• In NEJM, Fuchs and Milstein say docs need to step up

    In The New England Journal of Medicine last week, Victor Fuchs and Arnold Milstein ask why cost effective care has been so slow to diffuse. They spread the blame widely. The meat of the short paper (ungated) is a series of paragraphs critiquing the media, legislators, hospital administrators, academic health centers, and pharmaceutical and device manufacturers. Somewhere in the middle of all this, they also describe physicians’ role. It isn’t clear until the end that they think it’s the docs who really need to step up, who have the power, trust, and obligation to do something serious about health care.

    Physicians themselves generally resist major changes in the way they practice — for both nonfinancial and financial reasons. They see that their peers who practice most cost-effectively typically standardize their approaches to care, rely on group decision making, and emphasize outcome measurement and peer review. Most physicians are reluctant to embrace these reductions in autonomy. They also see that many of the most successful health plans forgo fee-for-service physician payment in favor of alternative methods, such as capitation or value-based remuneration. They fear that the projected cost savings will not be fully realized or will be captured by insurance companies and hospitals. And indeed, physicians in highly paid specialties would probably lose income in a more cost-effective system, though primary care physicians would probably come out ahead. […]

    [T]he public’s visceral distrust of policies aimed at improving the cost-effectiveness of health care can be neutralized only by their confidence in what their physicians support. The Physician Charter, a modern version of the Hippocratic Oath, has been adopted by physicians’ organizations that include a majority of U.S. physicians. It ethically commits physicians to working toward “the wise and cost-effective management of limited clinical resources.” There is not much that physicians can do directly to change the behavior of insurance companies, employers, or other stakeholders, but physicians are the most influential element in health care. The public’s trust in them makes physicians the only plausible catalyst of policies to accelerate diffusion of cost-effective care. Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this national fiscal and ethical imperative? It’s a $640 billion question.

    Perhaps for physicians, it’s an uncomfortable question, but at least Fuchs and Milstein think it is the right one. What about you?

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