Rapid advances in health care delivery and biomedical innovation have evolved at once to signal the successes of our research and practice endeavors but at the same time raised concerns in an environment of increasing health care expenditure about the growing need for health care priority setting in the United States. It has become clear that there is an inflexion point at which overused therapeutic and diagnostic technologies stop benefiting patients and only divert health care spending toward potentially low-benefit or unnecessary applications (so-called “low value care”), limiting our ability to provision consistent, broad-reaching health care to society.

The public has become intimately aware of this conflict over the recent years, where, for example, the scope of inappropriate coronary stenting has sounded public alarms about an “epidemic of medical waste.” In response, external physician-level scrutiny has increased, and broad, sometimes ill-fitting “quality metrics” have been implemented which could at times paradoxically limit our delivery of appropriate care. Society needs to see physicians as fair and equitable brokers of health care technology, who deliver consistent, high-quality care, but are mindful of the necessarily finite resources of the society in which they practice. Overall, an enhanced focus on health care priority setting presents itself as an opportunity to more fairly distribute limited health care resources to society and to effect better health care at better value.

For a number of years, health care rationing in the United States on a population level has become the role of health insurance organizations and managed health care providers, who have implemented utilization constraints in the form of coverage limits, physician profiling, and prior ​ authorization. In so doing, the role of physicians as decision makers in public health care policy has inherently been restricted. In response in part to these pressures and a sense of divested professional autonomy, the American College of Cardiology Foundation in conjunction with subspecialty societies and other organizations developed their first set of Appropriate Use Criteria (AUC) in 2005, initially focusing on defining appropriate and inappropriate indications for radionuclide imaging. The methods used to construct these criteria were transparent, and evidence is mounting that the AUCs positively impact delivery of appropriate clinical care. Here, guidelines groups presented clinicians with recommendations not to do something not only because it is potentially harmful (class III recommendations) but because it was of uncertain benefit.

Although the evident success of the AUC stands in testimony to the leadership role that physicians’ can, and should, continue to play in policy decisions for health care priority setting in the United States, other efforts have not met with this degree of success. In the 1990s, significant controversy arose when the Agency for Health Care Policy and Research (AHCPR, which would subsequently be renamed the Agency for Health Care Research and Quality, seemingly to de-emphasize the “policy” role it might play) proposed several practice guidelines, including advising limiting the number of spinal fusion procedures physicians were performing for lower back pain as the surgery had unproven benefit. These guidelines were met with intractable controversy, as many groups believed their preferences and values had been neglected in the process of generating the recommendations. The AHCPR would stop issuing clinical practice guidelines shortly thereafter. Where previous efforts have struggled, though, insight can be garnered which serves as the basis for constructing a new model which at once addresses the concerns of the public and returns the role of health care priority setting from insurers/payers back to physicians.

Taken from these models and experiences, health care priority setting could become the provenance of clinical practice guidelines. Priority setting in health care contends that services with uncertain or no documented effects can be legitimately withheld, and clinical evidence, therefore, comprises the “natural building blocks in any system of setting fair priorities.” Others have contended that, “since the rationing of scarce resources requires a targeting of those resources to obtain best value for money, it is important to have mechanisms for assuring effective health care. Clinical practice guidelines offer an opportunity for introducing evidence-based health care into local practice and for influencing the commissioning of effective health care.” Indeed, as potential instruments for health care policy, clinical practice guidelines would seem to be able to empower physicians to take back the autonomy for making population-based health care decisions.

Such a model is practical, and ethically defensible, contingent on certain conditions. First, there must be agreement on fundamental common goals—to maximize average healthy life expectancy and distribute health fairly across patient groups. Generally, these principles run concordantly. When there is discordance, however, the public and other stakeholders must be involved, and value choices have to be made on the appropriate trade-offs. Such value choices permeate our health care policy landscape currently but are often not the product of active intent but rather emerge secondary to “of target” value-based decision-making (e.g., choosing to preferentially fund research for one disease inherently chooses to divert funding away from another). Therefore, priority setting decisions should be made transparently, satisfying the requirements of public accountability. Although guidelines committees’ deliberations must of course culminate in decisions, absence of “voice” should not be felt by any interested stakeholder. Such practice would form a sound basis of deliberative democracy. In essence, physicians writing clinical practice guidelines would not be responsible for accounting for all possible streams of influence endorsed by different ethical philosophies (egalitarianism, prioritarianism, utilitarianism, and others). Rather, their role would be translating the public preferences for priority setting into conscious, evidence-based decision-making and practice recommendations. Cost-effectiveness analysis could play a more central role in recommendations made by clinical practice guidelines, generating efficient, evidenced-based priority setting strategies to maximize health care delivery.

Is there evidence that health care priority setting could be effectively accomplished by clinical practice guidelines? Initial studies looking at the influence of the American College of Cardiology Foundation AUC have suggested favorable impact on reducing unnecessary imaging and therapeutic procedures. However, the discordance between clinical practice guidelines, AUCs, and insurer restrictions can leave clinicians pulled between diverging practice recommendations, emphasizing the growing need for a more integrated, cohesive guidelines approach. Examples of this integrated approach include Britain’s National Institute for Health and Clinical Excellence, which has achieved nationwide promotion of evidence-based, clinically relevant, cost-effective, and publicly informed priority setting. Additionally, Norway and Sweden have begun introducing priority setting in their clinical practice guidelines, for example, for primary prevention of cardiovascular disease and treatment of stroke, and other countries are expected to follow.

Overall, in an era of increasing health care expenditure and anticipated growing need with an aging population, the public has looked to physicians for provision of efficient, high-quality care, now with the added provision of sustainability. Our shortcomings in fulfilling this promise have left us with less influence on policy-level decision-making. We are not without our defense, though, and expanding the role of clinical practice guidelines as dynamic instruments for health care priority setting could restore collective physician autonomy for health care delivery in the United States.