This research, of course, conflicts with the idea of market-based and consumer-driven health plans, which want to "empower
consumers" to decide for themselves. But we have always tended to believe that physicians, not patients, are the right people
to decide what is and is not appropriate. By all means, doctors should review treatment options with patients, and even let
patients make the final decision—but the physician is the expert we trust to tell the patient about the likely consequences
of different treatment options, or of no treatment.
Needed: Discourse and Debate
There are several reasons why cutting inappropriate care will be very difficult.
One is the culture of American medicine, so well described some years ago by Lynn Payer in the book Medicine & Culture. American doctors are, it seems, the most aggressive in the world and are educated that "if in doubt, do something." Payer
contrasted this approach with the British medical culture of "watchful waiting"—in other words, "take an aspirin and come
back if it still hurts".
Furthermore most physicians and hospitals make money from doing more rather than less. The financial incentives to deliver
more care are very powerful. Doctors' productivity and compensation are usually based on how many dollars they generate. The
more care they deliver —appropriate or inappropriate—the more money they and their hospitals make. And sometimes inapproprate
care is generated by defensive medicine to avoid malpractice suits.
Whatever the causes of inappropriate care, there is almost universal consensus on the desirability of reducing it substantially.
It is the one goal on which both the left and the right can agree. They disagree passionately on the roles of government,
the market, global budgeting, single-payer systems, and tax incentives. But who could be against cutting unnecessary care?
Health information technology, quality measures, patient protocols, and pay-for-performance are all steps toward improving
the quality and appropriateness of care. The unresolved question is who should be mainly responsible for cutting inappropriate
care: government regulators, employers, insurers, hospitals, doctors, or consumers?
Advocates of market-based solutions—those who think patients should pay a much larger share of their costs—argue that this
is something the patient should take responsibility for. This sounds good, but real-world data show that when people have
to pay more for medical care, they reduce their use of both inappropriate and appropriate care. Higher co-pays and deductibles
increase noncompliance. And noncompliance often increases healthcare costs.
Can we really believe that patients who are sick, in pain, or frightened can tell what is and is not appropriate? The idea
that patients should be expected to know better than their doctors whether tests, treatments, surgeries, or medications are
inappropriate—before they receive them—seems fanciful. Yet many are swallowing this pill of personal responsibility without
stopping to think about it. For some reason this issue of how to and who should decide what care is appropriate does not seem
to be the subject of much debate. It should be, and it will be.
Humphrey Taylor is chairman of the Harris Poll, Harris Interactive. He can be reached at firstname.lastname@example.org