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Will Rationing Care Become Part Of Reform?

The impetus for government to control healthcare costs should be obvious to us all and intervention now appears unavoidable.  Two issues will soon come to light: the exorbitant costs to fight disease at the end of life, often when the approach of death is barely retarded and the wide disparity in costs between different geographical regions of our country for similarly aged patients.  It is estimated that 27% of Medicare’s annual $327 billion budget – one fourth of its operating budget – goes to care for patients in their final year of life while Medicare averages $20,000 more dollars for patients in Manhattan than in some rural areas of our country.

With this in mind, I share a deep concern with many of my colleagues that part of the healthcare reform debate will turn to the rationing of healthcare. This appears a logical progression from the proposed establishment of guidelines and advisory committees currently allowed for in the Health Reform bill already passed. The question as to who should receive possibly futile care is not clear, rather it is fraught with complexity, often relying as much on evidence-based research as it is on assessments made by the medical practitioner in light of the relationship the doctor has with the patient.

At the heart of the rationing issue are two, often warring, sides of medicine:  art and science. Medicine began as an art thousands of years ago, and moved more towards science when, in Ancient Greece, Hippocrates taught physicians to observe the results of their treatments and make adjustments. However, art should not be removed from medicine, for this is where the doctor-patient relationship comes to play, serving as a cornerstone of effective and humane medicine.  It would be impossible for physicians to uphold the noble traditions of the medical profession, adequately serve society, or preserve the dignity of human life if doctors were to become, purely, scientists.  As long as we are treating people, medicine should never become solely a science.

Rationing, however, would be based purely on science, completely devoid of any art and, I believe, serve as a blow against the sanctity of the medical profession.  Setting up rationing guidelines as they pertain to the end of life would circumvent patient’s trust in the doctor-patient relationship and risk the very soul of medicine by negating the importance of the doctor-patient relationship. Evidence-based recommendations can and should be set forth pertaining to protocols for offering treatments as the end of life seems near.  This would likely reduce some of the high and disparate costs in caring for our elders; however, it is important to consider the input of a doctor aware of the needs and desires of his patient.

I come to this argument both as a physician and from personal experience. Several years ago, my 75 year old father was hospitalized four times over five months.  His medical team, led by a kind and experienced surgeon, unburdened by guidelines or anyone else’s recommendations, gave him a chance despite long odds against his survival.  Medically speaking, I am still surprised he made it out of the hospital to live a normal life again.  During the subsequent five years, he has welcomed three grandchildren into our family; I would challenge anyone to assign a monetary value for that life experience.  My professional and personal experience leaves me quite sure that he would have fallen a victim of any rationing guidelines that could ever exist.

In short, as the average life span increases most of us nurture the hope to live longer, cheering as science opens the door to seemingly innumerable advancements. Yet are we, as a society, equipped, whether it be emotionally or fiscally, to handle the decisions that must be made as the end of life draws near? More importantly, should government be allowed to set up strict guidelines without an active debate from physicians and patients?  These guidelines could sacrifice what has long been and should still remain most important to healthcare: the doctor-patient relationship.


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4 Responses to “Will Rationing Care Become Part Of Reform?”

  1. MedMinded says:

    “Rationing, however, would be based purely on science, completely devoid of any art and, I believe, serve as a blow against the sanctity of the medical profession.”

    Americans are blessed with abundance. We tend to have seemingly endless resources (as long as you can afford them). However, our health system already rations health care — those who are unable to afford insurance premiums don't get adequate care.

    It's de facto rationing. The financial risk of policy holders is reflected in the cost of health plan premiums. If everyone over-consumes costly care (especially in the last few weeks of life), then the financial risk involved for insurers is much higher. What happens when an insurance company needs more money to cover all their financial risk? They charge more for premiums.

    With 47 million uninsured Americans and a tremendous number of 'underinsured', it's evident that Americans already have problems affording plans that provide adequate care. And Medicare is on it's way towards bankruptcy. At it's current rate, Medicare will either have to cease to exist (no health care after 65?) or threaten engulfing every other portion of the national budget (no schools or roads?).

    What's the solution? Simply saying that health care resources should be rationed belittles the ethical complexity of the problem. However, continuing to allow every insured patient to endlessly chase immortality will perpetuate the de facto rationing of care away from poorer individuals.

  2. MedMinded says:

    “Rationing, however, would be based purely on science, completely devoid of any art and, I believe, serve as a blow against the sanctity of the medical profession.”

    Americans are blessed with abundance. We tend to have seemingly endless resources (as long as you can afford them). However, our health system already rations health care — those who are unable to afford insurance premiums don't get adequate care.

