Many people believe doctors shouldn't have to worry about high medical costs that it's the turf of the insurance executive or HMO administrator. But today's practicing physicians have a vital interest in the cost debate.

Basically, we'd like to know that in prescribing a procedure, we aren't asking our patient to choose between paying the rent or getting the treatment.

We are fortunate to live in an era when the science of medicine regularly produces miracles. Advances in treatments, pharmaceuticals and technology in the last 30 years eclipse the collective achievements of the prior 300 years and have clearly extended and improved our quality of life. But the price tags that come with these advances have pushed health care coverage out of the reach of many individuals and employers.

As we've heard, the newest fertility treatments work very well. Science can help an infertile woman conceive and deliver a child, and sometimes twins, triplets, and recently, quadruplets. The treatment is expensive and the pre- and post-natal costs of caring for multiple babies can reach the millions. At the same time, we have hundreds of thousands of children already among us whose parents' lack of coverage means they haven't had basic immunizations.

In short, medical advances offer us unprecedented opportunities to counteract debilities and improve our quality of life, but create dilemmas about how to allocate them. Because we don't have societal consensus or a system in place to make allocation decisions, that role has been falling more and more to the health plans and insurers.

Every day someone somewhere is making difficult decisions about the application of limited resources in order to find a balance between access to cutting-edge technology for the fortunate, and access to basic health care services for the general public. Employers (and their employees) should be paying attention to who is making these choices in their health plans.

There are two key arenas for discussions of resource allocation: the hypothetical, global arena in which scientific effectiveness is examined and treatment guidelines are created, and the up-close-and-personal arena the exam room where a physician and patent are deciding on an individual course of treatment.

As a doctor who has practiced medicine for 25 years, I can tell you that the first question all employers and patients should ask when choosing a health plan is, "Are the doctors able to make treatment decisions with the patient and no one else involved?" To do this, doctors need to have available the most current research and treatment information (and it doesn't matter whether the source is a scientific institution or the insurer as long as it's good information). Then, they must be allowed to practice medicine, which means that the business side of the health care equation should not intrude into the patient-physician decision-making.

The doctor in the exam room plays a role in resource allocation. We have a responsibility to make treatment decisions that are based on scientific evidence and to educate patients about what is and isn't indicated in their care. A doctor's priority must be the wellbeing of the patient. But this is not incompatible with a physician taking personal responsibility for practicing quality-, not quantity-based, medicine.

"Managing resources" is not code for limiting care. Physicians can contribute to restraining cost increases without compromising care if they work in an environment where financial incentives for and against quantity of treatment have been eliminated, where they have control of the treatment decisions, and where the provision of quality health care services is an organizational priority.

Outside the exam room, it is crucial that physicians be at the front table with the business and insurance side of the health care formula, where new technologies are examined for effectiveness, coverage decisions are made, and resource priorities are set. On this more global, policy-setting level, doctors are central and their voices and priorities must be heard.

The United States spends almost 14 percent of its GNP on health care. That's more than any other country yet we haven't managed to cover our whole populace. A January 1999 report by the Latino Coalition for a Healthy California found that 1.5 million Latinas lack health coverage, making them one of the most under-served populations in California. Many of these women have jobs, but work in occupations where health benefits are rare. Our society is on a slippery slope when the people who "bring home the bacon" have no access to care even as we spend more that $1 trillion annually on health services.

We physicians aren't supposed to worry ourselves with the cost of health care. Traditionally, our job is to prescribe and treat. But in this modern era of wonderful but costly medical advances, our nation will reach a limit someday soon on what can be spent on health care services. And when we sit down to decide how much of our national resources we devote to health care and how they should be allocated, doctors must play a central role.

Oliver Goldsmith is medical director and chairman of the board of the Southern California Permanente Medical Group, the medical entity which, with Kaiser Foundation Health Plan, is known as Kaiser Permanente. He is also clinical associate professor of medicine at UCLA.

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