Engaging public in consensus can help eliminate much of the $700 billion of health care spending

ACP's groundbreaking paper a first in calling for discussion and framework for decisions

In a groundbreaking policy paper released today, the American College of Physicians (ACP) offered more than a dozen principles for engaging the public in a process that it hopes will lead to consensus on conserving and allocating resources based on the best evidence of clinical effectiveness and value. How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently?, is, to ACP's knowledge, the first time that a major physician membership society has made such a call for a national discussion and proposed a framework on how to make such decisions.

"Every country makes decisions on how to allocate available health care resources, but their approaches vary widely, reflecting the different political and cultural conditions in each country," J. Fred Ralston Jr., MD, FACP, president of ACP, said at an afternoon news conference. "The United States limits access to services based on access to affordable health insurance coverage and insurance company decisions on covered benefits and cost-sharing. Socio-economic and racial and ethnic characteristics of the population being served, the availability of physicians and health care facilities, and other factors clearly impact the access to care in the US."

Yet, the U.S. has largely failed to address the reality that health care spending is increasing at a rate the country can't afford, ACP's president said. "This is a societal issue that transcends medical care itself-how much should we as a society spend using public funds on health care versus education, the environment, or the defense of our country?

"Democratically elected countries have a responsibility to develop ways to determine the allocation of public resources that have broad public support; such decisions in the U.S. cannot and must not be "imposed" on the population without the consent of the people."

This means that:

• At the patient encounter level, physicians-in consultation with patients-have a responsibility to use health care resources wisely, based on evidence of safety and effectiveness, the particular needs and circumstances of the patient, and with consideration of cost.

• At the societal level, allocation decisions should be informed by evidence on the value of different interventions, be in accord with societal values, reflect moral, ethical, cultural, and professional standards, and be developed with broad public input.

"To be clear, ACP is not proposing that care be rationed," emphasized Dr. Ralston. "Rationing is a term that is poorly understood, emotionally-driven, and not conducive to reaching consensus. It conjures up images of shortages, delays in obtaining treatment, long waiting lines, and government bureaucrats coming between patients and their physicians."

Dr. Ralston noted that there is a difference between medical rationing - in which decisions are made about the allocation of scarce medical resources - and who receives them, and rational medical decision-making - in which judicious choices are made among clinically effective alternatives,

ACP's paper proposes specific principles for achieving such a consensus on conserving and distributing health care at both the patient encounter and societal levels in a way that is politically acceptable given American views of personal freedom and responsibility.

"We believe that engaging the public in such a consensus can help eliminate much of the $700 billion of health care spending per year, 5 percent of the nation's GDP, which studies suggest are wasted on tests and procedures that do not improve health outcomes," Dr. Ralston concluded. "We also believe that eliminating wasteful spending may be the only way that the United States can avoid the explicit medical rationing that exists in other countries."

"We know it won't be easy. We know we don't have all of the answers on how to initiate such a discussion. We offer our paper, though, in the fervent hope that it will lead to a non-partisan dialogue on how best to ensure that spending on health care is sustainable and doesn't bankrupt our country."