• 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?


    • Cassel proposes:
      rationing = distributive justice (societal)
      parsimony = individualized, stepwise, appropriate care

      Evidence rarely clarifying, and the line between both too thin for distinction. The commentary reads nicely, but I did not find conclusions satisfying. LIke yourself I think.

    • Parsimony is not paying $32K for proton beam treatment if $19,000 radiation works as well. Rationing is not letting someone use the therapy they think is better, (proton beam after successful direct-to-consumer advertising) because it’s more expensive than the not-so-good alternative.

      Maybe it would be easier to see if the difference if we required a lot more truth in advertising.

      • Is there any reason to expect “truth” in advertising will advance any farther in health care (including Rx, devices) than it has in any other sector of the economy? This is the USA, remember, where money doesn’t talk, it swears. And where SCOTUS deems money = speech protected by the Constitution.

        Let’s face it, there is no “market solution” to health care that doesn’t screw consumers/patients so that providers/makers can profit. The advocates of refusing to pay for care that is demonstrably ineffective (or even harmful) can dress it up as “conservative” or “parsimonious” all they want, and as long as hospitals and doctors get paid for doing stuff they will continue to do stuff, no matter how ineffective and costly that stuff actually is.

      • The reason this is messy is that it’s rarely clear that the $19K treatment works just as well as the $32K treatment. And what if it actually does work just slightly better? How much is that slightly better worth?

        This is important, but not easy.

        • Very good point. And what is even more difficult is what if it is no better for 90% of patients but it actually does work significantly better for 10% of patients yet we can’t differentiate the two patient types a priori. This, I think, is where we stand with a lot of treatments in the real world.

          • Perhaps. There are also a lot of treatments that are known to be applied in cases for which they do not help the patient. Much of antibiotic prescribing for upper respiratory illnesses fall into this category. Lots of CTs do. Much stenting. The list is pretty long.

            • The best experts healthcare has to offer provide opposite answers to these questions even when they have no financial interest in whatever decision is made. Thus a decision with regard to what to cover and what not to cover must be clearly made available in advance so it is clear to the consumer that these things aren’t covered giving the consumer the opportunity to prepare for those things not covered.

              That leads us to two different types of personalities. Those that like to make their own decisions and those that have difficulty with uncertainty and responsibility so they wish to leave the decision to others.

    • In “Health Status, Health Care and Inequality: Canada vs. the U.S.” NBER 13429 after comparing the two nations they made an interesting statement that I think should be carefully considered.

      “But costs may be more easily overcome than the absence of services.”

      That is a very wise statement if one truly understands what they are saying and recognizes how overbearing government bureaucracies function. Parsimonious care is defined by the one paying for the care and can create an absence of service just as easily as it can create a list of good services.

      • Be very careful with consideration of “bureaucracy”. As someone focused in this field, as I assume you are, I have no belief that government programs (i.e., Medicare) are more bureaucratic than commercial insurers (i.e., BCBS). In fact, I would argue that commercial insurers are far more bureaucratic.

        • I’m with you Jack. The private insurers create my headaches and most of my paperwork. Good thing they pay a lot more.


        • Jake, our commercial insurers are not functioning in a free environment. If they were things would be quite different. Medicare is dictatorial and at least in the past has broken laws and used intimidation as a method of realizing their desires. Medicare lost many cases in the federal courts and continues to try and get through back doors. The state has sovereign immunity so Medicare has in the past broken laws without fear of being sued for anything more than the money they owe in paying a claim. The insurers follow Medicare’s lead with regard to many things.

          • No doubt they are great people if only they were free. I am sure that is hwy we had to pass clean claims laws just so we could actually get paid.


            • Steve, this problem has more to do with lack of competition than anything else. Much of the lack of competition is due to excessive state micro management of health care. Again, government can enter to protect against monopoly and create a level playing field as a force for justice, but once they become an active player they start engaging in all the bad things they are supposed to prevent.

    • People on Medicare do not want rationing or parsimonious care.

      And the thing that angers me the most is that they speak as if Medicare refusing to pay for a treatment means that people cannot get the treatment when of course they can they just have to pay directly.

