Can we control health costs without rationing?

Robert Brook, MD, health services researcher extraordinaire, wrote a provocative commentary in JAMA – as he is accustomed to doing – entitled “What If Physicians Actually Had to Control Medical Costs?” In his piece, Brook challenged physicians to take a lead role in addressing the cost dilemma and called on physicians to find alternative strategies to rationing.

No matter how spot on Brook was in his call to physicians to lead these efforts, his use of the “R word” will not engage them in this important issue.  Telling physicians that they must be involved in explicit rationing will always be a nonstarter.  Rationing is the extreme view; there is a lot that can be done to control costs without having to resort to rationing.

For starters, let’s address waste, unnecessary care and care of marginal benefit and see what that produces in terms of better quality and lower costs. In addition, solving the cost issue must be seen as a shared responsibility by all stakeholders – including patients, payers/purchasers, government and communities. Physicians will rise to this challenge when they are being supported and aided by all of these constituencies. If physicians feel it’s a shared responsibility with shared accountability, they are more likely to become engaged in this mission and their patients will benefit from their engagement.

Patients need to take an active role in their care, be encouraged by their physicians and get involved in decisions related to medical decisions.  They need to recognize that some care may be harmful and more is not always better. The public at-large needs to recognize that overuse of health care resources has an impact on other vital community services like education.

The more we can equip physicians with evidence, decision support and IT support, the more we relieve physicians of the need to make bedside rationing decisions.  We don’t need to return to the political firestorms we saw last summer about what to do with my 89-year-old mother when she becomes gravely sick. What my mother and I don’t need is an unnecessary test.

Daniel Wolfson is COO of the ABIM Foundation and blogs at The Medical Professionalism Blog.

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