Tuesday, September 14, 2010

The Doctor Autonomy Dilemma: Who Decides?

In recent political debates, the autonomous physician has been portrayed as a problem to be solved, an out-of-control actor motivated by greed – and a major cause of rising health –care costs. Insurance companies and the federal government have sought to control physician behavior with the dual aim of decreasing costs and improving care. In their view, individual and regional disparities in rates of medical testing, hospitalization, and surgical procedures are ipso-facto demonstrations of physician autonomy run amok.

Saul Greenfield, MD, director of pediatric urology at the Women and Children’s Hospital of Buffalo, “In Defense of Physician Autonomy,” Wall Street Journal, September 9, 2010

The practice of medicine, and who pays for it, is a highly personal, emotionally charged, politically volatile element of current policy debates.

Who should pay? The government, the employer, the patient. That is the first question.

Who should decide for what to pay? The government, the employer, the patient, or the physician. That is the second question.

What criteria should be used to establish for what to pay? That is a third question.

Should government make the decision – using statistical criteria developed by comparative effectiveness research, outcomes, and regional disparities? That is a fourth question.

Should employers, and their surrogates, health plans, using federal criteria as well as their own, decide? That is fifth question.

The sixth and last question is: Should autonomous physicians, in concert with their patients, decide? Physicians and patients are, after all, closest to the scene of the illness and know most intimately the stakes involved.

The answers to these questions comes down to yet another question: How does one control runaway spending in an aging population in a democracy in which politicians promise affordability and protection against the dire consequences of illness?

One can rely on government rationing, usually presented as “cuts” in “waste,”"savings," or "increased efficiency." One can rely on market forces promoting “competition.” One can rely on consumers spending their own money, thereby incenting them to be selective on what they will pay for.

Or finally, one can place your bets on controlling costs by dictating physician behavior. In the final accounting, most politicians believe the physician’s pen, or increasingly, his or her computer keys, determines the cost. To control behavior, one uses anonymous statistical data, based on large population studies, to assure uniform, standardized behavior to control physician autonomy.

Doctor Greenfield, who I quoted in the opening of this essay, summarizes the irony of it all with this telling sentence, “Physician autonomy is a major defense against those who comfortably sit in remote offices and make calculations based on concerns other than an individual patient’s welfare.”

Remote bureaucrats, of either the public or private stripe, will never be able to gauge the hopes, feelings, and consequences of their remote judgments when a patient and a doctor meet in the exam room to decide what is best for the patient. The outcome of this meeting hinges on those imperishable elements of a democracy called individual freedoms of choice and action and clinical judgment.


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