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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