Managing Medical Resources: Title and subTitle BreakReturn to the Commons?

The inexorable increase in health care costs, seemingly impervious to most market-based attempts at amelioration, has led to a growing interest in measuring efficiency of health care as a key component of quality of care.¹ Although there have been creative attempts by the insurance industry to develop meaningful efficiency measures, physicians are suspicious that payers are concerned only about the cost component and not about the quality component when measuring efficiency.² But, in addition to questions about the method and accuracy of measurements of efficiency, an underlying set of concerns have been expressed by the physician sector of the health care provider community regarding their role in managing health care resources, concerns that stem from the deep and profound roots of medical ethics.

The Physician's Charter on Medical Professionalism maintains that among other responsibilities, physicians must be committed to managing medical resources.^{3 - 4} This responsibility is controversial largely because it can be seen as in conflict with the more traditional altruistic commitment of the physician to the patient. Moreover, control of cost is inextricably linked to the business interests of insurers. Physicians ask, is this really our responsibility?

The answer is yes. Physicians cannot afford to ignore the profound logic of the link between care for individual patients and the costs of care. The more care costs, the more likely many individuals will be without good insurance, and research clearly shows their health will suffer.⁵ It is impossible to avoid the fact that physicians live and work in a medical commons and bear responsibility for it.

The traditional core value of medicine is the primacy of the patient's well-being over the self-interest of the physician and implicitly over other social concerns as well. This is desirable, if one realizes the proprietary potential of the patient-physician relationship and the fundamental inequality of knowledge and power when a patient who is very ill seeks help from a physician. When in dire situations, most patients would like their well-being to be at forefront of their physicians' concerns.

In the United States, this disconnect between responsibility over the management of resources and responsibility to the individual patient is made even greater by the historical disconnect between the public health sectors and the world of medical practice. This is no accident: as Starr⁶ pointed out more than 20 years ago, the allopathic profession worked hard to assert its control over medicine and eschewed public health models while championing fee-for-service payment.

In addressing the fundamental ethical conundrum of managing resources, Hiatt adapted in 1975⁷ Hardin's “Tragedy of the Commons”—which posited that the commons would be destroyed should every farmer let his or her livestock graze freely—as an analogy for the erosion of the health care system under the fee-for-service model, powerless to curb the unrelenting increase in health care costs. However, he believed that physicians should not be the ones setting limits on resource utilization; rather, that task should fall to “society.” He believed—even as a public health physician—that the individual patient-physician relationship should take primacy, acknowledging that although limits do need to be set, these limits should be set by some larger social force—perhaps by establishing a global budget for health care or guidelines for utilization.

A decade later, but still well before the managed care revolution and counterrevolution, Daniels⁸ suggested why saying no in the United States is so difficult. He argued that physicians do not have “moral agency.” The fee-for-service model does not allow physicians to affect where saved resources go, so why would they try to avoid costly interventions in the name of helping other patients? The key insight is that the physician is not part of a commons. Indeed, the physician has no assurance that any money saved would even go into expanding health care but rather might go to paying off the deficit (in a publicly funded system), or to profit margins of corporate entities (in a privately funded system). This is one of the pitfalls of what Daniels called “bedside rationing”—that restricting marginally effective imaging studies will not allow that physician to ensure that more children are immunized or that health insurance is made more available to the uninsured.

Without some sense of commons, physician-based management of resources does not accomplish its end. But if there were a viable notion of commons, Hiatt's ethical basis for physicians to be resource managers could be challenged.

If clinicians are to be absolved of any need to manage resources, then in the United States, the job falls to government oversight or market dynamics, but each might be inadequate without real physician participation. Consider government oversight of the cost of physician services, focusing on the Medicare system's sustainable growth rate calculations. Every year in early winter, a political drama unfolds in which the physician lobbyists attempt to avoid the decrease in Medicare rates that would come from the Centers for Medicare & Medicaid Services' calculation of the number of services offered and the price that should be paid.⁹

The rate at which physicians are paid by Medicare is based on whether overall volume of services used meets certain targets. This is clearly intended to manage resources and control costs. Yet this strategy accomplishes neither. Physicians have no community in which they examine aggregate utilization data and decide how to set priorities. Quite the contrary, each physician is like the farmer in the “Tragedy of the Commons” trying to maximize his or her own good. Indeed, when fees are decreased, the logical financial course for a physician is to increase the rate of utilization of services to avoid a decrease in income. Thus, year after year, the sustainable growth rate has been exceeded, and physicians continue to be threatened with decreases in their income, so they find ways to do more.

Does the market do any better? The same moral-agency dilemma occurs in the physician's relationship with the commercial insurance industry, in which case making marginal decisions to contain costs or to forgo expensive interventions of unclear effectiveness have a downside for the physician in potentially leading to less revenue for the practice and to mistrust by patients. Physicians understand the importance of the quarterly profit margins to the insurance companies and are not likely to believe that this money will necessarily be used to improve health care or expand coverage.

How can the physician's accountability be strengthened without undermining the quality of patient care? Consumer-directed care and greater transparency about quality and cost will enable patients to make more informed decisions and probably lead to better management of resources. Yet such approaches will not provide the organizational structure and incentives that would be the ethical basis for real physician accountability for costs. Except in prepaid group practices, there is no explicit commons that would link the moral duty to individual patients with responsibility to a community, and the moral duties remain exhortations. In the world of preferred provider organization practice, relatively wide networks, and fee-for-service, there is no accountability unit within which a physician knows about the resource use associated with specific patients or is responsible for that resource use and has any influence over it.

