Rationing Health Care

Before I begin my blog post today, I would like to extend my sympathy to the Kennedy family on the loss of Sen. Ted Kennedy. Regardless of one’s political views or affiliations, it is clear that yesterday, health care reform lost a great friend, and our country lost a great legislator and a bright light upon the death of Sen. Kennedy. His legislative legacy is great, but I am disappointed that the great man who fought for health care coverage for all Americans since 1966 did not live to see the current reform initiatives brought to fruition.

As the health care reform debate reaches a fever pitch, one of the constant concerns being expressed in public forums and congressional offices is that reform will bring about the rationing of health care, meaning the government or some designated body will be given the ability to control when and what services are provided to patients.

In reality, rationing is occurring in health systems in some form all across America today. People are denied access to primary care appointments, must wait in line to see some specialists, are told by some physicians that their conditions are not severe enough and should wait for further deterioration or increasing pain before a “curative procedure” will be provided, etc. In addition, blood bank supplies are not endless, and often borderline anemic patients do not receive transfusions that are given to patients who are much more critically ill or who suffer from trauma or having large procedures on their heart or vascular systems.

Clearly, as new technologies such as contrast-related MRIs and robotic surgical robots are developed, they are slowly made available as they are tested and made more affordable, during which time they are extremely limited to small populations of people who are in the right place or whose financial situations or insurance gives them the opportunity to take advantage of this service during this initial startup phase. This is one way in which rationing is a part of our health care system every day—new technologies are available only to a select few who can access and afford them.

But an even clearer example of rationing is in the area of dialysis, a much more common procedure which is increasingly utilized by a larger number of people in America in order to sustain their lives until either their kidney disease is reversed with new and more modern medicine, or kidneys become available through live or cadaver donors. When dialysis was first developed, just like the initial MRI, the procedure was only available in the very largest of health centers, and was only provided in a very high cost and intensive inpatient setting. During this development phase, there were many people who could not avail themselves of this much-needed procedure, and hence died. In addition, because the number of people who could benefit from dialysis--even at the centers that were fully operational--exceeded the staffing and machine capabilities of these centers, the patients were prioritized according to the ones who would receive the most benefit from these limited services, and the others were denied access.

Clearly, this was rationing at its best and worst. Because the life-saving technologies both proven and yet-to-be developed will never meet all the needs of every person who might benefit from them, either permanently or temporarily, those who would only receive marginal benefit from such technologies will inevitably be put on a waiting list, never reaching the point on this list where those services will be available.

Fortunately, over the years more and more evidence-based scientifically driven protocols have been developed that defined--to the best of the provider’s ability--those patients who will receive value from each and every process and procedure. Where there are excessive resources, everyone who will benefit will receive the appropriate care. However, the downside of excessive resources is that many people who would not benefit from such procedures will inevitably receive them also—the overuse of health care. This is truly the negative side of rationing.

So although the recent health care dialogue has escalated the concern that the government or a government-related entity will decide who will receive specific health care and therefore decide who will live and who will die, the fact is that rationing has been, is, and will always be a part of the health care environment. The downside is that yes, occasionally there is someone who could benefit from the care who will not receive it. This is the underuse of health care. But in my 41 years of experience, I have rarely seen a case where such occurred. A person who really needs and can benefit from a procedure will find a provider who will make that happen by utilizing, at times, referral patterns and processes that are non-traditional, much like the child in California living in a low-income home who required a highly technical lifesaving cardiac procedure who was flown by a volunteer pilots association to CHRISTUS Santa Rosa Children’s Hospital in San Antonio, where the procedure was performed free of charge, both by the physicians and the hospital.

In contrast, without the need for rationing, the misuse and overuse of health care, the major drivers of the high cost of health care, quickly occur, i.e., the cardiac cath that could be avoided, the stent that did not need to be put in the borderline patient and the MRI or CAT scan for which a simple physical diagnosis or skull X-ray could suffice for a patient, particularly a pro-football player who suffered a mild concussion.

Yes, rationing is necessary, and should be supported. The concern should be that it will be done by people who have no medical background. Necessary and good rationing can and must be done by people who are well-trained and committed to the highest quality, low cost medical care which demands that proper use rather than over-, under- or misuse is the guiding principal.