The rapid rise in health care costs is receiving a good deal of attention these days. Proposed responses include the deliberate rationing of expensive medical technologies, such as organ transplantation, and a redirection of our efforts toward preventive care. Although preventive care may improve our health, it cannot be assumed to reduce medical costs, since a later death may be as expensive as an earlier one. I suggest that a major and rapidly growing component of medical costs stems from the widespread application of tests and procedures when they are of no demonstrated benefit and may even be harmful. Identifying and curtailing such unnecessary medical care, rather than rationing beneficial technologies, should be the thrust of cost-containment efforts. Fee schedules should be revised so that they neither encourage nor discourage the use of tests and procedures; we should undertake systematic studies to assess technologies and practices; and we should make every effort to discourage the practice of defensive medicine. The involvement of physicians in rationing is not only premature; it is also inconsistent with our role as advocates for the health of our patients.
KIE: Angell, senior deputy editor of the New England Journal of Medicine, rejects controlling health care costs either by the rationing of expensive medical technologies or by the redirection of efforts toward preventive care that may only postpone expenditures. She suggests that a major component of health care costs is consumed by nonbeneficial, even harmful, procedures. Identifying, assessing, and curtailing of such procedures by neutrality in fee schedules and by discouraging the practice of defensive medicine should be the thrust of cost containment efforts. Physicians are urged to reject involvement in rationing as inconsistent with their role as patient advocates and to support technology assessment, fee revisions, and more stringent self regulation as ways to discourage malpractice suits.