Michael Welker | Eva Winkler | John Witte, Jr. | Stephen Pickard (Eds.): The Impact of Health Care (Leseprobe)

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26 Eva C. Winkler amonth. Fifty-nine percent reported that they withheld therapeutic measures for cost reasons, even though the measures were approved and would have a demonstrable advantage over cheaper alternatives, because—in the calculation of these physicians—the therapeutic benefit was too small compared to the difference in cost. 12 Many oncologists experience arole conflict in making decisions about the provision of indicated but expensive therapies. In particular, the ambivalence between the goal of promoting the well-being of the patient and, at the same time, the need to deal appropriately with the cost pressure on the clinics was viewed as problematic. 13 Hence, many doctors feel caught between two demands—namely, between that of patients, who rightly demand the best available care, and that of society, which expects that physicians, as gatekeepers, must use the system’s resources wisely, or even one step further, commercially oriented hospitals, which expect that health care will generate revenue. Different Strategies toDeal with Cost Pressures and Their Ethical Evaluation We have seen from reported studies that there are at least three different strategies in practice to respond to cost pressures: a.) enhancing efficiency to achieve the same result with fewer resources; b.) increasing revenue—that is, putting more money into the system either by redistributing public money into the health sector or by generating more revenues in the health system itself; c.) rationing or forgoing effective medical interventions to save money. In the following, all three strategies are discussed with regard totheir ethical justifiability. Increasing Efficiency Rationalization, understood as guaranteeingthe same treatment result with less resource input, is ethically unproblematic, provided that all relevant input variables are included in the calculation. This excludes, for example, the case where agoal can beachieved only through unpaid overtime or at the expense of time spent talking to patients. In the DRG system, for example, talking medicine in 12 13 See Hasenfuß et al., “Initiative ‘Klug entscheiden.’” Sandra Fernau et al., “The Role of Physicians in Rationing Cancer Care: Attitudes of German Oncologists,” Oncology Research and Treatment 40, no. 9(2017): 490–94.
Time for aNew Oath? 27 the sense of involving patients in jointdecision-making or involvingrelatives in the course of treatment is not abasis for remuneration, whereas other services (for example, surgical interventions or ventilation) are constitutive for aDRG case group and thereby aprerequisite for billing. Interdisciplinary or interprofessional coordination isalso largely uncompensated. Thus, streamlining this system is likely done at the expense of time for patient-centered care—especially for time- and personnel-intensive treatment of children and adolescents, but also of frail elders. Clarifying complex cases and joint decision-making are therefore not aneutral increase of efficiency. 14 However, aslong as economization in the form of streamlining helps to avoid unnecessary work, cost savings and patient welfare dopoint in the same direction. This synergism between economy and patient-centeredness can be understood as “good economization.” The “Choosing Wisely” initiative aims, for example, at identifying diagnostic and therapeutic interventions for each specialty that can be dispensed without negative consequences for patients. 15 The campaign was initiated in 1989 by the ABIM Foundation (American Board of Internal Medicine) with the goal of advancing the core values of medical professionalism and has spread worldwide, with over eighty medical specialty societies that have published more than six hundred recommendations regarding overused tests and treatments that clinicians and patients should discuss. Increasing Revenues One reason for the overuse of medical services is that it generates revenue for the physician’sown practice, department, or hospital independent of its medical merits. The above-mentioned survey among members of the German Society of Internal Medicine (DEGIM) illustrates an already existing awareness of the problems related to the negative effects of such an incentive and decision culture: 93 percent of physicians state that health-care expenditures are increased in this way; 63 percent fear that patients are harmed. 16 If health-care services that are not clearly indicated are increasingly offered in order to generate revenue for the physicians’ own health-care institution, this represents overuse that cannot be ethically justified, since on one hand such interventions are unnecessarily stressful for patients (and in the worst case even harms them), and on the other hand, suchprocedures also reduce the available resources for measures that are actually indicated and evidence-based. 14 15 16 Deutscher Ethikrat, Patientenwohl als ethischer Maßstab fu rdas Krankenhaus. https://abimfoundation.org/what-we-do/choosing-wisely. Hasenfuß, “Initiative ‘Klug entscheiden.’”
Page 1: Michael Welker Eva Winkler John Wit
Page 4 and 5: 6 Table of Contents Karla Alex and
Page 7 and 8: Preface to the Series Five hundred
Page 9 and 10: Preface to the Series 11 family, ed
Page 11 and 12: Introduction Eva C. Winkler and Mic
Page 13 and 14: Introduction 15 Anthony D. Ho uses
Page 15 and 16: Introduction 17 first presents glio
Page 17 and 18: Time for aNew Oath? The Role of the
Page 19: Time for aNew Oath? 25 cision-makin
Page 24 and 25: 36 Günter Thomas b) The tradition
Page 26 and 27: 38 Günter Thomas erences of the me
Page 29 and 30: Ethical Tensions in the Medical Tre

Michael Welker | Eva Winkler | John Witte, Jr. | Stephen Pickard (Eds.): The Impact of Health Care (Leseprobe)

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