    It's de facto rationing. The financial risk of policy holders is reflected in the cost of health plan premiums. If everyone over-consumes costly care (especially in the last few weeks of life), then the financial risk involved for insurers is much higher. What happens when an insurance company needs more money to cover all their financial risk? They charge more for premiums.

    With 47 million uninsured Americans and a tremendous number of 'underinsured', it's evident that Americans already have problems affording plans that provide adequate care. And Medicare is on it's way towards bankruptcy. At it's current rate, Medicare will either have to cease to exist (no health care after 65?) or threaten engulfing every other portion of the national budget (no schools or roads?).

    What's the solution? Simply saying that health care resources should be rationed belittles the ethical complexity of the problem. However, continuing to allow every insured patient to endlessly chase immortality will perpetuate the de facto rationing of care away from poorer individuals.

  3. Ethical Complexity is a good way to put it but I would not trust hard and fast preconceived rules set up in Washington. Perhaps some type of regional or local arbitration board with a rotating membership (this would help guarantee actually working physicians had a chance to serve) and not beholden to Washington, could serve as a protection for society, patients, and the autonomy of the medical profession in deciding on potentially futile or exorbitantly expensive medical cases.

    I suspect every physician can think of someone who could be described as ‘chasing immortality’ but this is not limited to the uninsured. Certainly, the uninsured in our society do not get the same care as those that are insured (well described in Maggie Mahar’s book, Money Driven Medicine) but the current system does not uniformly deny them potentially futile care, with great variation in different geographical areas. While it would be easy for an insurer to say a bone marrow transplant is too expensive, so ‘no’; it would not allow for a ventilator to be turned off because of lack of money. Would rationing allow such a thing? Maybe, and after how many days? and so forth.

    Who is to blame for over-consuming costly care? I tend to believe that we are all to blame- physicians, patients, and third-party payers. Third party payers are seeking profit without actually providing any care to patients. Physicians seek reimbursement and have to focus on third-party payers rules instead of providing medical care. Most patients would choose to spend $1,000 dollars of the insurance companies money than twenty dollars of their own, a real ‘moral-hazard’- to use the insurance term. This is a big mess.

    Your argument that there is rationing anyway because of there being three different types of patients (insured, under-insured, and un-insured) is one that I agree with. But, I am skeptical that government is going to be the answer and am saddened that not enough physicians have “stepped up” and recognized just how broken our current system is. Government does not have a good track record and I would point towards Medicare as a prime example. The theme of most of my blogs has been that physicians need to recognize how broken things are and step up and do something about it before someone ‘fixes’ it for us. So, yes, government telling me what I can or can not do for a patient, with no other recourse, would serve as a blow against the sanctity of the medical profession- I just hope physicians don’t have it coming, because I’m sure patients don’t deserve it.

  4. Steve Simmons, MD says:

    Ethical Complexity is a good way to put it but I would not trust hard and fast preconceived rules set up in Washington. Perhaps some type of regional or local arbitration board with a rotating membership (this would help guarantee actually working physicians had a chance to serve) and not beholden to Washington, could serve as a protection for society, patients, and the autonomy of the medical profession in deciding on potentially futile or exorbitantly expensive medical cases.

    I suspect every physician can think of someone who could be described as ‘chasing immortality’ but this is not limited to the uninsured. Certainly, the uninsured in our society do not get the same care as those that are insured (well described in Maggie Mahar’s book, Money Driven Medicine) but the current system does not uniformly deny them potentially futile care, with great variation in different geographical areas. While it would be easy for an insurer to say a bone marrow transplant is too expensive, so ‘no’; it would not allow for a ventilator to be turned off because of lack of money. Would rationing allow such a thing? Maybe, and after how many days? Etc.

    Who is to blame for over-consuming costly care? I tend to believe that we are all to blame- physicians, patients, and third-party payers. Third party payers are seeking profit without actually providing any care to patients. Physicians seek reimbursement and have to focus on third-party payers rules instead of providing medical care. Most patients would choose to spend $1,000 dollars of the insurance companies money than twenty dollars of their own, a real ‘moral-hazard’- to use the insurance term. This is a really big mess.

    Your argument that there is rationing anyway because of there being three different types of patients (insured, under-insured, and un-insured) is one that I agree with. But, I am skeptical that government is going to be the answer and am saddened that not enough physicians have “stepped up” and recognized just how broken our current system is. Government does not have a good track record and I would point towards Medicare as a prime example. The theme of most of my blogs has been that physicians need to recognize how broken things are and step up and do something about it before someone ‘fixes’ it for us. So, yes, government telling me what I can or can not do for a patient, with no other recourse, would serve as a blow against the sanctity of the medical profession- I just hope physicians don’t have it coming, because I’m sure patients don’t deserve it.

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