How to Factor Economics into Medical Decision Making

With the increasing demand for expanded services, new technologies, and a growing elderly population, conflicts must arise between payers, clinicians, and patients regarding what services to provide, to whom, and on what basis. Our health economist colleague, Dr. Bruce Hillner, calls this the "What to do to whom, with whose money, at what cost?" question. There are several ways to factor economic costs and treatment effectiveness into decision making. The most informative types of analyses are cost-minimization, cost-effectiveness, and cost-utility; the methods are listed in Table 11.1. We briefly discuss each with regard to its advantages, liabilities, and possible application to clinical practice.

A significant problem is the reluctance of some clinicians and patients to accept limitation of resources or rationing by cost-effectiveness or any other method.3 Although a full discussion of the thorny ethical, legal, and economic issues is beyond the scope of this chapter, some overriding factors based on our experience are listed in Table 11.2. Ethicists,4,5 and now clinicians,6 have argued that the least ethical way to allocate resources is to continue in the usual unexamined mode and that ignoring the economic issues is not morally defensible. Until there is general consensus in society on "what to do to whom, with whose money, at what cost," these issues will continue under debate. Concurrently, all payers have limited budgets, so they are doing some form of implicit or explicit rationing now.

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