• What’s “rationing”?

    Ezra Klein defines “rationing”:

    [T]he only thing that’s really rationing is the thing your doctor tells you is rationing. If he can’t start you on a fourth drug regimen because the insurance won’t pay for it or the government says no, that’s rationing. If he doesn’t start you on a fourth drug regimen because he doesn’t think it’ll help and the focus now has to be on making you comfortable and trying to get you into a clinical trial, well, that’s just good care.

    I know, I know, strictly speaking there is no such thing as “no rationing.” However, that renders “rationing” essentially meaningless, hence semantically useless (though still politically charged). So, Ezra’s being helpful here in making a distinction that highlights a difference.

    The next step is to help the doctor and the patient know when that fourth drug regimen will be of help. That’s what comparative effectiveness research is for. The final step is to get doctors to do what Ezra’s hypothetical doctor did: follow the evidence. These are not simple steps, not least of which because they’ve been hijacked by political and financial incentives.

    By the way, Ezra cites a Merill Goozner piece that is worth reading.

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    • Rationing is when you need medical care but can’t pay for it.

    • There is a concept that needs to be added to Ezra’s definition.

      Defining rationing only by its interference in doctor-patient relationships and decision making is overly narrow and not totally rational, since that interference may be warranted by valid health care concerns and already occurs on a regular basis. Generally as of now it is used to enhance quality, safety, and cost effectiveness.

      Insurance companies and the government are capable of making rational decisions — in some cases more rational than doctors.

      If your doctor wants to give you coffee enemas to treat malignant mesothelioma, but the insurance company or the government will not pay for it because the overwhelming evidence is that it will not help at all, that is not rationing. Neither are a long list of health care restrictions imposed by the FDA, the NRC, and various other state and national health agencies, as well as by hospitals and health care organizations, intended to protect the public from ineffective, harmful, and fraudulent patient management. It is just good care, but it makes the somewhat controversial assumption that doctors are not always correct or even always well informed or honest.

      Health care rationing is when the government, insurance company, or some other party tells you that you cannot have an EFFECTIVE treatment without offering a better substitution.

      In the bad old days, refusal to put people on renal dialysis based on their age, race, sex, and status was rationing, laboriously performed by boards of experts and citizens. Refusal to put you on renal dialysis because the overwhelming evidence indicates that your kidney disease can be managed without dialysis is not rationing.

      Any rational discussion of health care must reflect an awareness of the effectiveness of any treatment and of the potential effectiveness of substitutions which may cost less, be safer, or be better in other ways.

    • But what is “overwhelming evidence”? The recent mammogram imbroglio started when some pretty strong evidence pointed to fewer screens before age 40. But the mammogram guidelines were returned to the previous recommendations pretty quickly after an outcry. It is really hard for government to take away perceived benefits from a favored group (less so for groups out of favor, but can we really improve Medicare finances solely on the backs of white males?).

      And most of medical care is much more uncertain. A drug with a 60% response rate is doing really well, and probably 2/3 of that positive response would be duplicated by a placebo. Probably the strongest evidence in the last 50 years of medical research is that placebos have a positive response in 30-40% of the participants. They are cheap (usually). Should we require that everyone have a placebo trial before using more expensive drugs? Pure logic would say this would be worth trying.

      Any rational discussion of health care must reflect an awareness that we don’t know the effectiveness of many treatments, and that there is a significant minority of illnesses and treatments for which we cannot know effectiveness (because it will cost more to do the research than just pay for the treatments) until scientific understanding of the underlying processes expands to cover those areas.

      • There are many controversies in medicine in which there is not overwhelming evidence, and attempts to manage them as if there were are not a service to patients.

        However, there are many areas in which the evidence is truly overwhelming, and pretending that it is not is a disservice as well. Fortunately for the potential future, these include management techniques which could be dropped at a savings of hundreds of billions of dollars while actually improving quality of care.

    • I’m not sure I understand what you mean when you say “strictly speaking there is no such thing as ‘no rationing’.” Do you mean that rationing is always present in the health care system, including rationing by ability and willingness to pay? If so, I agree, but I don’t think that “renders ‘rationing’ essentially meaningless.” We need to press the point that we already have rationing and that some form inevitable and inescapable. The issue to debate is how to ration rationally.

      By arguing that this policy or that policy (e.g. IPAB) is not rationing, we give the advantage to those who pretend that rationing is not necessary. Then, if they can demonstrate that our policy involves, in some sense of the word, rationing — which it always does — we lose the argument.