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Cost-effectiveness: no easy choices or answers.

It's hard to argue against “cost-effectiveness,” as long as it means getting great value for price paid. Who wouldn't prefer the same product at half the price, or a superior one for just a little bit more—particularly if that extra little bit is being paid by someone else? So it's hardly surprising that almost all the physicians surveyed by Ginsburg et al, using this definition of cost-effectiveness, claimed to consider it an appropriate part of their day-to-day decision making. 
 
Before we make too much of this, however, it's worth noting that surveys test what people say, rather than what they do—so it's possible that in actual practice, many of these respondents do not actually worry about the cost of the care they deliver. Furthermore, the fact that most of the same physicians agree that “if a medical intervention has any chance (no matter how small) of helping the patient, it is the physician's duty to offer it (regardless of cost)” suggests that their commitment to cost-effectiveness may indeed be limited. 
 
There is an inherent contradiction in a physician supporting “cost containment” and simultaneously being unwilling to spare any expense for an individual patient. This contradiction is understandable when we consider the really hard question, which the authors didn't ask. That is, “Would you consider choosing a possibly inferior result, in an individual patient, to save substantial resources overall?” This is where the rubber meets the road and where physicians are often placed in an untenable position by the simultaneous demands of the health care system, of “society” overall (demanding that we “save money”), and of patients to whom we have a fiduciary responsibility (“spare no expense to maximize my chances”). 
 
The choices are even more complex than that. Modern American society not only wants us to spend less, but also expects us to perform miracles, given all the resources available to us. On the other side of the equation, even though we have been taught that our commitment to our patients must trump any other concerns, 43 million Americans are still uninsured, and a great many elderly cannot afford their medicines. Perhaps if we collectively did not spend so much on intensive care at the extreme ends of life, expensive new drugs that promise the possibility of marginal benefit, or ever-more-costly technologies searching for an indication, we might be willing to pay for universal access and achieve better outcomes overall. America continues to pay far more for health care than any other nation, despite the many supposedly “cost-cutting” innovations of the past decade. At the same time, we are doing no better, and in many cases substantially worse, than others who spend considerably less, according to standardized population outcome measures such as infant mortality, teenage pregnancy, or life expectancy. 
 
In answering a related question, almost three quarters of respondents said that only patients and their physicians should “decide if a treatment is `worth' the cost.” What, then, is the role for “society” as the third party in such matters? Individual doctors and individual patients almost never pay health care bills directly, and as long as someone else is picking up the tab, it's all too easy for them to decide, together, that no cost is too steep. But we routinely decide, as a community, that some costs are indeed too steep, even when such spending would save lives. We don't pay, for example, to erect rubber barriers along every inch of our highways because that would increase our taxes. We don't force auto makers to build safer cars because they'd turn around and charge us more. We don't even demand lower speed limits because that would slow us down. So why do we allow a multitude of individual physicians to spend unlimited amounts, for the possibility of benefit, in a multitude of individual patients? 
 
When it comes to cost-effectiveness, physicians are placed in the middle of a conundrum, with no easy choices or answers. Studies that try to understand how physicians think about this issue are useful because physicians should and must play an important role in the many discussions that will continue to arise—as advocates for those we treat, as well for our larger community. But we must also keep in mind that these issues are not ours to decide alone or in private conversations with patients and families. And we must ask ourselves harder questions, about conflicting values and interests, rather than merely affirming that apple pie is delicious, just as cost-containment is wonderful, as long as it doesn't require us to spend a single penny less.