Can we open the doors to everyone?
We are in a tailspin: Individual patients drive up costs, which are passed on to other people, who try to recover their ‘fair share’ by overusing services when their turn comes around. —David M. Eddy4
The easiest course of action is to simply do nothing and allow US society to continue to devote more resources to health care. This choice, however, is likely not acceptable to that family of 4 that already devotes more than $10,000 per year for this care in direct and indirect costs.
In addition, it may not be financially feasible in the world economy. Managed care organizations pass on their costs to the companies, large and small, that ultimately pay for health care. Most clinicians and lay-persons are all too familiar with the problem of high business costs leading to many US businesses relocating their manufacturing plants in other countries where the costs are lower. One of the leading determinants of the costs of doing business in the United States is the cost of health care for the workers.
Historically, the costs of health care have generally risen at a rate of approximately 3% above the yearly rate of inflation. Eliminating many costs of health care services Table 1 which would be unrealistic—would produce a reduction in health care spending for about 5 years until the continued outpacing of inflation by health care costs would return us to the steady rise we currently are experiencing.
Another cost-sparing approach is to eliminate coverage for potentially beneficial health care services that are not essential. Patients would have the option of obtaining these services, but only if they choose to pay for them at full price. This approach takes away a major incentive that drives up medical costs; patients who pay insurance premiums often want to get their money’s worth, whether or not they need the care. Patients, not physicians, may therefore make decisions concerning whether they would like to pay for beneficial but not absolutely necessary services.
Rationing
I think it’s clear that future generations will marvel at our capacity to invent and document effective health services; let’s hope they will not marvel equally at our failure to deliver access to these services. —Mark Chassin1
Deciding where the split occurs between necessary and beneficial is not as easy as it sounds. For example, if we had to choose between paying for mammograms for all women starting at age 50 years, or paying for bone marrow transplants for metastatic breast cancer, how would we decide? Would it be fair to ask a 50-year-old woman with metastatic breast cancer, her family, or her doctor? Of course not.
Instead, what would happen if we were able to ask the same 50-year-old woman with breast cancer when she was only 20 years old and cancer free? Which option would she have chosen at that time in her life: mammogram screening starting at age 50 or bone marrow transplant for metastatic cancer? Chances are good that she would have picked periodic mammography screening, since the likelihood of benefit would appear to her to be greater. More likely, though, a woman, her family, and her doctor would want both.
Faced with limited resources, paying for both and not making a choice leaves us in our present position: We don’t ration services in the United States, we ration people.
The R word—rationing—seems to induce the ire of most of us in health care. To many, rationing is defined as “denying necessary health care to persons who need it,” “not allowing people to receive expensive services,” or “interference by government or business entities in the practice of medicine.” Whatever the definition, explicit debate about methods of rationing health care is emotional and seems to focus on issues of a moral nature.
Yet clinicians already ration health care based on need. The patient with crushing substernal chest pain is given more time and effort than the hypochondriacal patient who comes in every month for a reassurance visit. Clinicians frequently make decisions about how to deliver health care based on a comparison of individual need—rationing in its purest form.
Understanding Rationing
This type of rationing is justifiable because it does not seem to violate the patient’s best interest—although patients might derive additional benefit from a few minutes of your time, this benefit would be small and not essential. When discussing rationing of services, one needs to make this crucial distinction between beneficial and necessary services, especially when resources are limited.16
Several other misunderstandings cloud the concept of rationing.17 The more-is-better fallacy stipulates that more care is synonymous with better care, and, since rationing limits care, it must be wrong. Research and common sense do not bear out this assumption. The common build-it-and-they-will-come approach to offering new health care services offers many examples of increased care without better outcomes.18,19