• How to ration?

    [A] ban on valuing life extension presents its own ethical dilemmas. Taken literally, it means that spending resources to extend by a month the life of a 100-year-old person who is in a vegetative state cannot be valued differently from spending resources to extend the life of a child by many healthy years. Though the ACA may be seeking to avert discrimination, it instead helps to perpetuate the current system of implicit rationing and hidden biases.

    The antagonism toward cost-per-QALY comparisons also suggests a bit of magical thinking — the notion that the country can avoid the difficult trade-offs that cost-utility analysis helps to illuminate. It pretends that we can avert our eyes from such choices, and it kicks the can of cost-consciousness farther down the road. It represents another example of our country’s avoidance of unpleasant truths about our resource constraints.

    That’s from a NEJM article out today by Peter Neumann and Milton Weinstein. It’s worth a full read.

    Like it or not, we ration. In a perfect market, or markets reasonably close to that standard, rationing by price is reasonable and defensible (though still, when it comes to health one could argue). But, with the health care market famously full of severe failures, other forms of rationing are at least worth considering.

    Moreover, care can’t be fully rationed by price for the tens of millions of individuals paying very little of their own care. Even high-deductible health plans can’t ration care in the catastrophic range of spending. But the ACA explicitly forbids the HHS Secretary from considering QALY-based rationing for Medicare, Medicaid, or other programs.

    It’s so easy to defeat rationing with demagoguery. The result is that taxpayers–not the individuals receiving the care–will spend more and more to finance care of lower and lower value. Finding folks to take that money and provide low-value care is easy. Finding the resources to provide it will become very hard. This stuff doesn’t grow on trees. In a few hours I’ll be hard at work creating some. Maybe after you read this you’ll do the same. I wish the subset earmarked for public health programs would only go for high-QALY care. It won’t.

    Later: Because people extrapolate, I’m coming back just to clarify: I have no problem with people spending their own money on care of any QALY they like. I do have an issue with the expenditure of taxpayers’ money on low-QALY care for others. We should buy all the care we can afford with taxpayer money, starting with high-QALY care. At some point resources exhaust.

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    • I read this earlier and hoped you would comment upon it. This is very disheartening. At the individual patient level, how am I supposed to decide what is better for my patients w/o this kind of data. At the national level, the absence of this data means we cannot know how to best use limited resources. I think the authors are correct in stating that there is a lot of magical thinking going on.

      Steve