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.

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 htaylor@harrisinteractive.com