    • The following excellent article by one of our local UC physicians addresses the rationing/parsimony issue in an indirect, but compelling fashion:

    • An argument will be made (not that I necessarily agree with it) that malpractice lawsuits are a detriment to parsimonious care. A doctor’s decision to avoid “unnecessary care” can be interpreted by a patient as “negligence”, especially in a case of a bad outcome, regardless of the medically sound decisions made prior to the outcome.

      It’s human nature to blame someone when things go wrong, and if the legal system supports this blaming, then you will err on the side of caution (and profits!) in delivering care.

    • A distinction can be drawn between rationing and at least some forms of “parsimony” by means of the distinction between consequentialist and non-consequentialist reasons. The distinction is standard in normative ethics. (Note that non-consequentialists define the distinction so that consequentialist reasons are *exclusively* consequentialist, leaving room for non-consequentialists to give some weight to consequences.)

      Tilburt and Cassel define “rationing” as “explicit or implicit withholding and allocation of beneficial resources from some patients for the sake of others.” This captures the basic consequentialist idea that moral reasoning is a rational decision, involving trade-offs. Non-consequentialist claim that some reasons are not accommodated correctly by trade-offs.

      The issue is raised by “for the sake of,” particularly when it pits one person’s illness against another’s. That *is* correct for consequentialists, but not for deontologists.

      Distribution of care can be controlled in other ways, *for the sake of* other purposes. Suppose we can define an intrinsic reason why one illness warrants care with greater priority to another.

      This prioritization can be justified by non-consequentialist reasons. The non-consequentialist reasons are things like: “Saving lives is more important than saving limbs,” or “Maternal care is more important than caring for the rest of us, other things being equal.” (I’m thinking of the Oregon Prioritized List http://www.oregon.gov/oha/healthplan/pages/priorlist/main.aspx )

      (We may also try to give consequentialist reasons for the same prioritization in addition to the non-consequentialist ones.)

      It can be objected, and for good reason, that these non-consequentialist maxims (Kant’s word) are vague and might not have much to do with genuine morality. Other good objections might be made. Maybe all these objections are excellent.

      But even if this non-consequentialist moral reason-giving is just an elaborate illusion or public relations campaign, it may actually work to provide *publicly acceptable* prioritization.

      Then, if this prioritization has been done in a publicly trusted way, a different authority, such as a legislature or insurance company or public agency, can allocate a budget to spend down to the level that can be afforded.

      The key idea is to separate the decision about how much to spend from the prioritization. That removes the objection to “rationing” in the sense that Tilburt and Cassel define it (which I agree is the relevant sense).

      I’ve just argued that Tilburt’s and Cassel’s distinction corresponds to the standard one for ethicists between consequentialist and non-consequentialist reasons. I’ve also argued that we use non-consequentialist reasons in prioritizing healthcare, at least some of the time. I’ve also argued that even if you disagree with this non-consequentialist reasoning (or deny that it is really reasoning at all) then at least it addresses the important concern for public acceptability of prioritization.

      Unfortunately, the library where I work gets JAMA only in print, so I have not yet read Tilburt’s and Cassel’s full article. But I think they’ve got a good point!

    • Health care isn’t a good or service, it is MILLIONS of goods and services.

      An X-Ray is pretty good, and a MRI is better.

      Don’ confuse this one unavoidable rule: The people who paid in the most get the MRI first.

      That rule is NEVER going away and you shouldn’t want it to. If it is in place, the price of the MRI, and the next thing, and the next drops fastest.

      If you stop thinking about care as a single good, but as a giant market of possible treatments and services, you will be fine.

      This also helps you get away from worrying about someone getting “too much” care, no one wants unnecessary treatments going to someone who is not paying out of pocket, or someone being sold a giant bill of goods.

      But an MRI can be X% better, and cost lots more, and if you are TRULY a health care economist, you are thinking about he long term R&D innovation, and the whole ball of wax.

      But since rationing does happen, and will continue to happen, to increase access, we want to drive down prices, by ringing clarity to market pricing, reducing licensing service barriers, and getting price shopping going.

      Parsimonious care is stupid. get over it.