20 July 2009

Rationing, frankly discussed

Bab Wachter has a great opening salvo, well worth the read:

Wachter's World : Healthcare Rationing: Why Stalin Had it Right
I just finished a couple of weeks on the wards, and once again cared for several patients – cachectic, bedbound, sometimes stuck on ventilators – in the late stages of severe and unfixable chronic illnesses whose families wanted to “do everything.” As I wrote last year, there are limits (like chest compressions) on what I am willing to do in these circumstances, but they are mostly symbolic – basically, I am a bit player in this crazy house, with no choice but to flog the helpless patient at a cost of $10,000 a day in a system that is nearly broke and whose burn rate threatens to ruin our country. Go figure.

Is there anything we can do? The favored solution, a board resembling the UK’s National Institute for Health and Clinical Excellence (NICE) with the teeth to limit certain new drugs and technologies, is hard enough. But even if we were able to get a NICE-like organization in place (doubtful), that doesn’t really address the brutally tough issue: is our ethical model one in which we do everything possible, irrespective of cost, for every patient when there is any chance of benefit, or one in which we place limits on what we’ll do in order to do the most good for the most people. An American “NICE” isn’t going to limit ICU care for 80-year-olds with metastatic cancer. That will require a much broader public discussion, and even harder choices – since they will need to be made at the bedside.


  1. Yep, I just wrote an editorial on this very topic. There are two absolutes in healthcare.

    1. There is a finite amount of money, doesn't matter if you pay premiums, taxes, whatever, there is still only so much money available.

    2. There is a limited number of resources, the AAMC is predicting a 124,000 physician shortage by 2025, now, PA's and NP's can HELP, but we are not complete substitutes.

    Once you accept those two absolutes, then rationing becomes inevitable. There is no way around it.

    We already ration now, however, NOW, we ration financially, IE; if you have good insurance, and/or personal assets you will get good care, if not, well tough luck. You can go to the ER of course, but one should never mistake the ER for the comprehensive care that one's PCP can provide, they are not the same.

  2. Nice post and I couldn't agree more.

    But Liam, we could easily institute a NICE like board in the US if we took the issue of government out of the political equation.

    The people who go wild over socialized medicine are not crazy- they simply don't want socialized medicine.

    I am quite certain that the creation of a non-governmental board which sets rationing policies (or simply suggests what various options cost) and which different insurers (and patients) would be free to use to create a legally binding contract is not something conservatives would oppose- they just don't want choice removed (Indeed, I might remind you that with a few notable exceptions, it is the conservative states and not the liberal ones who do ration care better).

    All that would be needed would be:

    1. Preventing patients from jumping ship to new plans once they don't like the one they chose.

    2. Health care providers, institutions and insurers would be immune from from any legal action take by patients IF they followed the rationing agreement appropriately.

    There is nothing special that says a set of rationing rules need to run through the government (as it does with NICE in the UK).

    In fact, I still personally think care delivery would be far more efficient in the UK if their rationing was not delivered in socialized institutions.

    We know the issue is inappropriate utilization AND the much higher rates of trauma American's experience (we do love to shoot each other)- there are many ways to skin this cat without nationalizing the system.

    Think outside the box

    And Mike, I agree with you but I think mid level providers can engage in even wider scopes of practice that we common use you today. Further, we can train more of you at a much lower cost in a much shorter time than we could train an equivalent number of physicians.

  3. Tell me with a straight face that ANY board is going to tell Sen Kennedy that his malignancy is fatal and that no further treatment is going to be approved. It will NEVER happen, EVER. It is human nature...what is good enough for the commoners will never do for those in power. Just as Congress carefully exempted themselves from the current healthcare plan, those who are "special" will never be bothered by any of the rationing that will be placed on the rest of us by these plans.
    As to current rationing, it seems to me that when someone needs something done it almost always IS done. Pacemaker, emergency surgery, transplant.....it gets done.


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