Abstract

Physicians are feeling the heat of cost containment. Pressures on doctors to contain costs have mounted - from hospital and Health Maintenance Organization (HMO) administrators, from state and national government, from medical staffs. Medicare payment reforms, corporate and insurer demands, and market pressures have all come together to pressure health care providers to cap escalating health care costs. This article posits that such pressures to control costs are not always counter to the patient's best interests and that the ethical debate needs to incorporate the emergence of bureaucratic medicine and its sensitivity to cost. The pressure to reduce cost has intensified the tension felt by physicians as they balance their ethical obligations to treat their patients and their desires to maintain the financial health of their health care institutions and their own financial security. The line between pure medical decisions and economic decisions has blurred. The essence of the complaint is simply stated: "... economic imperatives may weaken what should be a strong fiduciary relationship between doctor and patient. A physician cannot easily service his patients as trusted counselor and agent when he has economic ties to profit-seeking businesses that regard those patients as customers. The current ethical debate seems to revolve primarily around middle class medicine, where physician autonomy in treating patients has been most dramatically limited by new modes of health care delivery and reimbursement. Prospective payment mechanisms have been implemented through the federal Medicare program, but hospitals have applied DRG categories across the board to their delivery of health care. As hospitals struggle to contain costs, they have implemented cost controls that affect a doctor's practice generally and not just that segment involving Medicare patients.