Can ration US health care

Plea for an open debate on rationing

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The rationing of medical services is inevitable, says the editor-in-chief of the British Medical Journal. He called for an open debate on this issue. Most health systems around the world are in crisis. The main reason for this is the inability to respond to the widening gap between what would be possible with unconstrained resources and what can actually be afforded. One possible response would be to openly address the need to ration medical services. The governor of the US state of Oregon, the doctor John Kitzhaber, put it this way: "The question of which services should be provided in the health system is certainly the most difficult, the most controversial, but possibly the most important. It is the sine qua non one Healthcare reform. Therefore, a process must be started to solve this problem that is understandable and involves the public as well as the reality of limited resources. "
Rationing health care means depriving patients of effective treatment. "Setting priorities" sounds politically more acceptable, but it means the same thing. If one proceeds from the thesis that the rationing of medical services is inevitable, it should be done openly rather than disguised. As a result, healthcare leaders must admit rationing and decide how to do it.
The rationing debate has progressed differently around the world. In many states, possibly most, the discussion has not even started. Politicians pretend that everything that needs to be done is done for the sick and the public believes them. Countries like New Zealand, the Netherlands, Sweden and Norway have accepted the inevitability of rationing and pushed the discussion about it. Others like the UK are somewhere between these positions: most healthcare workers recognize the inevitability of rationing (as does the media) but the government refuses to admit it.
Relationship between costs and benefits
Most healthcare professionals recognize that not everything can be done for everyone. Doctors in the UK have seen this for years. But how can this inevitability be proven?
While therapeutic and diagnostic procedures are cost-effective in some patients, costs and benefits are no longer related to others. An example: The mortality of patients with coronary heart disease and high cholesterol levels has been shown to be reduced if they were treated with statins. Statin therapy is extremely inexpensive in seriously ill, middle-aged men. For women aged 45 to 54 with angina pectoris and a cholesterol concentration of 5.5 to 6.0 nmol / L, however, each additional year of life costs 361,000 pounds. The same - proven effectiveness at disproportionately high costs - applies, among other things, to patients with high blood pressure who are treated with ACE inhibitors. Another example concerns a recommendation from the United States to conduct six tests for occult blood in stool to detect colon cancer. The additional cost of detecting a cancer undiagnosed by five previous tests is nearly £ 50 million. It may save a life, but the cost is prohibitive. This means that decisions must be made to withhold effective diagnostics and therapy from some patients.
In Great Britain and other countries, the use of new but expensive drugs against Alzheimer's and multiple sclerosis, among other things, is currently being discussed. The high costs are offset by a relatively low benefit for a small group of patients. The drugs do not cure the diseases, but they do delay their progression. In this way, they increase the prevalence of the diseases and thus also the overall costs. In the UK, only a minority of affected patients are currently receiving the new funds. To whom they are prescribed often resembles a game of chance.
David Eddy, American cardiac surgeon and recognized health care professional, believes that health care limits mean rationing. For example, mammography is available to women between the ages of 50 and 65 in the UK. Women over 65, who have a higher incidence of breast cancer, would likely benefit more from this study. The same applies to women under 50, especially if they have a family history. To draw the age limit here means rationing.
Eddy differentiates between "sensible" and "nonsensical" rationing. As an example, he cites the treatment of patients with high cholesterol levels. Many guidelines specify a cholesterol level at which treatment should begin. But, says Eddy, doctors should keep an eye on more than the limit value. A young woman with a cholesterol level above the limit, but no other risk factors, is much less likely to die of heart disease than an old man with diabetes, high blood pressure, and obesity whose cholesterol happens to be below the limit. That is why Eddy advocates reallocating resources to where they can achieve the greatest possible benefit. To achieve this, doctors, among other things, need to think about costs and benefits. However, according to Eddy, the cost aspect of medical services is taboo by doctors. You keep an eye on benefits and quality, while managers keep an eye on costs. As a result, both fight each other because, as in every other area of ​​life, costs and benefits have to be put in relation to one another. The solution, Eddy believes, is for a person or team to weigh the benefits and costs of healthcare. This means that doctors are included in the rationing. In the UK, for example, this is evident in the case of general practitioners who manage their own budget.
Ronald Dworkin, Professor of Law at Harvard and Oxford Universities and a leading medical ethicist, looks at the inevitability of rationing in health care and the societal response to it in a slightly different way. He calls his theory the "wisdom of the insurance principle".
