Should the health care forest be selectively thinned by physicians or clear cut by payers?

As the need to set limits in health care becomes more generally accepted, physicians and policymakers need to consider who can best decide how to allocate medical resources among patients. This commentary focuses on the two obvious candidates: payers and physicians. Although payer-based allocation has the advantage of allowing physicians to act strictly on behalf of their patients, it lacks precision and flexibility. Physician-based allocation places allocation decisions in the hands of individuals better positioned and better equipped to make choices that maximize health outputs. To preserve clinical freedom and minimize micromanagement of individual patients, physicians should expand their advocacy role beyond individual patients and recognize their responsibility to populations. In doing so, physicians would acknowledge that societal and patient interests differ and that health care is just one of many important social goods. For physicians willing to make these choices, five general guidelines are offered. Finally, mechanisms to encourage physician-based allocation are considered.