Commentary: In defense of health care rationing
This article first appeared in the St. Louis Beacon, Dec. 8, 2009 - The cacophonous screed about pulling the plug on grandma may have been the product of know-nothing health-care activists and exploitive politicians. But know-nothing or not, their crude advocacy contained a bolus of accidental insight through an understanding that genuine health-care reform requires rationing.
Rationing is at the unavoidable heart of all health-care systems. It is unavoidable because every finite resource must be rationed by definition when demand exceeds supply. In much of the world, rationing by outcome discourages the use of unproven health care.
But in America, there are few such constraints. Instead, economic circumstance and the bottom lines of for-profit insurance companies are the primary determinants of health-care access. Consequences include a shorter life span, ubiquitous health-cost-induced personal bankruptcies, and tens of millions without insurance, tens of thousands of whom die needlessly every year as a result.
It is important to acknowledge that when we pursue rationing by outcome as we must, we will sometimes make mistakes. Science is imperfect and biology is fickle. When research concludes that one procedure is more effective than another, the reverse may be true for some patients. When a physician eschews a CT scan because of "certainty" that your pain has a benign cause, you are being protected from radiation. But occasionally, unanticipated cancers are missed.
In Britain, a board determines whether a drug will be excluded by the Health Service because of cost and unproven merit. Sometimes board members get it wrong. In Britain, PSA (prostate specific antigen) testing is not routine. So fewer indolent cancers that would never grow or kill are identified and unnecessarily treated. There is less resulting incontinence and impotence. Billions are saved and prostate cancer mortality in Britain and the U.S. are similar. But reduced surveillance is occasionally inadequate.
There is no free lunch. But like most of the developed world, Britain has universal care, a higher life expectancy and less infant mortality than the United States. The British match favorably in treating and preventing most chronic diseases and there are no health-cost induced bankruptcies. Because Britain spends half as much per capita on health, it has extra money for child care, elder care and a multitude of social services. The country does remarkably well with rationing by outcome.
We must learn to do the same. In 2008, then Congressional Budget Office Director Peter Orszag estimated that we waste $700 billion a year on medical tests and procedures that do not benefit patients. Often, they yield adverse effects that diminish our health.
The examples are legion. Hospital-to-hospital variability in radical mastectomy prevalence is ubiquitous. Billions are wasted annually as thousands of women with early breast cancers receive disfiguring radical surgery when research shows conclusively that the surgery is unnecessary.
Intrinsic financial incentives yield similar overuse of back surgery, coronary artery bypass surgery, magnetic resonance imaging and countless other procedures. Largely because of limited outcomes based rationing, per-capita Medicare costs can be twice as much in one state or locality as in another, with no health benefit in high cost regions. A 2007 New England Journal of Medicine paper concluded that 31 percent of hospitalizations for community acquired pneumonia are unnecessary. Once again, billions are wasted.
This is an unsustainable template. Health insurance premiums have risen four times as fast as wages in the last decade. Health-care costs have doubled to 16 percent of gross domestic product during decades of inflation. The CBO estimates that health costs will exceed 30 percent of GDP by 2035. If that happens, our status as a modern economy will end and our health-care system will implode.
The health reform package inching through Congress has much to offer: Millions more covered, budget neutrality, constraints on the most egregious insurance industry practices. Versions of the bill include modest anti-inflation efforts like health-care exchanges, taxing Cadillac insurance plans, and cost sharing by covering low-cost healthy individuals. The legislation is revolutionary in what it does, but inadequate in its gentle anti-inflation jabs.
We are beyond gentle. We must transcend debate defined by zealotry and taboos. The broad guidelines of anti-inflationary reform are both obvious and politically toxic. They include eschewing fee-for-service and promoting fixed physician salaries with bonuses based on results, not use. Expensive insurance riders should discourage procedures or drugs that do not improve outcomes. There should be no financial incentives for prescribing an MRI or blood test or for operating on a patient.
Everyone deserves the health care they need, and we have the resources to provide it. But the cost of modern medicine precludes providing all we might want. Because demand exceeds supply, we have no choice but to ration.
We ration today using the most dysfunctional possible approach.
We will be rationing tomorrow. The only question is how.
Ken Schechtman is a freelance writer and a professor at the Washington University School of Medicine.