Sunday, August 9, 2009

Health-Care Rationing - A Practical Construct

The concept of health-care rationing has not been adequately discussed in public because it’s a touchy subject, appropriately so. But a discussion of health-care rationing and treatment delays is imperative as these are serious long-term consequences of government run public and single-payer options. On a recent news program, Secretary Sebelius has indicated that rationing goes on all the time. Yes and no; i.e. not all forms of rationing are equivalent.

First of all, rationing must not be confused with good medicine. A physician’s decision not to order a test or perform a procedure not indicated for a patient’s symptoms or disease is not rationing; rather, it’s just good medicine. We can distinguish three types of health-care rationing: natural, self and fiscal. Natural rationing is a consequence of a limited biologic resource. An example would be limitations in the number of hearts available for heart transplants. Bottom line, not everyone who needs a heart gets one. Self rationing is when a patient’s clinical situation precludes interventional therapies. For example, an individual with a broken hip and advanced cancer of the pancreas with less than two months to live would not receive a hip replacement. Physicians make these decisions all the time. It is most disappointing, to say the least, to hear talking heads and politicians (who, by the way, know little to nothing of medicine) suggest that doctors are not doing this. Furthermore, no one would dispute this form of rationing. Lastly, fiscal rationing is the limiting of health-care because of arbitrary financial constraints; e.g. where an indicated treatment (surgery, chemotherapy etc) that will improve survival and/or quality of life is not provided because of arbitrary measures (generally fiscal, but others such as age would be considered) and/or inherent delays (e.g. insufficient number of physicians). It is this type of rationing that is not standardly practiced in the U.S. and scares Americans.

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