Caring and Cost: The Challenge for Physician Advocacy

Traditional Patient Advocacy

In the dominant paradigm of the patient–physician relationship in the United States today, patient advocacy is encapsulated—protected, or isolated, depending on one's viewpoint—from population-based ethics, in which rationing is an ethical and practical necessity.

Well, what could be wrong with this? Isn't it reassuring to know that your physician is on your side, using his or her clinical skills to determine whether a treatment would be—or even might be—beneficial for you, and then fighting for your right to get it? More than reassuring, this model of patient advocacy has many strengths and has stood the test of time. On the other hand, in addition to adding to the inflationary pressures on health care services, this form of patient advocacy also runs the risk of reinforcing inequities in our health care system. Physicians practicing in this model exercise what could be called “Darwinian” patient advocacy (top panel of the Figure). Because the effort to control costs comes only from outside the patient–physician relationship, each patient–physician dyad competes with another for resources. Each dyad is blind to each others' needs, selfish, and even competitive in a Darwinian sense.

This kind of patient advocacy creates a significant risk for inefficient and unjust variation in care. It would hardly come as a surprise to learn that the patients who request and receive approval for marginally beneficial care are more likely to be white, affluent, and well educated. Is it fair for these patients to get marginally beneficial services when other, less advantaged patients might go without services that they need even more, just because they don't know how to ask persuasively? Resources foregone by one patient are not guaranteed to be used directly by another for greater benefit, but when physicians join with their patients to capture all the marginal care resources they can, one view is that they are not taking from administrators or insurers—they are ultimately taking from other patients (15). Morreim calls this a problem of “contributive justice,” the notion that any use of health care resources should be seen as denying the opportunity for some other patient to use the money for potentially greater benefit (10). In short, traditional Darwinian advocacy ignores the economic reality of limited resources and fails to grapple with the ethical reality that these resources are shared.

An Alternative Model of Patient Advocacy

Although it may be easy intellectually to call for a “balance” between the needs of individual patients and those of other patients and other social priorities, practicing physicians know that this concept is difficult even to imagine when caring for a real individual patient, when pain and illness call forth the deepest human instincts to care, and to care deeply, and to care without reservation. Can these honored features of the patient–physician relationship be retained while a new model of patient advocacy that will avoid the pitfalls of Darwinian advocacy is adopted? I think it is possible, although a new model will carry its own risks. The alternative model for the patient–physician relationship is one that can be called “proportional” advocacy (16). In this model, the key concept is that the physician and patient are linked together not as an isolated dyad but within a group in which other physicians and other patients are also drawing from a limited and shared pool of resources (bottom panel of the Figure). The pressure to allocate and ration resources within acknowledged limits arises from within this balanced structure and is applied uniformly across physician–patient dyads that operate in open cooperation and collaboration—instead of in the competition of the Darwinian model.

Proportional advocacy requires a critical weighing of risk and benefit in every clinical decision, a process that is both logical and ethical. But this kind of balancing of multiple considerations, with ultimate integration into a coherent assessment and plan, is not foreign to physicians. Excellent physicians can make complex clinical decisions by weighing the likelihood and quality of clinical outcomes and integrating these with patient and family values. Proportional advocacy draws upon these same time-honored skills.

One element of this model needs to be stressed: The individual physician is not rationing the care of his or her individual patient blindly or alone. A physician rationing care in isolation is far worse than a physician advocating for individual patients without concern for others. Physicians should ration only when they can join each other and their community in a shared quest for justice and mercy in the face of life's limits.

Putting Proportional Advocacy into Action

But should proportional advocacy even be entertained as an option when for-profit health plans dominate the marketplace, when physicians share much of the financial risk associated with capitation while maintaining their incomes at a level significantly higher than in other countries, and when individual patients will always be vulnerable to having care withheld without their knowledge (17, 18)? These are challenging questions. Yet, the advocate for proportional advocacy would argue that even if the landscape of U.S. health care were swept clean and replaced with a single-payer system, physicians would be charged with the task of prudently using the explicitly finite resources to improve health. To do that, physicians would need to discuss with patients when beneficial care did not meet the threshold for which common resources should be used to pay for it. Whether now or later, how might physicians and patients conduct these conversations? Specifically, what would patients need to hear from their physicians to believe that it was fair and reasonable for them not to receive coverage for a test or treatment that would be of some benefit?

My answer to this question is summarized in the Table and demonstrated in the quotes shown below. For the example below, I have recreated a composite case from pieces of my own experience and that of many colleagues. It is the case of a general internist and her patient discussing the patient's knee pain, pain that has worsened with conservative management. The patient requests a referral to an orthopedist who is a well-known knee specialist—one who is a member of the health plan's extended physician network but who is not part of the internist's local risk-sharing group. Thus, a referral to this orthopedic subspecialist would cost the medical group more money than if the patient were seen by the “regular” orthopedist who is a member of the referring physician's risk-sharing practice group. The internist believes that the requested orthopedist is indeed more skilled at complex cases but that the regular orthopedist to whom she usually refers patients is very likely to be competent to assess and treat this patient's medical needs.

