Rationing vs parsimonious medicine

From Jon Tilburt and Christine Cassel in JAMA:

Rationing means explicit or implicit withholding and allocation of beneficial resources from some patients for the sake of others. In the United States, health care rationing occurs routinely (and justifiably) in situations of absolute resource scarcity such as organ transplantation, distribution of blood products, or mass casualty events. In these circumstances, prespecified principles guide the timing of how the resource is delivered to maximize benefit. In other circumstances, health care is rationed de facto (and arguably less justifiably) by financing schemes, even when the resource in question exists in adequate supply. In the current US system, health care is rationed by ability to pay: underinsured and uninsured patients do not receive the care they need more frequently than those who are well insured.[…]

But parsimonious medicine is not rationing; it means delivering appropriate health care that fits the needs and circumstances of patients and that actively avoids wasteful care—care that does not benefit patients. […]

Parsimonious care is not “rationing,” because it does not withhold something effective to provide it to others; on the contrary, it restrains the use of unnecessary and potentially harmful services.

Correct me if you think I’m wrong, but I don’t think very many policy wonks want to see rationing and, instead, are supportive of parsimonious care. Perhaps the consequences of what they support with good intention will include rationing. Perhaps it’s hard to achieve parsimony with out at least a touch of it. If that’s the case, how much rationing will we tolerate to achieve some additional efficiency? Keep in mind, today we have a high level of rationing by ability to pay and a low level of parsimony. Are the gains bigger than the losses if we tilt a bit in another direction?


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