If government control is so great, why are German physicians so unhappy?
Subject: Physicians (Practice)
Medical care, Cost of (Analysis)
Administrative agencies (Health policy)
Authors: Crespo, Alphonse
Stevens, Philip
Pub Date: 06/22/2011
Publication: Name: Journal of American Physicians and Surgeons Publisher: Association of American Physicians and Surgeons, Inc. Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2011 Association of American Physicians and Surgeons, Inc. ISSN: 1543-4826
Issue: Date: Summer, 2011 Source Volume: 16 Source Issue: 2
Topic: Event Code: 200 Management dynamics; 970 Government domestic functions
Product: Product Code: 8011000 Physicians & Surgeons NAICS Code: 621111 Offices of Physicians (except Mental Health Specialists)
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 267810801
Full Text: In order to drive total spending levels down, the federal government is determined to introduce more "comparative effectiveness research"(CER) into American medicine.

The purported aim of such research is to compare the relative clinical and cost effectiveness of different treatments and interventions in order to determine which treatments should be used in which circumstance. According to the bureaucrats, compelling physicians to adhere to the clinical guidelines derived from such research should in theory help reduce the number of needless and ineffective operations, and ensure that only the most cost effective drugs are reimbursed by private health plans or government schemes like Medicare. Proponents of CER argue that up to 30% of total U.S. health spending is being wastefully spent on treatments with little or no value.

Such thinking fits well with government attempts to increasingly mandate, centralize, and standardize medical care in the name of cost containment. While CER clearly suits the bureaucratic mindset, those at the clinical sharp end are rather less keen, according to a recent international study of doctor perceptions on the impact of healthcare environments on their mission. (1,2)

The study, commissioned by Medicine & Liberty (MedLib), consisted of an online survey of 1,000 physicians, surgeons, and general practitioners in the U.S., Germany, Switzerland, and Singapore, on topics ranging from the role of doctors in society, to the influence of insurance companies on the patient physician relationship, to access to medical innovations. The interviews were carried out by Consensus Research Group, Inc., through August and September 2010.

One of the most striking findings from doctors in all four countries was the importance they place on professional autonomy and the need to treat patients as individuals, not as statistics (see Figure 1). About 70% of respondents considered professional autonomy to be one of the most important elements of proper patient care, and 62% of German and 47% of U.S. doctors are strongly dissatisfied with their levels of freedom to choose the prescriptions, treatments, and procedures that they consider most appropriate.

While CER is unlikely to be responsible for U.S. doctors' dissatisfaction with their professional freedom, it is almost certainly a major contributory factor for German doctors. Unlike in the U.S. (for the present moment, at least) CER is firmly established in Germany, and has a strong influence on the clinical guidelines and payment decisions of the various German health insurance funds. The guidelines produced by the German CER agency IQWiG (Institut fur Qualitat und Wirtschaftlichkeit im Gesundheitswesen--Institute for Quality and Efficiency in Health Care) are voluntary. However, many insurance funds do implement its advice--meaning that German doctors have far less clinical autonomy than their U.S. counterparts, who are yet to be bound by mandatory federal CER guidelines.

In a related question, MedLib's survey also asked doctors to describe their role in society. Dishearteningly, German doctors were most likely to describe themselves as "administrative participants in the German health care bureaucracy," rather than autonomous, trusted medical professionals. U.S. doctors, by contrast, still tend to see themselves as "community leaders" who are "prominent" and "influential." U.S. doctors should make the most of this status, as the arrival of mandatory one size fits all clinical guidelines from federal CER could well soon result in a Germanic style bureaucratization of U.S. clinical life, as federal commands, diktats, and mandates remove their ability to determine which course of treatment is most appropriate for each individual patient.

What of those countries that as yet have implemented only minimal centralized CER? The two other countries surveyed, Switzerland and Singapore, have competition and choice between various private insurers and the public sector, with a strong national health savings account program (Medisave) in Singapore. Their doctors are far more satisfied with their professional freedom--only 8% of doctors in Singapore are dissatisfied in this area, and 17% in Switzerland.

Crucially, neither country has yet integrated CER into its healthcare system to the same extent as in Germany (and indeed most other European countries). Switzerland does have a federal agency for CER, but it limits itself to comparative research into the treatment and prevention of HIV/AIDS, illegal drugs, and a few other public health issues. Although Swiss insurance cartels do put some pressure on physicians' prescribing through drug reimbursement policies, they have not fully moved to centrally mandated guidelines on their clinicians. Singapore also makes limited use of CER, mainly for the make-up of the public sector's standard drug list and for licensing medical clinics. By empowering patients with some degree of control of their ordinary health expenses, Singapore's Medisave also shields them from excessive "cost-effective" rationing of care.

In contrast to the faith many healthcare reformers have in government to make the right decisions about treatments and interventions, it turns out that many physicians have a completely opposite view. About 52% of German doctors, 49% of U.S. doctors, and 38% of Swiss doctors are in favor of the abolition of government regulation of prescriptions of medicines or procedures--as long as the medicines and procedures conform to established norms for safety and side effects.

These figures suggest that if CER is made mandatory in the U.S., it will lack the confidence and support of doctors because it strikes at the heart of physician professional autonomy. Predictable opposition to centralization of therapeutic decisions seriously undermines the stated objectives of CER--if doctors find ways to ignore it, it will become yet another healthcare white elephant on a par with some of the high profile information technology spending debacles. Also there will be the predictable conflict between advances in precision medicine--that move physicians toward genetically guided personalized treatment--and centralized administrative assessments of "effectiveness" grounded on volatile statistical estimates that blur individual patient characteristics.

Finally, the survey shows that 45% of doctors are already dissatisfied with the amount of time and bureaucracy involved in government approval of new medicines and treatments. If another layer of bureaucracy is added in the form of CER, these delays will only worsen. This should worry not only doctors, but above all patients, who do not always have the luxury of time.


(1) Consensus Research Group. Report of findings: a cross country comparative study of physician autonomy; 2010. Available at: http://www.medlib.ch/documents/%20042011MedLibStudyDeck.pdf. Accessed Apr 23, 2011.

(2) Medicine & Liberty: Doctors want more freedom to practice: new MedLib survey. Europe health care.eu; Apr 4, 2011. Available at: http://europe health care.eu/?p=104. Accessed Apr 23, 2011.

Alphonse Crespo, M.D., Philip Stevens

Alphonse Crespo, M.D., is founder of Medicine & Liberty physician network. Contact: acrespomd@medlib.ch.

Philip Stevens is Senior Fellow at the Center for Medicine in the Public Interest, www.cmpi.org. Contact: philip@cgwg.co.uk
Figure 1. Percentage of Physicians Who Rate Professional Autonomy
as Very Important

Very Important

Singapore        51%
Germany          69%
Switzerland      74%
USA              77%

Note: Table made from bar graph.
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