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Book Review

The Difficulty Of Controlling Health Costs

  1. David J. Rothman ( [email protected] ) is the Bernard Schoenberg Professor of Social Medicine, Columbia College of Physicians and Surgeons, in New York City.
PUBLISHED:Free Accesshttps://doi.org/10.1377/hlthaff.2011.1089


If anyone doubts the difficulty of enlisting physicians to help contain health care costs, Gregg Bloche’s The Hippocratic Myth will quickly demonstrate how extraordinary the barriers are to success. Principles once thought fundamental to the equitable delivery of health care in the United States now are subject to fierce debate, as this book aptly demonstrates.

Bloche, trained as a psychiatrist and now a professor of law at Georgetown University, has written astutely about many pressing issues in medical ethics. Here he opens by celebrating the Hippocratic Oath recited by doctors for its undivided commitment to patients’ well-being. But in short order he terms the oath a myth—and rejects the idea that physicians’ first and only duty is to the patient. He is determined to make community responsibility an integral part of the physician-patient relationship, but despite considerable knowledge and best efforts, he is unable to do so in a consistent way.

Bloche is rightly concerned with the social costs of unbounded medical spending. At the same time, like many others, he is apprehensive about physicians’ bringing a cost calculus into the examining room. He criticizes physicians for being willing to “control costs by forgoing beneficial care” and blames policy makers for demanding that doctors compromise their Hippocratic ideals. But he sees no way to counter the pressure of the policy demands. “We’ll eventually insist that doctors say no to beneficial or even life-saving treatments because society cannot afford them,” he warns.

The prospect of unaffordable treatments, Bloche fears, will mean that the medical profession will suffer a “loss of trustworthiness in the eyes of patients,” even as the spell cast by the Hippocratic Oath prevents physicians from admitting the truths about rationing resources to themselves or to their patients. In the end, however, he swallows his reservations and endorses bedside rationing—provided it is done with candor. “Medical practice can and should take public values into account,” Bloche writes. It cannot “stay apart from economics and politics.” Doctors must promote the public good, but do it somehow or other without breaching “the trust built in clinical relationships.”

Bloche does not share the hope expressed by some policy analysts that practice guidelines put in place on the basis of rigorous clinical research will reduce wasteful medical treatments and obviate the need for rationing. He believes that practice guidelines “that count cost are a policy imperative if America is to avert fiscal catastrophe.” Outcome data joined to a calculus of cost-effectiveness might help contain spending. But Bloche backs off this approach, arguing that guidelines of any sort give doctors too much space “to ration covertly under the clouds of scientific doubt.”

Morever, even when data unequivocally demonstrate that a specific medical intervention is ineffective, Bloche would not deny it to patients. Although the treatment fails to produce statistically significant clinical outcomes, it still might be appropriate because it provides “benefits that include hope and a sense of well being, not just years of life added.”

In these same terms, Bloche attacks the concept of medical futility. The concept of a treatment making little difference is so vague, he writes, as to create “a legal space for saying no to pricey care that is potentially life-saving.”

After considering all of these various strategies, Bloche presents his own prescription: “Getting to ‘No’ gently.” Despite his unease with physicians’ withholding care, he argues that they must do so, but without “quiet hypocrisy” and without “breaking faith at the bedside.” To this end, he would distinguish between decisive advances—represented by biological breakthroughs (exemplified for him by antibiotics and statins)—and halfway technologies—misused or unnecessary technologies that substitute for, but do not cure, physiology gone wrong.

Bloche’s model for a halfway technology misused is bypass surgery. Cardiac surgeons can make far more money by performing bypass operations than by prescribing statins; hospitals enjoy handsome returns; and venture capitalists are incentivized to invest in companies that develop other unnecessary technologies. Thus, he identifies halfway technologies as the “main culprits behind soaring costs,” although without providing supporting data.

But these categories, and this example of bypass surgery in particular, are not persuasive. Bloche has not a word to say about how physicians should tell patients with unstable angina and multivessel occlusion that they should forgo the surgical procedure and ignore the shortness of breath that comes after walking a few blocks, the accompanying chest pain, or the prospect of a fatal cardiac event. He admits that the consequences of his proposal would be “tragic” in some cases. But were there “visible allocation rules,” betrayal at the bedside would be avoided, and health costs would rise more slowly.

How would the nation go about implementing such a distinction? Progressive Americans, Bloche imagines, would accept the distinction. But what ultimately will be needed is a public agency, insulated from stakeholders, to make cost-benefit trade-offs and turn them into “clinical protocols for payers and providers.”

I have laid out Bloche’s arguments in some detail not simply to demonstrate internal contradictions or the limits of his policy proposals but also because many of his contentions, taken one by one, have their champions.

Many analysts want physicians to focus exclusively on their patients’ well-being, regardless of social costs. At the same time, other analysts want physicians to make the stewardship of resources part of their decision-making calculus. Some continue to believe that clinical guidelines are vital to delivering quality medical care and might well reduce costs. Still others are convinced that guideline writers too often have a financial stake in their recommendations; that guidelines are too removed from individual cases to be helpful; and, in all events, that final decisions should be left to patients. And for every critic impatient with halfway technologies, there are many others unwilling to deprive patients of such treatment modalities as dialysis or organ transplantation.

Among the most troubling aspects of these tensions is the cognitive dissonance that allows some individuals in this country to hold these conflicting propositions simultaneously. Even more important is their effect on the design of health policy: Physicians should be sensitive to social costs, but not too sensitive. We must learn more about clinical outcomes, but the findings should not curtail patient choice or determine Medicare or Medicaid coverage. Bloche has not managed to sort all of this out here—but neither have the rest of us.

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