Cost containment: challenging fidelity and justice.

Cost Containment: Challenging Fidelity and Justice While not the only vehicle for containing the rising cost of health care, prospective payment is one of the first and most powerful. It is also something of a paradigm of the way in which many cost containment mechanisms work. Currently applied only to hospitals, federal Diagnosis Related Groups (DRGs) do not directly affect physicians, who are ostensibly left free to practice medicine as they see fit. Similarly, other mechanisms such as utilization review often impinge directly upon people other than the physician--by restricting patients' reimbursement, for example--while leaving intact the physician's clinical freedom. And yet no one will be more affected by cost containment than the physician. The insular relationship in which the physician was able, ideally at least, to use his own best medical judgment to furtehr exclusively the best interests of his patient, is quickly dissolving into a complex network of entwining and sometimes conflicting obligations. Admittedly, physicians have always faced constraints upon their professional judgment. The approval of the medical and legal communities, as well as of patients themselves has limited physicians' options. And physicians have always had to ration--to allocate their own scarce time among the many who need it, or to determine which patient should receive the lone available intensive care bed or the newly available kidney for transplant. They have long faced conflicts of interest, as fee-for-service reimbursement rewarded excessive care. And they have always faced conflicts of obligation, as when the obstetrician considers cesarean delivery with its higher maternal risks to benefit a distressed fetus. But cost containment places physicians in a genuinely new situation, primarily because it changes the nature of the scarcity they face, and thereby of the necessary rationing decisions. In the days of virtually unlimited retrospective reimbursement, two kinds of scarcity appeared: inadequate access to health care, as some patients could not afford to pay or were geographically remote from health facilities; and commodity scarcities, or shortages of particular items such as transplant organs or hemodialysis units. Cost containment heralds a new sort of scarcity: fiscal scarcity, the general tightening of health care dollars. Because every medical decision has its cost, every health care intervention is now subject to scrutiny for its economic as well as its medical wisdom. Unlike commodity scarcity in which rationing decisions are episodic, the rationing under fiscal scarcity is chronic. Many cost containment mechanisms do not directly impinge upon physicians' clinical judgment. Nevertheless, those who control the purse strings of health care must coerce or entice the cooperation of physicians, whose decisions about what to order for whom determine up to 80 percent of health care expenditures. Physicians are therefore subjected to a variety of controls and incentives. The primary care physician may be unable to order expensive interventions without a specialist's approval; or the hospital's pharmacy may not stock the costly drug he'd like to prescribe. The health maintenance organization (HMO) physician may find his year-end salary substantially lower if he "overutilizes" hospitals and specialists. The fee-for-service physician will face an angry patient if the insurance company declines to pay for a procedure that was not "properly precertified"; he may face an angry hospital administrator if his Medicare patients consistently overspend their welcome. Throughout, the physician's traditional fiduciary obligations to his patients are challenged, and because every one of his medical decisions affects the level of resources available to other patients, he is also entangled in questions of justice. Challenges to Fidelity Clinical authority versus patient loyalty. …