Striking a balance between individual patient demands and public health resources - the role of the primary care physician*

M C S Wong 黃至生, M W L Chung 鍾惠玲, N C L Yuen 阮中鎏, S K S Foo 傅鑑蘇

HK Pract 2005;27: 62-67

Summary

Primary care physicians very often come across patient demands that may utilize public health resources in a cost-ineffective manner. In addition, policy makers and health economists experience tensions between the two extremes of advocating patient autonomy and distributive justice, especially when health care resources are scarce. This article addresses the dilemmas faced by physicians when imbalance between patient demand and public health needs occurs, and the complexity of factors that come into play in clinical decision making. We will discuss various potential strategies at the level of our surgeries, as well as community participation by primary care physicians. Their role in collaborating with Non-Governmental, and Patient Self-help organizations is highlighted, and their participation in health education and health promotion encouraged.

摘要

基層醫生經常會面對病人提出一些從公共醫療角度來說是不合乎成本效益的要求。 此外，在資源緊絀下，醫療決策者與經濟學家也難在推崇病人自主及公平資源分配之間作出取捨。 本文陳述醫生在面對個別病者要求與要顧及大眾醫療需求時的兩難局面，以及在臨床決定時所考慮的各種因素。 文章亦討論基層醫生在診所層面及參與社區工作的潛在策略，強調在與非政府或病人自助組織合作時的角色。 我們鼓勵家庭醫生參予健康教育及健康推廣之活動以舒緩需求不衡的現象。

Introduction

The imbalance in resource allocation in our health care system has been of much concern, and is an issue of continuing debate. The topic bears huge implications, ranging from the long-discussed health care reforms and medical bioethics. Indeed, from the macro-perspective of a public health policy-maker, the decision-making is of a tremendous challenge, and is never straight forward. Such dilemmas are often faced by the government, healthcare professionals and the economists.

For primary care physicians, how much attention should we pay to our health resources before we offer a particular investigation or treatment to our patients? Indeed, if a physician considers that a certain expensive treatment is in the best interest of the patient, but this may not be considered to be justified economically by the society, what approach should we adopt?

The international code of medical ethics states that "a doctor . . . . shall be dedicated to providing competent medical service in full technical and moral independence".¹ However, there is always a challenge for the family physician to make a balanced choice between the principles of patient autonomy and cost-effectiveness of any investigation or treatment decision. For example: if a patient requests a HA doctor to perform a MRI of the brain because of a headache of recent onset, and the physical finding does not indicate such an investigation, should the doctor comply with such a request?

The nature of patient demand

The human capital theory of Michael Grossman^2,3 has explained the real meaning of demand for health and health care. "It is not medical care per se that the consumer wants, but rather health . . . . people want health; they demand inputs to produce it".⁴ In other words, patient demand is actually a "derived" demand, or patient autonomy.

Apart from the severity of illness, medical demand is also closely associated with patient's age, gender, personal income, lifestyle, and health care standards.^5,6 To thoroughly assess individual patients' demands and expectations (or what patients actually need) would seem to be an insurmountable task.

Public health resources

The health care system of Hong Kong is under tremendous financial pressure. According to Domestic Accounts Estimates,⁷ the proportion between the medical expenditure of the Hong Kong Government and the Gross Domestic Product (GDP) has risen from 3.7% of the financial year 1989/1990 to 4.6% of 1996/1997. This is attributed to the very rapid growth of our medical expenditure outpacing the rise of GDP. From the Government's fiscal policy it would be difficult to anticipate a greater share of the total government expenditure towards the health care sector. Nevertheless, patients' demands are rising in an alarming manner.

As primary care physicians, do we have a role to play as gate-keepers in healthcare financing as some authorities advocate? The work of Starfield⁸ provided substantial evidence for the concept of primary care as the foundation for a healthcare system. Her eleven-nation study indicated the clear superiority of health systems with a primary care orientation which achieved better health levels, higher satisfaction with health services among their populations and lower costs of services overall.

The dilemma

Indeed, if an utopian city owned unlimited medical resources, the problem of allocation imbalance would perish. It is exactly due to the limited healthcare resources which make allocation a difficult and often challenging task. That means subsequent care of another is affected due to the lesser medical resources available. Putting it in an ethical framework, physicians could experience tensions and frustration between patient beneficence and distributive justice.

