AMA Journal of Ethics^®

In the public arena, discussions about health care focus almost obsessively on costs. Insurance premiums, deductibles, and patient copayments are climbing. The cost of prescription drugs is exploding. And successively larger portions of state and federal budgets are being devoted to health care costs.

Until now, discussions of cost have been abandoned as soon as the patient passes from the waiting room into the exam room. Yet it seems ever more unrealistic to expect that we can keep cost out of patient-doctor encounters [1]. This issue of Virtual Mentor begins with the assumption that, as cost increasingly dominates public and political discussions about health care, it will begin to infiltrate the private conversations and relationships between doctors and patients.

Underlying the discussion about health care costs is America’s deep struggle over what role cost should have in health care decisions. Ethicists and economists often speak about cost-consciousness in decision making in terms of “moral hazard”—the concept that the less likely one is to suffer the expected consequences of taking a risk, the more likely one is to take that risk. In the realm of health insurance, moral hazard theory suggests that generous health insurance will induce Americans to seek out health care that they do not need or to engage in riskier health-related behavior than they would if they were uninsured.

Conversely, some theorize that designing health insurance so that it does not protect patients from the consequences (ie, the costs) of seeking health care will promote cost-conscious decision making; unshielded by generous benefit plans, individuals will avoid frivolous services and their associated excessive cost. Experts have built volumes of economic models and collected scores of anecdotal experiences to argue for and against the impact—and even the existence—of moral hazard [2].

In this phrase, the qualifier “moral” invokes the lesser-used meaning of that word—“having influence on one’s character or conduct” [3]. But the more common connotation of “moral”—indicating the ethical correctness of an action or idea—certainly underlies commentary on moral hazard in health care. This month’s Virtual Mentor will look explicitly at how this implicit commentary influences medical decision making by patients and physicians.

When is it ethically permissible—or obligatory—for cost-consciousness to be acknowledged, discussed, or integrated into decision making in the patient-doctor encounter? When concerns about cost arise, how should physicians respond to them? What cost-related pressures are patients facing, and what resources and information do they need from physicians concerning cost (in addition, of course, to affordable health care)? This month’s expert authors will help us examine these quandaries.

Doctors are still intimately involved in the cost of health care for individual patients. They are the gatekeepers for services provided, diagnostic tests ordered, procedures performed, and drugs prescribed. In the 3 case studies that open this issue, Drs Federman, Danis, and Goodman help us consider situations in which cost comes up in clinical encounters. In our journal discussion, Drs Frankel and Stein comment on the findings of a nationwide survey that asked 660 Americans whether they discussed cost-related adherence problems to their doctors. These physician-authors offer insight into how we might analyze the role of cost-consciousness in patient care decisions.

In the medical education section, 3 experts offer pragmatic, widely applicable, evidence-based advice on how to acknowledge and aid patients who have concerns about medication costs. Drs Fischer and Avorn outline an innovative curriculum to help health care professionals recognize why medication cost matters and what they can do about its effect on patient care. Then Dr. Alexander gives us guidelines on how to initiate and facilitate discussions about medication costs with patients.

Next we turn to how cost-consciousness shapes our health care system and patients’ access to it. In the clinical pearl Niamey Pender examines the role of computed tomography (CT) in the diagnosis of appendicitis, specifically the need to balance clinical judgment and experimental evidence when making expensive risk-benefit decisions. In the medicine and society section, Dr. Plax and Mr. Seifert detail the burden that medical debt places on American individuals and families and explain how it impacts our health care access. Dr. Liang introduces us to a California health law case that defines physicians’ obligation to advocate for their patients when cost is an issue.

Finally, we turn to how reform of the health care system could acknowledge cost-consciousness while decreasing its burden on patients and physicians. In the policy forum, Dr. Rosenthal summarizes research on pay-for-performance initiatives, in which improvements in the quality of patient care earn economic rewards for physicians. Our 3 op-ed authors then address the moral hazard theory, as they examine the risks and benefits of cost-savvy, “consumer-driven health care.” Dr. Newhouse offers insight into how these plans affect patients’ health care utilization based on his legendary RAND Health Insurance Experiment. Drs Parkinson and Herrick provide 2 perspectives about the philosophy underlying consumer-driven health care and how plans could be designed to follow these new ideas.

Learning objectives for this issue include:

• Understand how changes in the US health care financing system influence the decisions of patients and doctors.

• Understand the effect that cost-consciousness can have on patient adherence and the patient-doctor relationship.

• Learn techniques for acknowledging, analyzing, and addressing concerns about costs in patient encounters.

My hope is that this collection of articles will help us think about how cost-consciousness impacts doctors, patients, and the relationship between them and about how we can change our clinical practice and our health care system to account for cost considerations without compromising patient trust or quality of care.