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    Physician in Cross Road

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    Vaida Bankauskaite

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    healty policy ELSEVIER Health Policy 37 1996) 185-198 Clinical practice, ethics and economics: the physician at the crossroads Pablo Lazaro*, Barbara Azcona Health Serices Research Unit, Institute of Health Carlos Il, Sinesio Delgado, 6, 28029 Madrid, Spain Received 16 May 1995; revved 20 February 1996, acepted 22 February 1996 Abstract In recent years health services have faced the challenge of increasingly complex services and rising costs, thus the consideration of costs is a key factor in health policy decisions. The {introduction of an economic perspective has sometimes been viewed as conflicting with the cthics of the health care system, especially atthe physician-patient level. This article explores the important role of the physician from the ethical and economic perspective in the distribution and allocation of servioss. An understanding of economic and ethical principles reveals that these two perspectives are compatible with good clinical practice: more efficient health care implies better care forthe individual patient and makes it possible to increase the ble to improve care for the population as a whole. Thus, being efficient is an ethical objective. The selective elimination of ineffective services would free resources to care for those who need effective diagnostic or therapeutic procedures. This requires a better understanding of the determinants and outcomes of clinical practice, physician motivation, the appropriate design and application of incentives, and the best use of limited resources. ‘The physician can play a key role in increasing the efficiency, equity, and quality of the health system without restricting the provision of effective services, Keywords: Clinical practice; Economies; Ethics; Physician behavior * Corresponding author. Tel: +34 1 3877893, ext, 2018; fax: +34 1 387896; e-mail plazaroG@isci.es. (0166-8510}96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved PU $0168-8510(96)00825-1 186 P. Lizaro, B. Azcona { Health Policy 37 (1996) 185-198 1, Introduction Health services are systems whose mission is to help improve the health of individuals and of society as a whole. Two conceptual principles are ‘generally admitted in health services: first, access to ‘the provision of services is the right of all citizens and should not depend on wealth or salary; second, the objective of health services is to produce the maximum impact on the health of the nation using the resources that society devotes to this purpose. The immediate implication derived from the assumption of these two principles is that it is ethical to_be TTetficent, because To Be inelicient_means to fail in the elhical objective of se TIZIGg the Umpacr On The health of society using the available resouroes (1). At the physician-patient relationship, the key ‘crossroads in this implication is the interrelation among clinical practice, ethics, and economics. In recent decades, health services have ‘been faced with such challenges as increasingly complex services, limited resources, rapid innovation and diffusion of medical technologies and procedures, pressures on the demand for services from both society and health professionals, and ignorance of the effects of these factors ‘on costs and the health status of the population. Added to this is the fact that in the last 25 years spending on health has grown twice as fast as wealth in the industrialized countries [2]. As @ result of these problems, cost containment has: ‘emerged as a key factor in health policy in the developed countries in_ recent years, ‘and economic analysis has developed as a scientific activity within the field of ‘health: services research. Since resources are limited, the choice of a large amount of alternative A means ‘that we must choose less of alternative B. This phenomenon occurs at both the ‘macro level (health system) and the micro level (physician-patient). The problem of choice at the level of physician-patient in the context of limited resources, a5 correctly pointed out by Williams, “...is ‘the agonizing reality that underlies the: tension between ‘clinical freedom’ and ‘social responsibility’...” [3]. ‘These facts suggest that in an era of limited resources and multiple options, decisions, and the ‘evaluation of these decisions, must include not only clinical but also economic and ethical perspectives. With these interrelated and complementary perspectives in mind, it is easy to understand that the emphasis on providing efficient (e.g. cost-effective) care is consistent with ‘excellence in care. More efficient health care implies better care for the individual patient and makes it possible to increase the resources available to improve care for the population as a whole (4,5). In short, it is important to know whether the sacrifice made by society in devoting part of its limited resources to health care produces greater well-being ‘than if these resources were devoted to other activities, and if the way health resources are used maximizes the health status ‘of the population. Debates and providers, patients, and researchers. Although physicians are sometimes researchers: in these analyses, their most important ‘role is as health care providers through their clinical practice. P. Lizaro, B. Azcona| Health Policy 37 (1996) 185-198 87 2. Clinical practice Clinical practice is the process of medical action with relation to patient care. Tt consists of the body of available knowledge, clinical data on patients, physicians’ perceptions, judgments, and reasoning, and the way health professionals maintain tnd perfect their clinical knowledge and skills (6). The basic objective of clinical practice is the transformation of a reality, the clinical status of the patient, for Mhich purpose knowledge is required. The scientific history of medicine is charac: {erized by considerable attention to the investigation of the biological causes and mechanisms of illness and very little to understanding how clinical knowledge ‘operates in practice [7,8]. The