Quality, cost, and clinical decisions

Clinical decisions require determining the objectives of care as well as selecting and implementing a strategy of care. At the very least the optimal strategy balances the expected benefit and harm from technical interventions. Health care practitioners tend to specify optimal strategies based on what they consider to be best for patients, without regard to monetary cost. This is an absolutist definition of quality. Individuals may place different valuations on the outcomes, are concerned with the monetary costs to themselves, and are particularly sensitive to the attributes of the interpersonal relationship with the practitioners. Including all of these leads to an individualized definition of the quality of care. But this specification of quality may be in conflict with a social definition of quality, which takes into account social as well as individual monetary costs, externalities, and the social distribution of quality. The health care professions may respond to the conflict in several ways, which are described in this article as evasion, rejection and confrontation, anticipation, advocacy, active complicity, passive complicity, and ambiguous adaptations.     

Self-regulation and the enforcement of professional codes

This study examines society's choice of inputs for the creation of trust in professional services. Professional codes and their enforcement are only one possible input that society has at its disposal for the production of this trust. Other inputs include civil and criminal codes. If society is modeled as a multi-input “firm,” then it will tend to use less of any input as that input grows less productive or more costly. To identify factors that might impact society's future use of professional self-regulation as a trust-producing input, the productivities and costs of enforcing professional codes are modeled. The effectiveness of professional enforcement is seen to have its origin in the losses members face if they leave the profession. These “exit costs” are analyzed in detail. Other factors affecting professional enforcement are also evaluated. A mathematical model of society's choice problem, contingent on exit costs and other factors, permits formal derivation of several results. Among these are the ideas that monopoly rents and specificity of skills are important in creating the conditions that make professional enforcement possible. As these deteriorate, society's reliance on professional enforcement will decline, and its dependence on courts will rise.