Physician: I know that the orthopedist you want to see is outstanding. On the other hand, the orthopedist I usually refer my patients to is quite good and should be able to care well for you. If there is ever something you need that I believe will be important for your health, I will make sure you get it. But in this case, if I send you to the orthopedist you want, the coordination of care between us may not be as good. In addition, to be honest, the cost of your going to the other orthopedist is not covered in the payment we get from your health plan, and in your case, I just don't think it makes sense to make a special exception to send you to see him.

Hard to say? Definitely, but there should be open and honest communication indicating that decisions about rationing potentially better care are being determined. Physicians should not hide behind clinical language (for example, “not indicated”) to avoid the reality that they are proposing to ration something of real or potential benefit to the patient. Physicians should also remember that they are not telling patients that they cannot have the particular referral, test, or treatment, just that they do not believe it is prudent to authorize the patient's health insurance to pay for it.

Patient: I don't understand why I shouldn't be able to see the best orthopedist if I want to. Is this really just about the money?

Physician: I can appreciate your concern. I am thinking about money—as I believe I should—but I am not “just” thinking about money. There are two reasons why I don't think I should authorize the referral: First and most important, I really do think you'll get excellent care from my regular orthopedist. If for some reason you don't, or your knee isn't responding as expected, we should reconsider. Second, yes, everybody is trying to keep down costs, and we're trying to do it in a fair way. Only if we are careful about how we spend money will we be able to help keep down your health insurance premiums in the future; and also, only if we're prudent will our group be able to expand important efforts, like cholesterol and cancer screening, that can really save lives and benefit many patients.

The physician should be able to communicate to the patient the basic idea of the social compact that justifies rationing one patient's care to benefit others. For many physicians, however, this is the point at which they feel they cannot honestly continue the conversation. It is true that the U.S. health care system is not “closed” and that money saved through the rationing of marginally beneficial care is not easily linked in a direct tradeoff with more beneficial care programs for the population (19). Even more problematic for proportional advocacy is the increasing role of for-profit health plans, which complicates any claims of the legitimacy of rationing by raising the specter of money being siphoned off into shareholder dividends or egregious executive salaries (20).

Nevertheless, rationing marginal care for the overall benefit of the population is not necessarily an ethical fiction. Although a single-payer health system would make it easier to justify rationing care, budgeting and payment systems in many medical groups do allow resources saved during one year to be consciously spent during the next fiscal cycle to improve care. Health plans and prepaid group practices should do more to make tangible the presence of internal trade-offs through which money saved can be funneled into new or better care elsewhere within the system.

Patient: Is this a decision that you are making by yourself?

Physician: No, this really isn't just me making the decision. My medical group has had discussions with your health plan, discussions that have even involved patient representatives, and the consensus has been that the group shouldn't pay routinely for outside referrals in situations like yours.

Physicians should work together with patients and other representatives of the community to decide which type of services do not represent the best use of available resources. The process used in Oregon for determining services covered under an expanded Medicaid program is a strong model of an attempt to engage physicians and the community in just this sort of decision making (21, 22). Health plans and provider groups need to do more to set up formal processes to gain members' input into these kinds of decisions. At the very least, physicians should work together within their own practice groups to jointly determine the thresholds between beneficial care and “marginally” beneficial care. Such a physician-driven process should be viewed as a step toward a fuller public engagement in the setting of priorities for health care spending. Toward this larger goal of achieving a greater sense of moral community in health care, physicians have a critically important role to play as teachers and midwives.

Patient: Tell me, really, wouldn't you let a big-shot corporate executive go outside your network? Wouldn't you authorize it for yourself?

Physician: Your trust in me and in this whole process is very important to me, and I want you to know that I would make the same decision for any other patient in this situation—myself included—and I believe the other physicians in my group would also make the same decision.

As the conversation continues, the patient will want to know that the same decision not to approve the request would be made for other patients in comparable situations. Would a physician or a “VIP” patient have the same limits applied to their requests? The answer must be “yes.” To buttress this claim of basic fairness, physicians should also consider whether they can claim that other physicians in their group would make the same decision. If this claim cannot be made honestly, patients will have good reason to question the legitimacy of the rationing decision.

Patient: From what I hear, you're under a lot of financial pressure these days. How much do you actually lose personally if you authorize the referral?

