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Clinical Decisions by Doctors, not Insurance or Government

By Dr. James Burdick

The dreaded “R” word - rationing - has appeared again, in “The Real Meaning of Rationing,” by Meltzer and Detsky in JAMA.   They correctly note the problem of the market in health care in which it is not reasonable for each consumer, that is, each sick patient, to be subject to the actual cost.  Thus, spreading the risk is the goal of health insurance.  And it is true that de facto rationing caused by this business model exists now.  But I disagree with their conclusion that it is inevitable. 

The problem they have is one that underlies a lot of health care policy thinking, which is that there is an analog nature to health care quality: a little care has some quality and a lot more care is seen by theoreticians as higher quality.  This allows one to think about it in terms of economic theory. 

But in fact health care is digital: there is only one high quality which is the right treatment for the health issue the patient has.  Less is not quality, nor is more – those would represent lack of coverage or overutilization, respectively. 

In the U.S. at present, we lack a way to ensure this correct care in each case and in fact are stuck with incentives that steer doctors away from providing just the correct treatment, no more, no less.  Right now, administrations in federal programs and private insurance, with intrusion of medical corporations, have huge power over clinical decision-making.  It is not done well, but there are rules.

Of course single payer is the way to go.  But there is not much talk about how the rules would be made.  An “Improved Medicare for All” is a nice slogan but an unrealistic idea.  People may presume that it would be done by expanding “big government,” which would have to be doing the rationing.  But there is another way.

To make single payer work we must create a formal, national but non-governmental role for doctors.  Put us in charge of policies on quality.  Not regarding payment, which is a separate issue. Payment could be done either by a federal fund or tightly regulated insurance.  But as doctors we must agree that if we have a national consensus based on professional authority that says this treatment is covered for that patient, it is – no hassles. The key is quality care determined by clinical criteria, neither more nor less.  This can improve quality, limit administration and overutilization, and save a whole lot of money.

If private insurance and federal controls regarding clinical rules can be taken over by doctors it will free us from insurance troubles and get around the automatic pairing of single payer with government control.  We can leave latitude for professional judgment in our unusual cases.  And the accounting shows that we can afford to extend this high quality for all Americans without rationing because of the savings.   Moreover, shedding the big government label can help improve public and therefore congressional support for single payer.  This is how we can achieve an effectively reformed health care system. 

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