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The novel coronavirus SARS-CoV-2 and resulting disease state COVID-19 pose a direct threat to an over-burdened U.S. medical care system and supporting supply chains for medications and materials. The principles of crisis standards of care (CSC) initially framed by the Institute of Medicine in 2009 ensure fair processes are in place to make clinically informed decisions about scarce resource allocation during an epidemic. This may include strategies such as preparing, conserving, substituting, adapting, re-using, and re-allocating resources. In this discussion paper for health care planners and clinicians, the authors discuss the application of CSC principles to clinical care, including personal protective equipment, critical care, and outpatient and emergency department capacity challenges posed by a coronavirus or other major epidemic or pandemic event. Health care facilities should be developing tiered, proactive strategies using the best available clinical information and building on their existing surge capacity plans to optimize resource use in the event the current outbreak spreads and creates severe resource demands. Health care systems and providers must be prepared to obtain the most benefi t from limited resources while mitigating harms to individuals, the health care system, and society.

Importance Physicians' views about health care costs are germane to pending policy reforms. Objective To assess physicians' attitudes toward and perceived role in addressing health care costs. Design, Setting, and Participants A cross-sectional survey mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile. Main Outcomes and Measures Enthusiasm for 17 cost-containment strategies and agreement with an 11-measure cost-consciousness scale. Results A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients' best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” In multivariable logistic regression models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for “eliminating fee for service” (salary plus bonus: odds ratio [OR], 3.3, 99% CI, 1.8-6.1; salary only: OR, 4.3, 99% CI, 2.2-8.5). In multivariable linear regression models, group or government practice setting (β = 0.87, 95% CI, 0.29 to 1.45, P = .004; and β = 0.99, 95% CI, 0.20 to 1.79, P = .01, respectively) and having a salary plus bonus compensation type (β = 0.82; 95% CI, 0.32 to 1.33; P = .002) were positively associated with cost-consciousness. Finding the “uncertainty involved in patient care disconcerting” was negatively associated with cost-consciousness (β = -1.95; 95% CI, -2.71 to -1.18; P < .001). Conclusion and Relevance In this survey about health care cost containment, US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models.

for a Task Force of the Association of Bioethics Program Directors* Background: The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies.