Cost control, doctors' ethics, and patient care.

PROLOGUE: The costs of medical care depend critically on doctors. They order the tests, prescribe the drugs, and decide whether patients are admitted to hospitals and when they are released. However, the major new Medicare reform, designed to curb hospital expenses, applies only to hospitals, not physicians. Under the prospective payment system (PPS), hospitals are now being paid a fixed price for each Medicare patient, determined on a disease-by-disease basis. Yet doctors are still reimbursed retrospectively on the basis of " usual and customary " fees. In this reflective essay, Arnold S.Relman, a physician and editor of the New England Journal of Medicine, points out that under this fee-for-service arrangement, the longer the patient remains in the hospital and the more services he receives, the more the doctor is paid. If hospital expenditures are to be significantly curtailed under any program, Relman argues, physicians will have to be given incentives for frugality. Yet extending the prospective payment system to doctors, as is now being considered, may have serious implications for the quality of patient care, he warns. In particular, Relman asks whether doctors can remain advocates and agents for their patients if they have an economic stake in reducing hospital services. Medicine in 1977, Relman has also been a professor of medicine at Harvard Medical School and a physician at Brigham and Women's Hospital. He has also been a visiting professor at some 25 medical schools and president of the Association of American Physicians.