News

The Feb. 16 issue of the New England Journal of Medicine had an excellent commentary by Peter Newman about how difficult it is to talk to the public about health care costs.

He captures the issue well:

“The problem is that no one in charge seems willing to acknowledge that getting a handle on cost growth will also involve uncomfortable trade-offs. We cannot as a society provide patients with unlimited access and unlimited choice. Providing better-quality care, though it is vital, won’t change that reality.”

He goes on to note that our political discourse—one that has emphasized a shift to patient-centeredness—has further compounded the difficulty in this conversation. He says:

“Changing the conversation to emphasize patients and stakeholders also has unhelpful consequences that few are willing to acknowledge. Focusing on patients’ own preferences to the exclusion of considerations of societal resources will only compound our cost problems. Engaging stakeholders is undoubtedly important, but one person’s stakeholder is another person’s interest group. Moreover, the only stakeholders seemingly not at the table are future taxpayers (our children and grandchildren).”

Newman’s commentary begins with a nod to the American College of Physicians’ (ACP’s) new ethics guidelines, which speak to the need for physicians to use resources efficiently, and indeed, “parsimoniously,” to help assure that resources are used equitably. He applauds the ACP for its guidance, and mentions several other entities that have a role in dealing with this issue, but in the end he does not suggest an answer to this important question: Who can have this conversation with the public?

While I, too, applaud the ACP for the clarity and rightness of their guidelines, I am not convinced that resource trade-offs should be in the purview of physicians—at least not in their one-on-one interactions with patients.

After all, where does the physician’s duty lie? Is it society at large, or the individual patient before them? If a procedure is very expensive and raises premiums for a particular group, while at the same time benefiting one patient, is it the physician’s responsibility to look out for the group, or the patient? As a patient, I hope my physician is looking out for me. While I agree that physicians have a duty to be efficient, that doesn’t go to the depth of making “uncomfortable trade-off” decisions. And it certainly cannot be other providers of care, for the same reasons as for physicians.

Who else is involved and can speak to the issue credibly?

Well, health plans make decisions about trade-offs like these; can they be the ones to lead the dialog with the public? I can say from personal experience that this is not a role for health care payers. Some years back, a physician recommended my father undergo a medical procedure that I thought might not be needed. I raised the concern with my dad; he told me in no uncertain terms that he believed my concern was prompted by my job (at that time) with a health insurer and that I was just interested in saving money. This despite the fact that I didn’t work for the insurer who provided his coverage, lived in a different state, and most importantly—he was my father—not a stranger. If I couldn’t convince my own father that my concern was based on the fact that too much medical care carries risks and can cause harm; I certainly couldn’t be the one to convince others.

So, not providers or health plans; who else is there? Well, I think it is safe to say it won’t be those who stand to gain financially by increased use of services (e.g. drug and device makers).

What about consumer advocates—could they take on this role? Not really. Their role is specific—advocating for the consumer, not for society as a whole or future generations.

Again, I ask: who is left? Who can have this conversation with the public?

Public policy makers. They have been elected to look out for the public interest; they are the ones who ought to be concerned about future generations; they are the ones who have the bully pulpit and can use it to communicate hard truths.

Unfortunately, our current public discourse does not promote this kind of dialog. Either the public doesn’t want to hear hard truths, or policy makers are too fearful to speak them. But until we are honest in our public discourse, we will not be able to moderate the increase in health care spending to any significant degree.

Better quality, better health, and patient-centered care are all good. But, as Newman notes, in the end “hard” trade-offs are necessary if we are going to address health care spending as well. For the sake of our children and our grandchildren, let’s hope that someday, we will have policy makers who are willing to have that honest conversation, and that we are willing to listen.