In a question-and-answer session with The New York Times, bioethicist Dr. Howard Brody follows up on his New England Journal of Medicine editorial making the case that doctors have a professional obligation to keep medical costs down. In the health-care debate, physicians have supported health insurance reforms but don't want those reforms to affect their incomes, he says:
Unlike previous health care reform discussions where doctors were put on a pedestal, people are now turning the searchlight, appropriately I think, on the medical profession and asking if we are the problem. But rather than rising to that challenge and exercising moral leadership in health care reform, we are acting like one more special interest group. Instead of saying we care about patients enough to put our own interests on the back burner, it has been as if we were more concerned about maximizing our income.
He notes that, of course, that's not true of all doctors. But it counters the idea that, since patients have no notion of the costs of their health care, they demand frivolous care that drives up costs. While consumer demands probably play a role, arguments like these from many economists ignore how much health insurance and health care has changed since the 1990s, when consumers did pose a problem for managed care plans. Without patients feeling the cost, they'll reject efforts by doctors and insurance plan managers to control the kind of care they receive, they argue. That is surely echoed in conservatives' fears, often disingenuous, that "big government" will get between patients and their doctors.
But the assertion that too few employees pay enough toward their plans to realize the full cost of their medical activities is true for fewer and fewer Americans. It's not as if employers are completely footing the bill as insurance premiums continue to rise astronomically; more and more employers are asking employees to chip in higher amounts. And higher numbers of employees can only afford plans with deductibles or co-insurance for every procedure but annual physicals, so people are paying something for each visit, more so than they were in the 1990s. It also ignores the fact that health-care consumers in many European countries pay little to nothing per doctor visit, and overall their medical costs are much lower than in the U.S.
While medical use decreases with increased co-pays, the amount patients pay is just one of the many factors at play. And it doesn't mean that forcing families to choose less care would make for overall better care. Squeezing families even harder doesn't seem like a good solution. Doctors who know more about which procedures are helpful, and which arenot, would be better at managing care if they were forced to considerscarce resources. Incentivizing all doctors to manage care better, at the same time that regulations are in place, can work better than it has in the past.
-- Monica Potts