Current spending in health care is based, more implicitly than explicitly, on the "isolation model". The model assumes three things: 1. Health care differs fundamentally from the supply of other goods. 2. Equal access to health services is essential. 3. If something can prevent death, it should also be done ("salvation principle").
In the United States, for example, this model has resulted in the separation of Siamese twins who had grown together at heart at a cost of millions of dollars. It was clear that one twin would die and the other had a one percent chance of survival and no chance of a normal life.
Dworkin considers the "isolation model" to be neither reasonable nor comprehensible. No society can spend all of its resources on health care at the expense of other areas such as education, housing or job creation.
Dworkin designs a society with five characteristics:
1 Wealth is evenly distributed.
1 Up-to-date information on the status and benefits of medicine is available to everyone.
1 People decide rationally.
1 Parents consider the interests of their children to be of equal importance to their own.
1 Nobody knows anything about the genetic, cultural or social predisposition to disease.
In this imaginary society, the government would not provide public health care. People would have to decide for themselves how and against what to get health insurance. Dworkin maintains that under such conditions a reasonable amount would be spent on health care and that everyone would have equal access to all medical services: people would make rational decisions about how much proportionately they would like to spend on their health care. You would decide for yourself whether to purchase an insurance policy that gives you access to cardiac surgery up to the age of 75, or a much more expensive one that allows you to do so up to the age of 90.
The question is whether many people would purchase a policy that would guarantee them life support measures even in the event that they fall into a permanent vegetative state (PVS). Dworkin claims that few would choose, yet it currently keeps some 10,000 PVS patients alive in the United States.
Would people choose a policy that would deny them life support if they died within the next four months, or a much more expensive policy that would provide all possible treatment? Dworkin says most would choose the former, even though 40 percent of Medicaid spending is currently in the last four months of patient life.
Most people would certainly choose insurance that would deny them life support from the age of 85, for example; partly because they may not even reach that age, but above all because otherwise they would have to forego a lot in order to pay the insurance premium.
Under the terms of Dworkin's model, three categories of care would likely evolve: services that nearly everyone deems necessary; Services that almost everyone considers unnecessary; and services where people make different choices. In the US, this would mean that people would choose between different insurance packages (which American employers are actually increasingly offering). In Great Britain it could mean that the state offers basic benefits and that additional benefits must be privately insured.
The thesis that rationing is inevitable can be demonstrated using practical examples. The methods can be classified in English by words that all begin with "d": denial (refusal), deflection (deflection), delay (holding back), dilution (thinning) and deterrence (deterrence).
Denial of service is commonplace in the UK. Patients who have passed a certain age are no longer admitted to intensive care units. Support is denied to carers of the chronically ill. In vitro fertilization is not available for many infertile couples.
Redirection means, for example, that patients in need of long-term care are transferred from the public health system to the private sector.
Delay is one of the main methods of rationing in the UK. Patients sometimes have to wait months for an appointment with a specialist, and then sometimes years for an operation.
Thinning is possibly the most common form of rationing in the UK healthcare system. Nurses look after 20 patients more often on a ward than the planned 16 patients! Patients are more likely to receive four-day drug courses than five-day courses. Surgeons use a cheaper prosthesis, although they are convinced that a more expensive one would be better for the patient. Rationing by deterrence results from provisions such as prescription fees, long distances to treatment, or from information only in English.
Do not disguise rationing processes
The inevitability of rationing is often denied. It is often emphasized that many medical treatments are ineffective. If, the argument goes, everything is neglected that is not proven to be effective, there would be no need to ration benefits. It is true that a large proportion of medical services (probably 85 percent according to the US Office for Technology Assessment) are not supported by qualified evidence. However, the lack of proof of effectiveness is not the same as proof of ineffectiveness. In addition, there is often good evidence that doctors should use the more expensive therapy instead of the inexpensive one.
While the argument to limit oneself to effective therapies is important, it is fundamentally different from that of rationing. Equally important is the discussion on how the efficiency of healthcare facilities can be improved. However, it will not eliminate the need for rationing any more than will the debate over health care financing. If more money is available for health, it has been argued, the need for rationing will diminish. This is usually brought forward in Great Britain by the respective opposition party. However, additional resources also require decisions on how to use them. Many doctors also fear that a discussion about rationing will release the payers from their duty to increase the funds for health care.
