Resource Allocation

We got a talk by Mitch Katz, Director of San Francisco's public health department, a really daunting job. He has a fascinating approach to and perspective on health care. He really sees things from a birds-eye view, and it's an intimidating task. To him, tax-payer money needs to be funneled into optimized health care outcomes, something few people would argue with. But he faces the reality of modern day medicine, meeting an annual budget, which focuses entirely on the ethical issue of distributive justice: how do we allocate resources fairly?

For most doctors, we want the best for our patients. Expensive drugs, fancy scans, resource intensive tests, an extra day in the hospital - it's all for the patient's good. But for those patients who are uninsured or underinsured, the hospital has to absorb the costs, and San Francisco General Hospital is run by the public health department. Dr. Katz finds himself the enemy as he tries to contain costs by changing the pharmacy's formulary or mandating that only attending physicians can order certain drugs or denying the purchase of a new scanner. How can there be so many barriers to patient care? We ask. But the truth is, the bottom line matters.

Indeed, we think it's always hypothetical that a patient staying an extra day in the ICU incurring thousands of dollars in cost translates to fewer vaccines for primary prevention. Dr. Katz made a huge point in emphasizing that this is not hypothetical, that it is reality. Every test we order, every drug we prescribe, everything we do that isn't reimbursed fully takes something away from another patient. He thinks that money should be going into providing housing for the homeless because that will make the biggest impact on health care. No other doctor without a public health approach sees things this way. I find it so fundamentally important.