Physician: Good question, one that's actually hard to answer. Although I do have an incentive overall to control costs since the whole group would lose money on this kind of referral, a single decision like this one wouldn't have a significant impact on my pocketbook, since the only way I see a difference is at the end of the year, when all costs are spread out across the whole group and the whole year. Even then, most of my take-home pay is determined by salary. I can definitely tell you that I am not saying “no” just to make more money for myself or to please your health plan.

For many physicians, this claim may be a difficult one to make, but it is central to the ability of patients and the public to trust in the concept of proportional advocacy. Of course, under fee-for-service reimbursement in the past, a clinical decision often had a direct impact on the physician's earnings. Financial incentives in managed care are often quite complex, but they should be structured so as to allow a physician to make the claim above in good conscience (23). If the physician cannot say something like this when contemplating the rationing of care, then there are serious ethical problems with the compensation system.

Patient: Silence.

Physician: Does this seem reasonable to you? (Pause) I hope you understand the reasoning behind my decision, but if you don't think it's right or fair, we have several options. I could consult with my orthopedist over the phone to make sure he feels he can take good care of you, you could certainly have an appointment with another internist here, or you could call your health plan and discuss the situation with their member appeals department.

Patient: No, that's OK, Doc. I guess it makes sense  … as long as you trust this other orthopedist as much as you say. Thanks for talking it through with me.

Physicians should always be aware that they may be missing something in the history or in the perspective of their patient, and so it is always appropriate to assess the patient's understanding and to consider whether the vital sense of partnership in any rationing decision has been maintained. Coupled with this assessment should be an offering of other avenues that can be pursued if the patient does not feel comfortable with the decision. Ultimately, trust will be greatly enhanced if there are clear, reasonable, and timely methods of appeal. Any system is only as good as its ability to handle exceptions, and patients will want to know that they have an option to appeal any rationing decision on the grounds that they have special reasons to receive insurance coverage for the service in question.

Conclusion

Implicit in this discussion of proportional advocacy is the idea that rationing by physicians is best applied at the margins, where the potential or real benefit to the individual patient is small. The approach discussed above would therefore apply only to a subset of clinical scenarios. But the example of an orthopedic referral is meant to convey that proportional advocacy need not be relegated only to situations for which the marginal benefit is easy to dismiss as vanishingly small. I and other physicians I know have agonized over just this kind of situation exactly because the benefit for the patient seems small to us—but it may not be zero, and it may not seem insignificant at all to the patient.

But what if the primary care physician had believed that the orthopedic surgeon who was outside the network was much better, that his superior skills would have been likely to make a significant difference in this patient's care? Here, I believe there is no argument: The physician should seek the outside referral and should be her patient's advocate in obtaining it. The appropriate exercise of proportional advocacy demands constant attention to the uniqueness of individual patients, to the relative strength of the clinical evidence, and to the maturity of the collaborative decision making that has been done to justify a decision to say “no.” Caution and humility are paramount. Over 25 years ago, Howard Hiatt described the need for a social compact between physicians and other groups in the society to draw the bright lines that would “protect the commons” (24). Today, that vision remains largely unfulfilled. Within our competitive and corporatized health care system, it would be a dangerous mistake for an individual physician to use proportional advocacy to justify withholding care of significant benefit. Proportional advocacy needs to remain in an incubator, but even bringing it into action sparingly, in considerations about marginally beneficial care, would be a useful first step for physicians, their patients, and a society that has been insulated from the realities of health care costs for too long.

Patients and physicians do confront choices every day that offer opportunities for the appropriate use of proportional advocacy. After a joint critical examination of the medical evidence, patients and physicians would probably find more medical care at the margin. In addition to the type of situation illustrated in the preceding section, other common examples include decisions about maximizing patient convenience in getting a test or treatment, questions about whether to order tests meant primarily to reduce the patient's anxiety, questions about using cheaper drugs with slightly less efficacy or slightly higher risk for side effects, and questions about substituting generic or other cheaper drugs for ones the patient may already be taking.

In all of these situations, I believe physicians and patients could discuss their options using the precepts of proportional advocacy. At first, these conversations may feel awkward and create tension, and such discussions could be impeded by the pressure to spend less time with patients. Yet, as our society learns more about issues of health care rationing, I believe these conversations can be held in a way that will build trust through the honesty and forthrightness with which such “difficult” topics are addressed. Proportional advocacy offers an avowedly communitarian ethic—one that, in my experience, patients respond to positively if invited in as a partner to consider the options fairly.

Can proportional advocacy capture the ethical imagination and instincts of more practicing physicians? Can it convince patients and the public that they are valued partners in rationing decisions? I think it can. Proportional advocacy—if it can grow hand-in-hand with greater communication, collaboration, and social justice in our health care system—may offer physicians and patients a way to join together and lead the effort to find the best way to take care of all of us within a responsible budget.