American College of Physicians: Internal Medicine — Doctors for Adults ®

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‘Rationing’ charge prevents real discourse on health care costs

From the March ACP Internist, copyright 2011 by the American College of Physicians

By Robert B. Doherty

A disheartening aspect of the ongoing debate on health care reform has been the propensity to label even the most modest proposals to address health care costs as “rationing.” Reimburse doctors for counseling patients on advance directives? “Rationing.” Research the effectiveness of different treatments? “Rationing.” Reduce the annual pay update to hospitals? “Rationing.” Fund pilot projects on aligning financial incentives with better outcomes? “Rationing.”

The misguided accusations of rationing have mostly come from GOP critics of the Affordable Care Act (ACA), even though many of the same people argue with the next breath that the ACA doesn’t do enough to control costs. But the Democrats haven’t been straightforward either about the challenge of tackling rising health care costs. They hide behind the Congressional Budget Office’s estimate that the ACA will reduce the deficit, but don’t add that CBO says this is because the ACA will raise more revenue (taxes) than it spends, not because it will reduce overall health care spending.

Instead of looking to the politicians for answers, ACP released in late January a position paper titled “How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently?”

The paper makes the case that rising health care spending poses a grave threat to the fiscal stability of the U.S. and the ability of individuals and families to afford the care they need. Every country makes decisions on how to allocate available health care resources, ACP notes, but their approaches vary widely, reflecting differing political and cultural conditions.

The U.S. already limits access to services based on access to affordable health insurance coverage, insurance company decisions on covered benefits and cost sharing, socioeconomic and racial and ethnic characteristics of the population being served, and the availability of physicians and health care facilities, among other factors. Even with such limits, which result in great inequities in access to needed medical care, per capita health care spending in the U.S. is higher than in any other industrialized country.

ACP makes a distinction between medical rationing, in which decisions are made about the allocation of scarce medical resources and who receives them, and rational medical decision making, by which judicious choices are made among clinically effective alternatives. Engaging the public in a discussion of how to conserve and allocate resources effectively, based on evidence of their value, would result in more judicious use of limited resources, and help the U.S. avoid the overt medical rationing that exists in other countries’ health care systems.

ACP argues that democratically elected countries have a responsibility to allocate public resources in ways that have broad public support, and that in the U.S. such decisions cannot and should not be imposed without the consent of the people. Rather, at the patient encounter level, physicians in consultation with patients have a responsibility to use health care resources wisely, based on evidence of safety and effectiveness and the particular needs and circumstances of the patient, along with consideration of cost. At the societal level, allocation decisions should be informed by evidence on the value of different interventions, should be in accord with societal values, and should reflect moral, ethical, cultural and professional standards.

In an effort to start the discussion, ACP proposes a framework for conserving and distributing health care resources. Among other ideals for allocating resources listed in the position paper are the following:

  • There should be a transparent process for making allocation decisions with a focus on medical efficacy, clinical effectiveness and need, with consideration of cost based on the best available medical evidence;
  • Allocation decisions should reflect American values and professional standards;
  • Allocation decisions should not discriminate against a class or category of patients;
  • The process should be flexible enough to address regional needs and accommodate special circumstances; and
  • Decisions should be periodically reviewed to reflect evolving values, new evidence and unwanted effects.

By putting forth its own ideas for conserving and distributing health care resources effectively and efficiently, ACP hopes to move the debate away from the tired arguments over “rationing,” a term that is poorly understood, emotionally driven, and not conducive to reaching consensus.

Slinging the rationing charge poisons the well for any serious discussion of controlling costs, but ducking the issue misleads the public into believing that the country can go on spending more on health care than we realistically can afford.

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