process of clinical practice has barely been studied. and not much is known about how physicians obtain and use clinical information, how they apply diagnostic and therapeutic procedures, predict outcomes, and evaluate their patients’ interests and preferences. In summary, we know very litle ‘about the determinants and consequences of clinical decisions [6]. ‘The evidence currently available shows that there are enormous variations in clinical practice. For example, in the United States (US), the probability that an 80-year-old man will have had a prostatectomy varies from 20% to 60% depending ‘on what city he lives in 9]. Even though Canada and the US have about the same ftumber of physicians per capita, the US has 33% more surgeons per capita than Canada, This does not mean that American surgeons enjoy more leisure time, but that US citizens undergo 40% more surgical interventions per capita then the Canadians {10}, Another example of variability in clinical practice has been Gocumented in Spain, where a 1994 study found that the proportion of women who had received a mammogram in the previous 2 years varied considerably by region, from 12% in Murcia to 74% in Navarre (11) ‘Not only is there large variability in clinical practice, but also in the proportion of appropriate use of procedures. In the US, where private health care and fee-forservice predominates, the proportion of inappropriate or uncertain use of some procedufes can vary from one-fourth to two-thirds (9. High levels of Inappropriate use have also been found in settings where other types of incentives Gperate, For example, in England, which has @ centralized budget and salaried physicians, the proportion of inappropriate coronary angiographies or coronary Eriery bypass operations is similar to that in the US {12}. In those countries where Studie have been carried out, the proportion of coronary angioplasties performed for inappropriate reasons varies from 15% to 40% In Spain, for example, the umber of angioplasties is increasing rapidly, practically doubling every 2 years, but the proportion of appropriate use of ths technique is unknown. If only 10% of such procedures were inappropriate — a conservative estimate — the cost of inaPPro- Prfate use may have reached the equivalent of $5.8 milion in 1991 {13], Under the Pome assumptions, the cost of inappropriate use in 1994 would have exceeded $11.2 million. ‘Given these variations in clinical practice and appropriateness levels, society is beginning to recognize that a variable degree of arbitrariness or discretionality permeates medical decision-making and is beginning to question the idea that these 188 P. Léaro, B. Azcona | Health Policy 37 (1986) 185-198 decisions are, by definition, the best of all possible ones [14]. The main reason for this variability is the uncertainty of clinical practice; it is a consequence of both the complexity and subjectivity of the clinical act and the lack of certainty in clinical knowledge, and the relative unpredictability of outcomes with relation to the procedures used [15,16], Although by the nature of clinical practice uncertainty Cannot be eliminated, it can be described and quantified, and its negative effects can be reduced and minimized through scientific knowledge of clinical practice (6). 3. The importance of physicians in health systems On the surface, it would seem that decisions about health resources should be made by politicians or managers. This may in some measure be true, but it is no less true that physicians’ decisions are at least as important. Physicians play a very important role in the use and distribution of health system resources. The following example are illustrative: Eisenberg has pointed out that in the US, the decisions of fess than 0.5% of the population (physicians) contribute to the use of more than 10% of the Gross Domestic Product (GDP) [17]. In Spain, health costs in, 1990 made up 6.7% of the GDP, and were determined by 0.38% of the population (physicians) or, if you will, 1.13% of the population (all health sector workers) (2) The average cost of prescriptions written by three physicians in Spain in 1 year can equal the capital cost of a magnetic resonance imaging unit (MRD [l8). But ‘obereas the decision to purchase an MRI entails a complicated process involving limited number of decision-makers, there are no important practical limitations on the preseriptions written by the almost 400000 physicians who prescribe medications ‘charged to the Spanish Social Security system. ‘In Spain, over USS 32.4 billion were devoted to health care in 1990, there were 5 million hospital admissions, and more than 240 million outpatient visits. This Jmpressive volume of costs and activities was carried out by 442000 health care workers, 148717 of whom were physicians [2]. The actions of these hundreds of thousands of workers will contribute to the quantity, type, and quality of proce- dures and, consequently, to the costs and results. The basis for the importance of physicians as providers of preventive, diagnostic, and therapeutic services can be explored from both an ethical and economic perspective. 4, Am ethical perspective Ethics can be conceptualized from several points of view and thus can be defined in a number of ways, Webster’s Ninth New Collegiate Dictionary defines ethics as “the discipline dealing with what is good and bad and with moral duty and obligation”; “a set of moral principles or values”; “a theory or system of moral Values"; and “the principles of conduct governing an individual or a group (professional ethics)” [19]. P. Lazaro, B. Azcona | Heath Policy 37 (1996) 185-198. 189 Reiser and Heitman, in a reflection on the ethical values of science, define ethics as “a discipline that establishes criteria and methods to decide whether actions are right or wrong” [20]. For this purpose, ethics defines the essential values that guide us in choosing right actions, and it establishes rules, guidelines, and policies that drive and support such values. ‘The viewpoint of physicians in the times of Hippocrates — as conscious, self-critical scientists — is still valid today. The Hippocratic oath proclaims a series of ethical standards to guide physicians in applying their knowledge, and defines the ‘elation between ethical and technological knowledge. The oath states that methods ‘and technologies in medicine should not be taught unless the ethical principles of the oath are accepted as a guide to their use. The formula was simple: technical Knowledge and authority cannot be exercised in the absence of ethical responsibil- ity, Technical skill was not enough to make a physician; ethical and humanistic jearning were also required [20]. Since Hippocrates, the ethics of medical practice has been based on six ethical principles (preserve life, relieve suffering, do no harm, tell the patient the truth, respect the patient's autonomy, and treat patients with justice) [21-24], These” principles can be reduced to four: monmalefcence, bbeneficence, autonomy, and justice. Under the principle of nonmaleficence, the physician ought not to inflict evil or ‘harm on the patient. This principle should be observed regardless of the will of the patient [21]. Duties of nonmaleficence include not imposing risks of harm as well as fot inflicting actual harms. In cases of risk imposition, law and morality recognize f standard of due care. This standard can be met when goals sought are weighty and important enough to justify the imposition of risks to others. The observance of this principle depends solely on the physician (24). ‘According to the principle of beneficence, the benefits to the patient derived from the application of a technology or procedure must be greater than its risks, The application of any medical technology involves certain risks to the patient, but if the expected benefits are greater than the probable risks, no ethical conflict arises under the principle of beneficence. The problem is that before applying the technology to a specific patient, the risks and benefits are, at best, known only in terms of probabilities (24). Thus, the key decision-maker under this ethical principle js the physician, the person who knows the balance between risks and benefits for the patient. “The principle of autonomy indicates that the patient must be adequately informed and his/her decision respected with regard to the application of the chosen technology. Sometimes it may not be possible to actively accept a procedure, for example, when the patient has problems with consciousness. In these cases, when ‘reflective acceptance’ is not possible, some authors suggest that a decision based on snon-refusal’ be used as a criterion [21]. But aside from these exceptional cases, one of the Key factors in applying this principle is the natural variability in patient decisions, Two patients with the same clinical condition and faced with the same procedure may choose differently. There are many reasons for this, but the two most important ones are that patients may have different values, and that their dattitudes about the risks versus the benefits produced by applying the technology 190 . Lizaro, B, Azcona | Health Policy 37 (1996) 185-198 ‘may also differ. Under the principle of autonomy, the decision-maker is, in theory. the patient. In most cases, however, the patient does not have enough appropriate information to make the decision. As a result, the decision either is left in the hands of the physician, or is made based on the physician’s information and advice, so that in practice it is the physician, or his/her influence, that plays the most important role under the principle of autonomy. The fourth principle is the principle of justice, according to which an act is not ethical unless it is equitable, that is, unless it is available to all who need it. To assure equality of opportunity for all citizens without any type of discrimination fand to avoid economic interferences are fundamental ethical factors in the access to effective medical technologies [21,25]. This principle may be compromised when the physician, in his or her eagerness to furnish the best and most care to a specific patient, may inadvertently make the resources unavailable to another patient who Reeds this or another type of care [3,26], As a result, under the principle of justice the physician significantly influences the distribution of resources among patients, "Thus, these reflections from the ethical perspective show the physician's impor- tance in and responsibility for the use of medical procedures, and emphasize the key role of the physician in health care systems. These considerations, however, do not minimize the responsibility of those who make health policy decisions and allocate resources to foster the development of effective procedures (principle of beneficence), to inform and promote the participation of patients and citizens (principle of autonomy), and to develop an equitable system (principle of justice) (4,21,23,25)- 5. An economic perspective ‘According to the most widely accepted definition, economics is the study of how persons and society choose to Use scarce resources (money and other resources) for production that could be used for other purposes, to produce goods and distribute them for consumption, now or in the future, among persons and groups in society. Economics analyzes the costs and benefits of different patterns of resource use [27). It follows that economics as a science is not necessarily concerned with money, but rather is a set of scientific methods for improving the use of resources which can be lused in different ways to achieve different ends. Economics as a discipline tries to provide knowledge so that all citizens will obtain the highest possible degree of Well-being with the available resources; such an objective is undeniably ethical “The consideration of health care from an economic perspective requires an understanding of some characteristics of this sector. If health care provision is considered as a ‘market, it is not a ‘perfect’ market. In a ‘perfect’ market the price Of resources and products reflects their social opportunity cost, and technical ficiency and allocative efficiency are guaranteed. ‘Opportunity cost’ is the actual ost of carrying out an activity, that is, the benefit not obtained by using the fesources in the chosen activity instead of allocating the