Friday, April 17, 2009

It's time to talk about the R word

Public opinion researchers have warned advocates of health reform to avoid using the "R" word. Lake Research Associates, a Democratic leaning polling firm, found that 62% of voters would express more doubts about health care reform if told it will lead to rationing.

Yet, a serious discussion about rationing is beginning to take place in the health care blogosphere.

One school of thought says that the United States already rations care, but irrationally and unfairly, based on ability to pay. This is how health economist Uwe Reinhardt describes it in the New York Times Economix blog:

"Evidently, many Americans do sincerely believe that when a public health plan refuses to pay for a procedure it is 'rationing,' while denial of health care to an uninsured, low-income individual who cannot afford to pay for that care is not. But as textbooks in economics explicitly teach, the role of prices in a market economy is precisely to ration scarce resources among unlimited demands. The American health system has rationed health care by price and ability to pay all along for a sizeable segment of the United States population. In its report "Hidden Cost, Value Lost," for example, a distinguished panel of experts convened by the Institute of Medicine of the National Academy of Sciences estimated that some 18,000 Americans die prematurely for want of health insurance and timely medical care. That is rationing life years."

Others acknowledge that the American health care system provides unequal access to care, but they favor rationing by markets, over rationing by government. This comment from conservative blogger Andrew Sullivan, responding to a reader's comment, says that markets enable rich people to buy more care than they need while leaving poorer people with less:

"And why should we have a problem with free people choosing to 'pour everything they have into high intensity, high tech, high cost, but in the end marginal extensions to their lifespan'? And isn't the market a more neutral and less politically manipulable form of rationing than government? I think you really do have to live in a socialist system to see how rational it looks from the outside and how mediocre, passive and bureaucratic it feels from within."

I think it is good that we are at least beginning to have a serious discussion about rationing, and that the question being addressed is not if the U.S. rations care (we do), but whether markets or government will do a better job. Even if the public and politicians don't want us to talk about it.

Today's questions: If rationing is inevitable, who do you think would do a better job at it - the government based on guidelines on cost and effectiveness, or markets based on ability to pay?


Steve Lucas said...

First we need to accept the fact that there is no perfect system. Waiting for one will only delay needed reform in the US. Looking at systems that are more successful at delivering health care at a lower cost, but still reflect many of our values, England's NICE comes to mind.

They have developed a very defined metric on life cost that, funny thing, most drug and device companies seem to be able to meet. There is also an appeal process for patients to request non-approved drugs. Those with money can also access private clinics.

In this case, this government model does work. Private sector control will always exclude those who cannot pay, and will always charge the highest price to maximize profit. That is the nature of business.

Steve Lucas

Jay Larson MD said...

Market based rationing has already proven to be a disaster. It is chaotic and not based on evidence. I remember bone marrow transplants for women with metastatic breast cancer. This expensive therapy ultimately proved to be of no benefit from convential therapy. Rationing should be based on clinical evidence first and cost as a secondary issue.

Robert J. Sobel, M.D. said...

Checks and balances would argue that we keep both systems and focus on coherent reform of the dysregulated parts of the health care system. Drugs and new technologies must be price regulated; royalties over time would reward those that we continue to use. We cannot sustain the upfront financing system we currently use.

Patients do not want unlimited care, despite what the textbooks say. The basic physician/patient relationship is mostly rational ("better safe than sorry" driving some of the over-utilization). As well, we refine our approaches over time and do better without over-reaching bureaucratic tangles. It is the costs that are not rational. If we can reduce the administrative waste of the managed care fallacy (drug-benefit companies; disease management duplication), we will have plenty of money to support independent primary care and its ancillary tests, rational specialty care, a regulated hospital infrastructure, and a modicum of procedures. I believe we can construct such a system without the harshness of putting cost before sense.

The Happy Hospitalist said...

Since when did the government ever price anything correctly?

Are they magical?