Who 'Owns' Health-Care Cost Decisions?

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Robert G. Uzzo, MD, FACS
Robert G. Uzzo, MD, FACS

The imperfections of our nation's delivery of health care have long been recognized. From poor access for the underinsured and uninsured to potential overutilization by the worried well-insured, the issue has risen to political prominence, with its costs front and center.

President Obama has called the rising costs of health care the “single greatest threat to America's fiscal health.” As with most political issues, blame abounds—from the high costs of prescription drugs to physician fees and hospital costs. Efforts over the past decade to control costs, including reducing physician reimbursements, have failed to avert crisis. The result: less time with more patients and higher costs.   

Recognizing that we live in a capitalist society, other avenues for physician-generated income have emerged. In a recent New Yorker article (“The Cost Conundrum,” June 1, 2009), Atul Gawande, MD, MPH, examines why the costs of medical care in McAllen, Tex., are among the highest in the nation.

The primary cause, he concludes, is “across the board overuse of medicine,” with physician ownership indicted as a culprit. But can physicians be entirely faulted for managing uncertainty with tests and treatments, and can patients be faulted at all for wanting to know everything about their disease or demanding aggressive treatment in an effort to limit uncertainties?

Overtesting and treatment rely on costly diagnostic and therapeutic technologies (some with unproven or marginal benefit). These technologies are heavily rewarded by commercial markets much more than cognitive or operational innovations.

Economists teach that every decision has a measurable price. So who in our health-care system is best able to calculate individual cost-benefit tradeoffs? Who “owns” individual health-care cost decisions? Patients cannot, government must not, courts will not, physicians currently do not, and public and private insurers have not.

Perhaps as Gawande and others have suggested, central to reform should be a national institute for health-care delivery that encourages the best practices of national and local health-care systems.  

As our system evolves over the next decade, we (physicians, patients, insurers, economists, civic leaders, industry, and governmental policymakers) must focus on operationalizing long-term efficiencies in health-care delivery, emphasizing cognitive trials and innovations. Only then will meaningful reform result.

Robert G. Uzzo, MD, FACS, is G. Willing Pepper Chairman and Professor, Department of Surgery, Fox Chase Cancer Center, Philadelphia, and the Renal & Urology News Medical Director for Urology.

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