Chicago Hope Meets the Chicago School

Twenty-five years after the enactment of the Federal Health Maintenance Organization Act and nearly five years after the failure of proposed federal health care reform, managed care has come to dominate the medical marketplace. As a result, the relationships among patients, payers, and physicians have changed fundamentally and dramatically. In this market-driven environment, health care – how much it costs, who receives treatment, and who pays for it – may have surpassed the weather as a topic of everyday conversation at dinner tables and water coolers across the country. In the popular press, reports concerning managed care, usually derogatory, are surpassed in number only by news of the latest political scandals. Scholars, too, find health care a rich topic for discussion. Professor Mark Hall’s new book, Making Medical Spending Decisions: The Law, Ethics, and Economics of Rationing Mechanisms, is the culmination of many years of his work on the “fundamental question” (p. 8) of who should make cost-based rationing decisions for health care services. Proceeding from the generally, although not universally, accepted premise that rationing of health care resources is inevitable, Professor Hall begins his analysis considering the role of three categories of potential decisionmakers for medical spending decisions: consumers of health care services, third parties external to the patient-physician relationship, and physicians at the bedside. After concluding that neither consumers nor any of the third parties are ideally suited for all types of medical spending decisions, Professor Hall turns to the role of the attending physician at the bedsides of individual patients. Bringing together legal, political, economic, and philosophical thinking on the role of cost in clinical decisionmaking in the current market-based health care delivery system, he ably establishes his thesis that a physician may in some circumstances and to some degree make cost-conscious clinical decisions at the bedside.