I wasn't planning on writing about rationing of health care again, since we covered it in my last post prompted by Don Berwick's resignation from CMS.
But two stories came up recently that prompt me to do it again. The American College of Physicians released their revised Ethics Manual this week, and included language regarding the use of cost effectiveness as a criteria for providing care, and even urged parsimony by physicians. In an accompanying editorial, Ezekiel Emanuel, lauds the ACP for this language, noting the physician's obligation to society as a whole, and not just to individual patients. (As we noted last time, the Charter on Medical Professionalism and theAMA Code of Ethics emphasize the physician's duty to social justice in the distribution of finite health care resources.)
All well and good, but NPR did a story on the Manual, and out it came. Scott Gottlieb, MD, of the American Enterprise Institute noted the general acceptance of cost effectiveness data in medical decision making, but then followed up that parsimony "really implies that care should be withheld. There's no definition of parsimonious that I know of that doesn't imply some kind of negative connotation in terms of being stingy about how you allocate something." (The definition I linked to above notes that parsimony can mean simply being careful with money or stingy.)
Daniel Callahan of the Hastings institute also got the vapors: "If you say certain things will not be cost-effective, they're not worth the money, well that's rationing, particularly if some patients might benefit or simply some might desire it whether they benefit or not, whether it benefits them or not. So that's where this all becomes a real viper's pit."
As we noted previously, America rations health care ruthlessly, largely by income and inability to pay (yes, I know that's a link to an NPR story), but also on quality of insurance, most acutely with private health insurance and Medicaid. I won't run through all of this again, please reread the last post for the details, but I cannot help but find it exasperating that supposedly knowledgeable people, like Gottlieb and Callahan, act as if utilizing cost effectiveness strategies necessarily means "withholding care," and, by extension, that all care, effective or not, cost-effective or not, is beneficial.
But more irksome is the implication that we don't ration now, and that this new, threatened "rationing," is somehow anathema to America. Which brings me to the second story that came up this past week, concerning money troubles in the British NHS and a regression in some areas to longer waiting times for certain procedures. The NHS had done quite a bit to repair their reputation and significantly shorten waiting times, but are apparently losing ground due to governmental austerity measures that (surprise!) actually effect people in real life. I noticed that conservative web site Townhall.com covered the story as an indictment of all health care, all over the world (and, of course, missing the irony that conservative austerity measures were the source of the problem). I pointed out over there with a flurry of comments that we're not so hot on this score ourselves, but also noted that Germany and France, in particular, provide health care for all, far more frugally (parsimoniously, even) than we do, and have no waiting times, no significant rationing of services compared to us. We remain the only industrialized nation that thinks nothing of rationing health care - and I mean this more literally than usual - as many of us give no thought to those struggling and suffering and dying for health care.
"A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy--a country that switched to Japanese cars the moment they were more reliable, and to Chinese Tshirts the moment they were five cents cheaper--has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers." - Malcolm Gladwell, The Moral Hazard Myth