"Reaping the maximum benefit for the maximum number of patients" is undoubtedly accepted by many parties as desirable criteria for resource allocation, including policy-makers, the general public and voluntary patient self-help groups. Nevertheless, what do we mean by maximum benefit? Are there any practical strategies to maximally benefit the maximum number of patients?

Achieving both economic efficiency and equitability is many policy-makers' societal goal. It is however difficult to expect the presence of both without compromises. Our culture's ethical values, existing medical resources and local disease burdens are some of the major factors which could tip the balance towards either goal at the expense of the other.

Two major social justice theories

Assume a patient with mild hyperlipidaemia came to your clinic, in a public out-patient setting, and requested a particular statin, which is available in your dispensary. He revealed no history of heart disease nor other concomitant cardiovascular risk factors. Nevertheless he could not afford the cost personally long-term. From an evidence-based literature search you determined that he personally might benefit from your prescription, although marginally, but that it seems cost-ineffective given the price the society has to pay.

What could be the various approaches, assuming the drug cost was financed by the society? In this case, what is the doctor's agenda, or is it appropriate to have an agenda at all? Should the doctor's objective be targeted towards saving more money to help other more needy patients (a public health perspective, hence dissuading the prescription)? Or should the doctor respect the patient's autonomy as our client (an individualism perspective, hence favouring the prescription) and agree with whatever is beneficial to our patients? On the other hand, would the doctor's agenda be superseded by the patient's demand, in concurring the promotion of patient's autonomy?

As has been discussed in many textbooks of health economics,⁹ social justice theories play tremendous roles in guiding resource allocation. We briefly discuss two major theories:

1. Utilitarianism

In its classical form it defines the social welfare function as the sum of individual utilities. In other words, "the greatest good for the greatest number", and the objective focuses on maximisation of society's total satisfaction. There are trade-offs among goals, and the society would accept some mal-efficiencies in order to achieve the maximal beneficence for the whole society. In our hyperlipidaemia case, if Cost-Effective Analysis (CEA) does not recommend the prescription, the patient will not be entitled to the statin, even though he lacks purchasing power.

2. Egalitarianism

As proposed by John Rawls¹⁰ in 1971, the main principle of justice is that we should ensure fair social choices. Equality is more emphasised as compared to utility, and the needs of the worse-off were regarded as a priority. This extends to the principle of "maximin"^10,11 where our society would support a system of justice to maximise those worse-off. That is in line with the basic economic concepts of "diminishing marginal efficiency of investment". It offers less weight to the health benefit of all, but is in favour of the moral theories of equity and distributive justice. This is also compatible to the concept of the philosopher Norman Daniels¹² on health care needs as "Fair equality of opportunity", as well as the Health Economist Alan Williams' promotion¹³ that people are entitled to their "fair innings" of health and life expectancy.

In our example we should prescribe the statin given the presumption the patient is the worse-off and it is the duty of doctors to offer the benefit, however marginal this would be.

The physician's difficulty

Is it possible to reconcile the above two approaches to achieve the optimal management option during our consultation? The decision whether to prescribe the statin is challenging because:

1. Evidence-Based Medicine (EBM) and CEA do not possess answers to the majority of clinical scenarios, and sometimes do not provide any clues at all. As addressed by Chan¹⁴ in a discussion on EBM, most of the questions asked during patient consultations remained unanswered. Apart from potential biases in medical literature which require careful critical appraisal, not all interventions, for instance newly emerged lipid-lowering agents, have solid evidence as regards its effectiveness. Physicians could suffer from a relative lack of information for decision-making.

2. Value judgment is a very crucial determining factor, which varies significantly from physician to physician. In addition, clinic guidelines are never binding. One should realise that evidence-based decisions are not straightforward, and are "influenced by evidence, economics and ethics."¹⁵ With the writing of the prescription, the factors that necessitate inevitable scrutiny are also huge and complicated, including patient demand, individual characteristics and administrative concerns. Even when all factors are fully available, these overloaded, unquantifiable parameters may even confuse the physician further.

Possible solutions for the role of the primary care physician

We regard this as not only a social welfare or resource allocation problem, but also an issue relating to the physician's responsibilities. The Government has an unshakable duty to take care of its citizen's health, but to what extent? When everybody focuses their attentions on their own health care needs, what would happen to our health care system in the future when scarcity of resources hampers societal beneficence?