How could physicians be engaged in ways that patients would trust? The commons must be reconstructed through organizational change. Kindig¹⁰ notes that pay-for-performance focused on quality of health care for specific individuals would be inadequate to significantly improve population health. He points out that most physicians do not know the denominator of their practice and further states that community-wide efforts and incentives need to be provided to engage consumers and address other factors in a community impacting health care including socioeconomic factors, education, the physical environment, and racial and ethnic disparities. Thus, a broader community focus and a shared responsibility are needed to build the ethical base for clinician management of health care resources. This may seem far fetched to many. Twenty percent of internists are in solo practices and more than half are in practices of fewer than 5 physicians.¹¹ In the meantime, because their patients also may receive care from a wide range of other physicians in the health plan network, many primary care physicians have no knowledge or oversight in their patients' overall use of resources.^{11 - 12}

Yet there are some examples on which to build. Some integrated delivery systems do offer some of the attributes of an accountable system. Enthoven and Tollen¹³ explain that the underlying principle of group practices is the notion of “group responsibility”—the responsibility of all the physicians within a medical group for the health of all patients within the population served. This dual responsibility for a population of patients and the traditional Hippocratic commitment to individual patients distinguishes these groups and compels the members to accept accountability for effective care, patient trust and satisfaction with cost and quality, prevention and wellness, safety, cost-effectiveness, and timeliness. Crosson¹⁴ further argues that multispecialty group practices supported with proper incentives offer coordination of care for complex and chronic conditions; infrastructure to support the use of evidence-based systematic care processes; and the ability to afford, invest in, and effectively deploy clinical information technology.

Fisher and colleagues¹⁵ suggest that reform could occur through what they called accountable care organizations, through which multispecialty physician groups and small practices would be affiliated with a hospital to define a population (community or region) for whom they assume responsibility. They argue that accountability at the level of hospitals and their extended medical staff offers inclusion of all physicians who contribute to the care of a population within the frame of measurement, the ability to establish accountability for capacity, and the capacity to invest in improving quality and lowering costs. The Medical Payment Advisory Commission has recently proposed the idea of accountable care organizations and similar virtual commons mechanisms as a possible pathway for Congress to consider in reforming sustainable growth rate.¹⁶ The patient-centered medical home mandate for Medicare demonstrations by the 2007 legislation¹⁷ that attempts to pay for coordination across clinicians and settings is promising but alone will not provide for the broader accountability.

Currently regional efforts are building infrastructures and working through some of the technical aspects necessary to move toward a community model of accountability. The Ambulatory Care Quality Alliance pilots, also known as better quality information projects, are designed to aggregate data from both public and private payers and publicly report that information to consumers.¹⁸ The Robert Wood Johnson Foundation's Aligning Forces for Quality: The Regional Market Project brings consumers, providers, business leaders, and other community stakeholders together on a regional basis to advance quality. This project provides support to local communities to cultivate and accelerate improvement through alignment of 3 market forces—performance measurement and public reporting, quality improvement capacity, and consumer engagement. And, the 100-plus Regional Health Information Organizations are harmonizing and facilitating the development of technical standards needed to connect a community of care clinicians and support local accountability.¹⁹ If, somehow, all of these could work together to create all of the components of a truly functional regional accountability, the role of physicians in managing medical resources could be ethically much clearer. Yet none of these collaborations alone is close to what the medical commons would have to be to create a sound ethical framework for effective resource management linked to high-quality care.

The model would have to entail collaboration of hospitals with primary care and specialty care physicians and other clinicians. To limit cost shifting, the provider consortium would have to be responsible for all the care for a population, entailing much more of a public health focus than US medicine has shown an appetite for in the past. The method of payment would likely be capitation, or some kind of patient-centered reimbursement, as opposed to unit-based reimbursement. Physicians would have to overcome their qualms about this approach and about the management of resources generally and gain the skills to respond to these values. This is a tall order, but treating health care as a commons likely calls for nothing less. No matter what the solution for the increasing costs of health care, these are issues that will have to be addressed.

Ethicists have asked, where does a professional responsibility end and a political choice begin?²⁰ One answer is that professional responsibilities inhere in the patient interaction. The care for patients diminishes when there are insufficient resources to care for all patients. The ever-rising costs of health care, now much greater 30 years after the Hiatt publication,⁷ threaten the care of many by increasing the number of the uninsured, whose care clearly is inferior.⁵ Although much of the technology driving these increased costs is effective,²¹ no one can deny that waste in the US health care system is pernicious. As long as the cost-access link is accepted, professional ethics demands consideration of health care resources.

In this context, the reestablished medical commons seems comparatively attractive and potentially more politically feasible. Hospitals and physician groups could be induced to pursue this model in specific geographic regions. Both public and private payers would likely be able to accommodate these changes in practice and payment, but the organizational impetus would have to come from physicians, other health care professionals, and hospitals. Market-based and regulatory approaches place the welfare of patients in hands other than those who provide medical care. Allocation decisions will be made but without regard for the caring, commitment, clinical expertise, and wisdom of experience that clinicians bring. Given this, physicians must make a professional decision about the correct approach and advocate for change both individually and collectively. This choice seems clear. Physician engagement in a medical commons, ideally with communities of consumers, is arguably the only approach that will ensure proper allocation of health care resources.