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All doctors and most politicians realize that health care in the United States must be rationed in some way. New procedures, new designer drugs and high-end imaging all drive the cost of U.S. health care beyond the country’s ability to pay for it. In fact, rationing of health care is already a reality. Financial rationing affects those who cannot afford or choose not to buy health insurance. Rationing by access occurs where schedules are full or limited and cannot accommodate additional patients. (Sounds like Canada, eh?) Consumers who have significant copays are less likely to utilize care, which may be bad (or good) for their health.
The question is not whether to ration but how to ration. To deliver the highest-quality, evidence-based, most affordable care for the greatest number of patients, it makes sense to ration care initially by delivering the best value (best quality for the least amount of money). Funding comparative effectiveness research is likely to yield an excellent return on investment and reduce the need for further rationing. As an example, why spend $2,000 per dose of Lucentis if the CATT trial shows that Avastin ($50 per dose) is not inferior? And why would we use topical antibiotics ($100 per bottle) after every intravitreal injection if future studies show they do not lower the incidence of endophthalmitis? Further rationing, if needed, should be based on a physician-led, society-wide discussion of what types of care we value enough to pay for (the Oregon model).
Rationing is one solution for providing care under a financially strained health care system, and there are other solutions worthy of discussion, such as balance billing (see the roundtable feature article “Is It Time for Balance Billing?” on page 49). The way I see it, the basic premise of insurance is to pay a regular premium that you can afford in order to cover those unexpected major expenses you cannot afford. Balance billing deprives the patient of part of this insurance benefit by decreasing coverage for the unexpected major expense. It makes better fiscal sense to increase the premium slightly for all patients, thus maximizing the insurance effect.
There are many Medicare patients who would not be able to come up with the increased copay necessary for major surgery or chemotherapy, and they would have to cancel or postpone it. In the feature story, Dr. David Chang suggests that these patients be given charity—discounting back to the Medicare limiting charge. This might be a good idea, but I fear I am not smart enough to separate the patients who really need a discount from those who merely wish a discount. And I doubt that balance billing is likely to replace a significant portion of the looming 23 percent fee cut.
However, as a practical political matter (and as Drs. Repka and Rich note in the roundtable feature), neither balance billing nor higher premiums is likely to be seriously considered by Congress unless patient access to Medicare physicians becomes limited.
And as our society searches for answers to these difficult questions, we must be wary that politicians do not cling to the false assumption that nonphysician practitioners cost less. These practitioners are paid exactly the same as physicians for each CPT code, and may actually raise costs compared with a physician by performing unnecessary and duplicative services.
This is Dr. Johnston’s personal opinion.