Wednesday, November 18, 2009

In Defense of "Bean Counters"

I've been speaking about health reform and managed care in different venues around the country. With regard to cost containment I often hear the phrase "bean counters" - as in "Do you want bean counters controlling your life by reducing your medical care to a set of numbers?"

This post is in praise of the much abused act of "bean counting."

When I first began to practice at the not-for-profit Harvard Community Health Plan HMO in 1975 I had a young patient with severe alcoholism. While drunk he got into a fight and was admitted to a psychiatric hospital. I'd been in charge of a psychiatric hospital unit before coming to the HMO and I knew that my patient would be better served by an alcohol treatment program, which would also, it happens, be cheaper. That's the basic definition of win/win.

But when I called the attending psychiatrist about my patient, to urge discharge to my care, I heard him say to the chief of the unit, who had been a teacher of mine during residency - "I have Sabin on the phone...he used to care about patients, but now he cares about money!"

I was really p - - - - d off by the comment, but it led to many years of thinking about how our health system can do a better job of caring about patients and caring about money. (See here for an article I wrote with that title 15 years ago.) I've come to use a framework that encourages all participants in health care to embrace two core values – compassionate fidelity to the needs of individual patients and responsible stewardship of the resources we place in public and private insurance pools.

Fidelity is about individuals. Stewardship is about populations. These two values are the pillars of an ethical health system.

Fidelity - the commitment to seek benefit for the patient and to avoid doing harm - has been at the heart of medical ethics since the time of Hippocrates. As long as health care was a transaction between a single patient and a single physician paid for by the patient’s own funds (or by barter), there was no need for insurance. Population concerns and stewardship were not important considerations.

But as health care became more complex and vastly more expensive societies created insurance mechanisms through which people pool funds to help them pay for care when they need it. In countries like Canada and England, where coverage is universal and paid for by taxes, the ethical importance of stewardship is easy to understand. As important as health care is the public has many uses for its funds. These societies see responsible stewardship as a moral requirement

In the complex U.S. health system it is much harder for the population and its leaders to understand how insurance funds are created. As a result, our society has not recognized stewardship as an ethically justifiable process. That's how we've come to demean attention to the cost of care as “bean counting.”

In the mind of the public (and some political leaders) “stewardship” is often confused with “rationing.” In health care, rationing refers to withholding beneficial services, such as very expensive cancer therapies, because of their cost. In reality, stewardship is the best way to avoid a need to ration! Responsible stewardship by insurers involves (a) seeking elimination of interventions that are not needed but can cause harm (as by side effects), (b) substituting equally effective but less costly interventions, such as generics for branded drugs, or prudent watchful waiting for doing a costly but unnecessary test today, and (c) careful contracting. The more insurers do (a) - (c) the less need society will have to (d) ration - in the sense of deliberately choosing not to provide interventions likely to be beneficial.

Stewardship isn't just a job for public and private insurers. It's best seen as a responsibility for all who are concerned with health and health care. As individuals we are stewards of our own well-being, even if most of us do a poor job. The provider community - physicians, nurses and other clinicians - is in the best position to differentiate between efficient and inefficient health care and to provide what patients need in the right way, at the right place, at the right time. And the employers who pay for insurance would rather invest more in employee wages and research and development than in ever-increasing health care costs.

Ideally, the health reform process would move our society along a learning curve towards better understanding and appreciation of the moral importance of stewardship. But so far the voices changing "bean counters - up against the wall!" have been the loudest.


Anonymous said...

I suppose the recent furor over breast cancer screening fits your comments, Jim.

Steve Moffic

Mary K said...

I love the way you distinguish between fidelity and stewardship. It just crystallized everything.

Jim Sabin said...

Hi Steve and Mary -

Thanks to both of you for your comments!

Steve - the breast cancer furor is indeed fascinating. I haven't yet read the Preventive Services Task Force report. When I do I'll probably write something about it. As of now I think of the furor as part of a societal learning curve with regard to evidence based practice, and, as you suggest, accepting the importance of considering population interests as well as individual interests.

Mary - I'm glad you find the fidelity/stewardship distinction useful. If I figure out how to upload a powerpoint image into the blog I'll post a visual that I use in teaching about the distnction that many folks have found useful.

In the meanwhile - have a great Thanksgiving holiday!



Ronn said...

Hi Jim, i want to apologize for contacting you here as i could not find any direct contact.I have taken a look at your and it seems very impressive about health care ethics. And we think your information need more exposure to the face of world. Your blog has a great traffic value and and hope more in future. We need a permission to write an article on Hospital and health care issues that you can post on your blog if you feel like to post it. Please reply me back for free feature listing on

Jim Sabin said...

Hi Ronn -

I'd be delighted to have you do an article at Since starting this blog two years ago I've "met" a lot of individuals, groups, and sites with related interests. Re reaching me directly, that can be done through the the Department of Population Medicine at Harvard Medical School.