Thomas Bodenheimer, MD; Alicia Fernandez, MD
Bodenheimer T, Fernandez A. High and Rising Health Care Costs. Part 4: Can Costs Be Controlled While Preserving Quality?. Ann Intern Med. 2005;143:26-31. doi: 10.7326/0003-4819-143-1-200507050-00007
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Published: Ann Intern Med. 2005;143(1):26-31.
Several interrelated strategies involving physician leadership and participation have been proposed to contain health care costs while preserving or improving quality. These include programs targeting the 10% of the population that incurs 70% of health care expenditures, disease management programs to prevent costly complications of chronic conditions, efforts to reduce medical errors, the strengthening of primary care practice, decision support tools to avoid inappropriate services, and improved diffusion of technology assessment.
An example of a cost-reducing, quality-enhancing program is post-hospital nurse monitoring and intervention for patients at high risk for repeated hospitalization for congestive heart failure. Disease management programs that target groups with a chronic condition rather than focusing efforts on high-utilizing individuals may be effective in improving quality but may not reduce costs. Error reduction has great potential to improve quality while reducing costs, although the probable cost reduction is a small portion of national health care expenditures. Access to primary care has been shown to correlate with reduced hospital use while preserving quality. Inappropriate care and overuse of new technologies can be reduced through shared decision-making between well-informed physicians and patients. Physicians have a central role to play in fostering these quality-enhancing strategies that can help to slow the growth of health care expenditures.
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William L. Berger
Medical College of Wisconsin
July 25, 2005
Values driving healthcare costs
"Doc, if you can't do a little better on that price, we'll just have to let Mama go." Doesn't sound familiar, does it? It would if medicine were a one-dimensional, market-driven enterprise such as Dr. Bodenheimer presents (1). Clearly, there is a second dimension influencing healthcare decisions and utilization, which is neither "market-driven" nor "rational."
Anyone sorting through the estate of a loved one has encountered a two-dimensional value system. Certainly, every item has a "market value" - that is why we have eBay. But many items also have a "sentimental value" that cannot be expressed in dollars. This second dimension of value is independent of, additive to, and often greater than the item's "market value." This and other human values, such as the need to feel that the world is fair, safe, connected, and in control, define a dimension of non-market value I broadly term "spiritual". Unlike the market value of traded commodities, spiritual value cannot be bought, transferred, or even quantified, yet it still heavily influences decisions. As physicians, we are at times counselor, comforter, and conduit of hope. These are spiritual dimensions of our work.
Medicine is a profession precisely because we operate, in part, within the dimension of spiritual values. Except in extreme cases, our function and responsibilities within the spiritual dimension are both unregulated and beyond the influence of market forces. Instead, our actions within this domain are bounded by a public oath [usually Hippocratic], which defines unique and sacred responsibilities to our patients and peers. Publicly professing our common responsibility is what defines us as "professionals," and acting in accordance with this professed obligation is "professionalism." That physicians have professed this oath for 3000 years reflects the centrality of this non-market value system to our work. In fact, the unique honor it is to be a physician derives from medicine's spiritual dimension.
American society routinely confuses "profession" with "something you do for money" (e.g. "professional golfer") so we naturally have trouble understanding the role of spiritual values in medicine, including how such factors can drive healthcare costs beyond all bounds of economic reason. Although spirituality is fundamentally personal, is not economically or politically insignificant. Opponents exploited this second dimension to doom the Clinton healthcare plan.
If we do not acknowledge and seek to better understand this spiritual dimension of medicine, we will never fully comprehend medicine, much less the "drivers of healthcare costs".
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