EyeNet Magazine

Allocation of Medical Care Is Rational Better Than Rationed?
By Richard P. Mills, MD, MPH, Chief Medical Editor, Eyenet
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Political pejorative is in the wind this election year, pandering to the fears of the electorate. If you can label something to give it a negative connotation—and make it stick—you can sway opinion more decisively than if you propose a good idea, which will promptly be attacked for its weaknesses. A perfect example of this occurred in 2009 during the debate over health care reform. One proposed bill would have paid physicians for providing voluntary counseling to Medicare patients about living wills, advance directives and end-of-life care options. It was a good idea co-proposed by Rep. Charles Boustany Jr. (La.), a heart surgeon and Republican. But opponents applied the term “death panels,” and the resulting furor caused the omission of the benefit from the 2010 Patient Protection and Affordable Care Act.

For a while, I had a hard time figuring out why the word “rationing” has such a negative connotation. After all, in a free economy, when resources are scarce, the price goes up, and not everyone can afford the item in question. Either that, or it’s the early bird gets the worm, as in the iPhone scrambles. That works fine for luxury items, but when it comes to necessities, governments have tended to step in to make allocation decisions out of a sense of social fairness. People don’t seem to object to the rationing per se; it’s when rationing is applied by governments irrationally so that it doesn’t work to fairly allocate the resource or encourage investment in new supply.

So what is it about rationing health care that people especially detest? De facto rationing already occurs for people who can’t obtain health insurance or can’t afford the cost sharing, and for those who reside in areas with few health care facilities. No one has objected to the allocation of scarce organs such as kidneys, though they may argue about the selection criteria for recipients. I contend that it’s when rationing threatens to affect them and their loved ones directly that the hackles get raised. Basically, rationing is OK for everybody else, but individuals want to preserve their personal choices, no matter how costly they are to the system. Physicians who want to retain their own personal choices on behalf of their patients, no matter how ineffective and/or costly these choices have proven to be, are accomplices. Those patients and physicians have found common ground in promoting the pejorative “rationing.” Spiraling health care costs become somebody else’s problem.

Controlling health care costs is a serious social problem that government will solve by irrational rationing unless physicians take ownership of the problem. A senior vice president of the American College of Physicians (ACP) observed, “Slinging the rationing charge poisons the well for any serious discussion of controlling costs, but ducking the issue misleads the public into believing that the country can go on spending more on health care than we realistically can afford.”1 Instead, ACP suggests that we talk about “rational medical decision making” by which choices are made among clinically effective alternatives. As ophthalmologists, we have opportunities to use health care resources wisely, based on evidence of safety and effectiveness, in the context of the particular needs and circumstances of the patient, along with consideration of cost. Perhaps a rallying call might be, “Rational choices—not rationed choices.”

1 Doherty RB. ACP Internist. 2011;31(3):5.


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