and it’s gone back and forth to CEJA, but we do believe they got it right this time,” said Dr. Stream, a Spokane, Wash., family physician. “It’s simply a reality of practice in our current health care system that our resources are limited and that we, as physicians, should have the discretion to be wise stewards of these resources.”

The ethics policy says “individual physicians alone cannot and should not be expected to address the systemic challenges of wisely managing health care resources” and calls on hospital administrators and others to make cost information transparent. Also, doctors should get training to inform themselves on health costs and how their decisions affect overall medical spending. Policy changes such as medical liability reform could help ease physician decision-making on costly care, the council report says.

Concern about economic profiling

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Alan M. Mindlin, MD, opposed the policy, saying it's not always obvious which medical alternative is less expensive. Photo by Peter Barreras / AP Images for American Medical News

Several delegates voiced reservations about the policy. Alan M. Mindlin, MD, opposed adoption, saying it is not always obvious which alternative is less expensive. An intervention that may be less expensive in the short term could be costlier in the long run, he said. The ethics report could be misinterpreted by payers or hospitals that are credentialing or profiling physicians on an economic basis, he added.

Dr. Mindlin also objected to the term “steward,” arguing it could undermine the physician’s role as patient advocate.

“I started as a physician-healer, then I became a provider, and now I’m a steward,” said Dr. Mindlin, a Bloomfield Hills, Mich., ophthalmologist and a Michigan State Medical Society delegate who spoke on the society’s behalf. “I will choose what’s best for my patient, even if I need to use more resources up-front. The bottom line is that may be a better outcome for the patient in their daily life.”

That kind of scenario is “a perfect example of physician judgment that’s also ethical stewardship,” said CEJA member Susan D. Goold, MD. If a medical option is clearly better for the patient and saves money over the long run, choosing it is a wise course, she said.

“We want to retain physicians’ discretion to make exactly those kind of judgments,” said Dr. Goold, an Ann Arbor, Mich., general internist.

The AMA’s action comes amid growing focus on restraining health spending. In January, the American College of Physicians published an updated version of its ethics manual that advises doctors to deliver “parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient.” In April, the American Board of Internal Medicine Foundation unveiled a list of 45 overused tests and procedures that nine specialty societies say doctors and patients should think twice about. Eight other societies this fall will release suggestions on interventions to avoid, the foundation said.

Meanwhile, the Medicare Independent Payment Advisory Board, enacted as part of the Affordable Care Act, has the power to restrain costs in a way the AMA has said is arbitrary, indiscriminate and adversely affects patients. The Association opposes the board and applauded the U.S. House of Representatives in April for passing a bill to repeal it. The legislation is stalled in the Senate.

Adopting ethics policy urging physicians to be conscious of cost is an act of leadership, said Dr. Goold, a professor of internal medicine at the University of Michigan Medical School.

“This is medicine taking the lead, saying we need to keep health care spending down so people can have access, so that the system works for patients, families and businesses,” she said. “If it’s not physicians saying this is what we need to do and how to do it, who would?”

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External links

Choosing Wisely, American Board of Internal Medicine Foundation (link)

“American College of Physicians Ethics Manual: Sixth Edition,” Annals of Internal Medicine, Jan. 3 (link)

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