same resources to the best {the most highly valued) alternative use [28] ‘Technical efficiency’ means that goods P, Lézaro, B. Azcona | Health Policy 37 (1996) 185-198 91 and services are produced in the most efficient way, since the market (consumers) will eliminate providers who are inefficient. ‘Allocative efficiency’ means that available resources are allocated to the most highly valued needs. Although it is doubtful that any market works perfectly, the ‘health care’ market has numerous exceptions that make it impossible to consider it a ‘perfect’ market [28,25] thus automatic market regulation does not necessarily lead to efficiency. Economists agree that the most notable exceptions in the health sector with respect to a perfect market are unpredictability of demand, uncertainty about the consequences of decisions, itrationality' of provider and consumer decisions, the existence of ‘externalities’, and the agency relationship [28,29]. In the context of this article, the most important exception is the agency relationship. ‘Agency relationship’ means that consumers (patients) do not usually have the knowledge required to make appropriate choices, so that health care providers (especially physicians) become key elements in determining the demand for treatment on behalf of their patients. Physicians, in this dual role as providers and as agents for their patients, may create fan increased patient demand, This effect, known as ‘supplier-induced demand’, is illustrated by a study of the variation in physician requests for chest X-rays for patients with respiratory symptoms depending on whether the physician has an Xcray device in his/her office or must request the X-ray from a radiologist. In the first case, the physician’s self-reference pattern results in the consumption of resources being multiplied by six. These resources could be used for different ends that could benefit the same or other patients [30]. The physician, therefore plays a key role in the distribution and allocation of resources in the health care system, not only from the ethical but also from the economic perspective. Tn order to achieve their mission, health services use resources and produce certain results, Resources can be used in many ways, and consequently the results produced will also be different, Society must attempt to achieve the most favorable possible relation between the resources used and the results produced [31], Health Core resources are inherently limited because the resources that society decides to Gevote to health are not infinite. The resources may be large or small, of high or jow quality, but they are always limited. Thus, not necessarily everything that is technically possible can be done. As a result, decision makers (physicians, man ‘agers, planners, ot policy-makers) are constantly making implicit or explicit choices among different alternatives. The problem is knowing how to make these choices {32}, To help choose among different alternatives, various methods have been leveloped which, taken together, may be called socioeconomic evaluation. Socioe- conomie evaluation is not necessarily concerned with money, nor just with costs, “Frrationality in this eontext means nonsmaximization of the tility function. 21nan ‘optima mafket situation, each individual's relative position is based on changes that are solinary and free of interference, External effects (externalities) ae introduoed when a third person aera petit or incurs a cost without specifically choosing i, as a consequence of another subject's Eason bout production or use, For example, treating (incurring costs in) © patent with active catetlis amproves (produces benefits for) both the patent and many other individuals by avoiding 92 P. Lézaro, B, Azcona | Health Policy 37 (1996) 185-198 but also takes results into account. Socioeconomic evaluation is not a way to control costs, it is a scientific way to improve decision making. Thus it is important to temphasize that the clinical effects of an intervention must be clearly identified (including any uncertainty about its effects) before generating the associated Socioeconomic hypotheses. There are several techniques for the socioeconomic valuation of health services or medical procedures, but common to alll of them are that the resources used are compared with the results. Each technique differs principally in how it measures and evaluates these results (33~36]. The results of an Fitervention can be expressed in four ways: (1) efficacy: the effect produced on the variable under ideal oF laboratory conditions; (2) effectiveness: the effeet produced on the variable under real-life conditions; (3) uility: the quantity and quality of life that a certain procedure provides to a certain individual; and (4) benefit: the results of an intervention measured in monetary units. Efficiency is the relationship between costs and outcomes, In order to concept ‘lize the meaning of efficiency, the objective of the organization must be kept in nind, The objective of health systems is to improve the health of the population in Such a way that the available resources have a maximum impact on the health status Sf the nation, therefore, efficiency is understood to be the relation between the Sutoomes obtained and the (social opportunity) cost of the resources used to obtain them. Since outcomes can be measured in various ways (efficacy, effectiveness, utility, and benef, four types of eflicency analysis can be formulated: cost-ffieacy, ost effectiveness, cost-utlty, and cost-benefit. In any type of efficiency analysis two important facts should be emphasized. Fist it requires explicit consideration Of beth resources consumed (costs) and health improvements obtained by applying the procedure. Thus improvements in efficiency should be distinguished from cost-oo% fing measures, which do not take account of the potential reduction ip progrart Tesnlts when resources are decreased. That is, the least costly option is not Tevessarly the most efficient. In the second place, efficiency analysis implies a broad sew deravion of costs, not just hospital costs, but also those produced at other levels

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