In a capitalised culture, it would be a rare instance that a patient would actively request a physician not to prescribe a more expensive and beneficial medication solely for the sake of public health resources. Indeed, the chance that the patient has sufficient knowledge on the present public health scenario is quite slim. In other words, our patient has neither sufficient incentive nor knowledge on the proper allocation of medical resources in one particular consultation. Therefore we would argue that patients should not be accountable for the imbalance, but this is something which the primary care physicians could act upon.

To prevent this phenomenon of imbalance, the key lies in improving patients' self awareness of their own condition and thus their corresponding expectations. The two major ways to do this at the primary care physicians level would be:

1. Relieving public health burden by minimising its wastage due to unrealistic patient demand (and sometimes due to doctors' own requests).

2. Satisfying patients' demand for health, rather than their demand for medical resources. This is in recognition of the concept of derived demand discussed above.

Practical strategies and the joint collaboration between patient self-help organizations (PSOs) and general practitioners (GPs)

For the hyperlipidemia example, we do not pretend there is a model answer. It is dependent on the physicians' own practice features and ethical values. However, we would like to raise some potential strategies to lessen the severity of demand-resource imbalance. We strongly believe that once the imbalance is alleviated, we would come across this type of dilemma less frequently in our consultations.

1. In our surgery

It is important to keep ourselves abreast of emerging medical knowledge, such as current clinical guidelines on the management of common conditions, appearance of new drugs in the health market, medical innovations and the like. By attending structured seminars, didactic lectures, and enrolling in diploma programmes and even organising informal discussion groups, we could keep ourselves updated on the latest current medical progress. These undoubtedly help to build a platform for us to facilitate our consultation when dilemma arises.

It is the duty of the primary care physician to safe-guard public health resources. Regular literature reviews, acquiring a basic technique in critical appraisal and some knowledge of health economics are desirable in order to make this possible. It may be also helpful under certain occasional circumstances to incorporate real concerns of societal beneficence and convey this to our patients, although we should always put our patients' best interest as the top priority. Simple language and certain public health principles may sometimes be needed during the consultation, but this should only be adopted judiciously and conscientiously. As an example, are we comfortable in explaining the concept of, for example, positive predictive value and the hazards of low specificity of a Prostate Specific Antigen (PSA) test to one requesting it?

To illustrate this point we will use our statin example. We could focus our consultation on exploring the patient's agenda for such a request, his concerns and expectations of innovative treatments; introducing the options of other forms of treatment like simple dietary manipulation, and a trial of first-line agents as recommended by local clinical guidelines. However, the patient's autonomy should be highly regarded in the shared decision making process.

2. Community participation

Indeed, the professional code of a major hospital has long addressed its importance. "Doctors have civil responsibilities to actively participate in community health activities and hence solve social problems in accordance with one's talent" (「積極參予社區健康活動，因應能力協助解決社會問題」 ¹⁶)

When chronic disease sufferers acquire a more thorough understanding of their real medical needs and hence their actual expectations on our health care provision, this would mean a big step towards a healthier medical system. Through health education and health promotion, PSOs and other health-related Non-Government Organizations (NGOs) become a potential and important source for this to occur. The implementation of this type of health promotion is not only to effectively alleviate health care costs, but will also build a strong foundation on patient's reasonable expectations of health care demand.

GPs can readily collaborate with PSOs and NGOs by offering more health education, interacting with patients in self-help groups and even establishing a close and friendly relationship with them. If the Government and the primary care physicians could set up a good communication linkage, participation in these PSOs could even strengthen GPs' understanding of patients' real concerns and thus voice their problems.

Indeed community participation by family doctors should be more recognised. The spectrum of activities which could be of interest range from regular health seminars to large-scale community projects to achieve the purpose of health education. Of course services provided by profiteering groups should be under appropriate monitoring and regulation. As our patients' advocates we would wish to have a closer communication channels with our policy makers, and to a similar extent, the public, in the future.

Conclusion

As primary care physicians, should we not only adopt in our practice a bio-medical model but also the bio-psycho-social (economical) model as well?

Acknowledgement

We wish to thank Dr. Tse Chun Yan, Chief Executive of the United Christian Hospital, whose support has made this article possible.

Key messages

1. Primary care physicians are often at crossroads between satisfying patient demand and safeguarding scarce public health resources in their clinics.
2. The clinical dilemmas have no simple answers but could be minimised by tuning patient demand and expectations appropriately via patient education.
3. Practical strategies at the level of our clinics include keeping abreast of medical progress and innovations, as well as acquiring knowledge in the area of public health.
4. Participation in community services and collaboration with patient self-help groups could also relieve the imbalance phenomenon.