News/Commentary

Howard Brody, M.D., Ph.D, and the author of The Future of Bioethics (Oxford University Press), has given physicians and patients a great gift.

He talks about the grizzly bear of health care reform.”I don’t want anybody getting between me and my doctor.”

How to avoid that? Dr. Brody has a sound, practical suggestion. Let doctors lead the way in a way which they have not up until now.

Dr. Brody writes:

“Finally, the best rebuttal to the antireform argument that all efforts to control medical costs amount to the “government getting between you and your doctor” is to have physicians, not “government,” take the lead in identifying the waste to be eliminated. Mark Twain said, “Always do right. This will gratify some people and astonish the rest.”

(Ed. Note:  The New England Journal of Medicine (NEJM) editors offer free, full text on public policy issues which they feel need discussion and debate. This excerpt is considerably longer than standard practice calls for when quoting another source but serves the editors’ intent. Think! Discuss tough issues! Thanks to the NEJM, below you will find an article that tackles a topic which nobody else has this way.)

New England Journal of Medicine

…”In my view, organized medicine must reverse its current approach to the political negotiations over health care reform. I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty’s “Top Five” list. The panels should include members with special expertise in clinical epidemiology, biostatistics, health policy, and evidence-based appraisal. The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit. Examples of items that could easily end up on such lists include arthroscopic surgery for knee osteoarthritis and many common uses of computed tomographic scans, which not only add to costs but also expose patients to the risks of radiation.^{4,5 (}(Emphasis added)

“Having once agreed on the Top Five list, each specialty society should come up with an implementation plan for educating its members as quickly as possible to discourage the use of the listed tests or treatments for specified categories of patients. Umbrella organizations such as the AMA might push hard on specialty societies and pressure the laggards to step up. (Emphasis added)

“Some societies will be tempted to bluff their way through the Top Five exercise, deliberately omitting cost-cutting measures that would particularly affect members’ revenue streams. Societies could display their professional seriousness by submitting their lists for review and comment to several societies in other specialties. (Emphasis added)

“Some would object that considerably more comparative-effectiveness research is needed before such lists can be compiled and implementation strategies developed. And indeed, today we have no idea how to implement a practical plan that would recapture the roughly 30% of health care expenditures estimated to be wasted on nonbeneficial measures.² I would guess, however, that if we were trying to save that entire sum of money, we would be proposing “Top Twenty” or “Top Fifty” lists for many specialties, not just the Top Five. I suggest that no matter how desirable more research is, we know enough today to make at least a down payment on medicine’s cost-cutting effort. As good citizens and patients’ advocates, we should begin where we can. (Emphasis added)

“A Top Five list also has the advantage that if we restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply “rationing” health care, regardless of the benefit, for cost-cutting purposes. As we inched closer to the entire 30% savings, we would inevitably face increasingly controversial treatment cutbacks — cases in which a substantial minority of experts believed a treatment provided real benefits for many populations. Such controversies should be postponed until the evidence is clearer and a more acceptable national structure for adjudicating such debates is in place. (Emphasis added)

“Another objection might come from primary care specialties. Given the serious shortage of primary care physicians in the United States, due partly to the income gap between that field and others, shouldn’t societies of primary care physicians get a pass on the Top Five list? Although I’m sensitive to the urgent need for increasing the primary care workforce, I would argue that all physicians have ethical responsibilities. Showing that we are ready to stand alongside all other specialties in examining our own practices in light of the best scientific evidence is an important aspect of professional integrity and should not be avoided by any specialty. (Emphasis added)

“Finally, the best rebuttal to the antireform argument that all efforts to control medical costs amount to the “government getting between you and your doctor” is to have physicians, not “government,” take the lead in identifying the waste to be eliminated. Mark Twain said, “Always do right. This will gratify some people and astonish the rest.” Today, meaningful health care reform seems to be in danger of taking a back seat to special-interest pleading and partisan squabbling. If physicians seized the moral high ground, we just might astonish enough other people to change the entire reform debate for the better.”

Citation: New England Journal of Medicine, (N Engl J Med Brody 10.1056/NEJMp0911423)