'Do no harm' - To patients or to populations?

Doctor's office by Shutterstock.com

Our focus on healthcare's rising costs seems slowly to be shifting the emphasis of American medicine from patients to populations, though there is sharp disagreement over whether this trend is encouraging or concerning.

The extent to which these represent two surprisingly distinct world views was emphasized by the impassioned and quite different responses I received in response to a recent post examining how the use of cheaper but slightly worse drugs should be prioritized by physicians and payors.

To many (but by no means all) physicians, the issue was clear: as one Nobel Laureate wrote,

"You raise a fundamental issue that goes to the core of medicine since Hippocrates.  A physician is required to prescribe the best treatment for the patient in front of him/her.  The physician must not under-treat one patient in order to help another patient.  Once we slide down that slippery slope, where will it end?  Would you trust a doctor who is trying to help someone else in preference to you?"

(I've argued along very similar lines - here and here; see also Scott Gottlieb's intelligent comments in this NPR piece focused on the emerging concept of parsimony in healthcare.)

For others - including many from an economics background - the answer was different, but equally clear; one thoughtful expert wrote,

"So far the system has made choices by random rationing: lousy or no care if you were uninsured, ok to good care if you had insurance.  The question is: how to get rational care for the most people.  If you could - as in the hypothetical example - give a much cheaper drug that was marginally less efficacious (and less efficacious only on a population basis - plenty of individuals would do just as well on one as the other), and you wouldn't be prevented from prescribing the more powerful drug if the cheaper one didn't work, then in my view there is no question you should start with the cheaper drug.

Increasingly, the system is going to have to make more rational choices.  It's irrational to give a more expensive drug to all the people that will be better only for a minority of people.  And as for the ethics of physicians going along with this idea: given the prices of new drugs, doctors should be factoring in cost as another side-effect of their prescribing."

As for the Hippocratic Oath, this expert asked, "Does economic harm caused by a physician's prescribing constitute harm for which a physician is responsible?"

I understand this perspective but respectfully disagree: I want my doctor to help me figure out what's the best medical option, period.  I don't want my doctor to be looking at each patient, and weighing, "how deserving is this patient of society's resources versus another patient?"  I don't want my doctor to decide I'm too old, or too doomed, or too disagreeable to merit the best treatment recommendation - who are they to say?

The real problem is that it's difficult to think of any ideal way to make what are often difficult choices; in the best of all worlds, every patient would be able to afford the best medicines in every category, but in a real-world, resource-constrained environment, what's the right way to allocate resources?

It's especially interesting to see how this dilemma is currently addressed in some physician practices.  At the recent Real Endpoints SymposiumRhonda Greenapple, of the consulting firm Reimbursement Intelligence, described how many oncologists actually offer their patients two different chemotherapy alternatives (essentially, an ideal option and a value option), and then leaves it to the office practice manager to sort out with the patient which will be more affordable, based on the patient's insurance coverage and ability to pay beyond that.

On the one hand, this approach enables physicians to offer the best care to each patient; at the same time, it's a bit of a Pyrrhic victory if the patient can't actually afford the best option - especially if that option is profoundly better, as is sometimes but not always the case.

The question is, can we find a better way?


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