Rationing takes different forms and takes place on different levels. In a government-funded system like the one in the UK, the government decides how much money to invest in health care relative to other areas of the national budget. Governments are increasingly reluctant to increase health care resources. They understand that the state of health of the population does not depend exclusively on the health system. Socio-economic factors such as wealth, level of education, employment structure or housing have a greater influence. Ultimately, higher spending on health care increases the proportion of sick people in a society.
Most British doctors accept rationing medical supplies. They don't like it and rarely discuss it openly with their patients. But they do it because they know that in a system with limited resources like the National Health Service, resources that benefit one patient are withheld from another.
Whether health services should be explicitly rationed or whether we should "cheat our way through" is one of the central points of the rationing debate. The main argument against openness of many commentators is: "It is impossible to solve the question of rationing morally and methodically to the satisfaction of all. Trying to be openness will destroy trust in doctors and health institutions."
However, rationing should not be done in secret just because it is difficult. People understand that not everyone can have everything. To pretend that this is possible is to incapacitate them. Patients are more likely to lose confidence in their doctors when they are deceived than when they are told that tough decisions must be made.
A second argument against openness is that it is likely to result in the public being directly involved in rationing decisions. This could possibly result in certain groups such as the elderly, the mentally ill or drug addicts being discriminated against. This objection, however, speaks in favor of better informing people rather than hiding the need for rationing from them.
A third argument is that public trust in health care facilities would be undermined if patients were withheld from therapy on the basis of abstract principles. Of course, there was great dismay in Great Britain when a girl suffering from leukemia was denied a second bone marrow transplant, apparently for reasons of cost. However, this is another argument in favor of more information and against obscuring the rationing processes.
An open approach to rationing issues is supported by the fact that adults should have access to the decisions that affect their lives. In a democracy, citizens must be allowed to influence decision-making processes. In addition, open decision-making processes prevent certain interest groups from making decisions based on tradition, prejudice or whim under the influence of powerful or wealthy groups. Rationing is a "dirty business" and that is precisely why the public must not be deceived.
In addition, clear principles of rationing do not codify behavior. They just draw moral boundaries for decisions on a case-by-case basis. In the discussion of total openness or total obfuscation, no society will take one of the extreme positions. Rather, it will decide at which point on the spectrum it feels comfortable.There is currently a noticeable movement towards openness in the UK.
The questions of who will perform rationing and how it should be done cannot be definitely answered. Each system will develop its own methods. No system will solve the problem because it cannot be solved. Rather, it requires continued discussion and development.
One solution comes from the US state of Oregon, a pioneer in open rationing of health care. The Oregon discussion began when the state decided not to cover the cost of transplants for patients covered by Medicare. The reason given was that the state would rather provide more funds for the medical care of a large group of people than take over expensive services for a small number of patients. The decision aroused violent protests, including from those who claimed that transplants were, under certain circumstances, cost-effective. However, this initiated a process in the course of which the inevitability of rationing was accepted as well as the need to disclose it. For example, the state conducted opinion polls on issues such as quality of life versus quantity of life. Public opinion was matched with the opinion of experts. This resulted in a ranking of various medical interventions. The goal: Parliament sets the Medicare budget, and the state uses it to finance medical services according to their respective priority on the list.
The New Zealanders have limited their open rationing to creating priority lists for certain patient groups who are waiting for a cataract operation, a coronary bypass or a hip or knee prosthesis, for example. They have developed a scoring system, with those with the highest scores receiving the required operation first. The instrumentation is primarily based on clinical need. There was heated debate about the extent to which social factors should be taken into account, such as age, risk to self-employment, care of dependent persons, ability to work and waiting time. Ultimately, some of these points were taken into account. Both the professional and public response to this "rationing offensive" has been positive.
Medical services are rationed in all health systems. Increasing efficiency and effectiveness will change this just as little as increasing health expenditure. However, it should be openly rationed to ensure accountability and maintain public trust. There are no simple solutions. Oregon and New Zealand have led the way, other countries must follow.
How this article is cited:
Dt Ärztebl 1998; 95: A-2453-2458
[Issue 40]


Author's address
Richard Smith
British Medical Journal
BMA House
Tavistock Square
London WC1H 9JR, UK
The text was translated from English by Friedrich Werner, Wiener Krankenanstaltenverbund.

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