• Explicit v. implicit rationing

    The publication of the American College of Physicians ethics manual has garnered lots of comment. Aaron has weighed in with two posts and the comments show that people have very strong feelings about the role of physicians in using cost and effectiveness information to make clinical decisions. On balance, I come down thinking that it would be unethical to completely ignore cost and effectiveness information. At the same time, I don’t want a robot providing my care who was just following guidelines, and there are areas of great uncertainty in any event. Though as Aaron and others have noted, ACP probably needs to work on their language.

    Seeking to push the discussion forward, you could define rationing in a variety of ways, but the way it tends to be used culturally in the U.S. is anything other than a patient get whatever s/he might want, desire, need (these are different, but I am leaving that aside for the moment) is rationing. Under this definition, it is not a question of whether there is rationing, but how? Larry Churchill has two great, short books* that are worth reading if you want to go deeper into this discussion; Paul Kelleher has also pulled together some great resources. Bill Gardner also has a great post.

    David Mechanic has an essay in Health Affairs in 1997 that provides a useful way to think about rationing: implicit v. explicit. I think that one of these rationing approaches likely scares people more than does the other, and the reasons individuals view them differently are idiosyncratic. Under Mechanic’s formulation the two choices given the inevitability of rationing are:

    Explicit rationing refers to decisions made by an administrative authority as to the amounts and types of resources to be made available, eligible populations, and specific rules for allocation. Significant amounts of explicit rationing occur in public and private plans regarding levels of available technology, location of facilities and programs, expenditure levels…

    Implicit rationing, in contrast, refers to discretionary decisions made by managers, professionals, and other health personnel functioning within a fixed budgetary allowance.

    When I did a post doctoral fellowship at the University of Manchester (U.K.) in the mid-1990s, I spent a fair amount of time talking to my GP, not as a my physician, but trying to better understand how primary care worked there. He seemed to embrace the role of implicit rationer as not only inevitable, but as good because he viewed himself as uniquely qualified to assist patients in making decisions, many of whom he had known for many years. He felt that this meant that could bring some insight into the likelihood of success, cost, and preferences of the patient as revealed over many years, all while realizing there was someone else in the waiting room who also needed care, and many others that he would never meet.

    His straightforward acknowledgment of this reality and his ease in discussing it was very foreign and even scary to me, but as Mechanic notes:

    Medicine is both a scientific activity and a cultural form. Most of the ways in which we ration care are invisible, obscured by cultural assumptions, political understandings, and economic realities.

    What was jarring to me, was old hat to him. As has been said by us on this blog in many cases, the hardest part about rationing is not technical, but cultural. We don’t need to, nor could we copy how other nation’s ration; we have to figure out what works for us. The hardest part for us Americans seems to be even starting the conversation, and acknowledging that it is a question of how, not if.

    *********

    Larry R. Churchill. Rationing health care in America: perceptions and principles of justice. 1987; University of Notre Dame Press.

    Larry R. Churchill. Self-interest and universal health care: why well-insured Americans should support coverage for everyone. 1994; Harvard University Press.

    DT

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