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Is explicit rationing of health care inevitable in the United States?
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Health care costs must be reduced
The day may be coming when it will be considered inappropriate, if a patient meets certain criteria of illness, to continue using resources. In a free society such as our own, that is anathema. However, at the rate at which health care costs are rising, they’re unsustainable. There needs to be some way to curb expenses. You can curb expenses by trying not to expend dollars in situations where spending more money is exceedingly unlikely to result in more benefit.
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I’d rather not endorse the term “rationing” because I’m not in a position to suggest that’s what we should be doing. In the best of all possible worlds, we would adopt a different social contract — that is, we would decide to support humane and kind symptomatic care, and not inappropriately aggressive care when the medical parameters dictate it’s almost hopeless to do so.
What we should be doing is explaining to our patients what the treatment options are, rather than avoiding discussion of a treatment because it’s more costly. No matter how humane the reason, it’s important to be complete in our discussions with patients and use evidence — evidence is the coin of the realm — to help them understand that a more expensive treatment is, for them, not necessarily a better treatment.
Patients and families put a tremendous amount of pressure on physicians to provide additional treatment. That’s natural. One of the things that’s very difficult for physicians to do is essentially put the brakes on that expressed wish, and speak in terms that can certainly be supported by the available evidence — additional treatment will have a very tiny chance of being effective and almost certainly make the patient more ill — but that takes a lot of time, and that kind of persistence can be very challenging emotionally for the doctor. That’s not an excuse, but an understanding of the realities of the interaction.
Lowell E. Schnipper, MD, is Chief of Hematology/Oncology at Beth Israel Deaconess Medical Center and Chair of the ASCO Cost of Cancer Task Force.
Not rationing, but rational care, is the goal
To some extent, rationing occurs even now. If you are asking, however, whether I think health care in the United States will evolve into a system where administrative panels decide arbitrarily who lives and who dies (eg, denying life-support for patients and families who want it), that seems highly unlikely. Our research suggests that rather than institutional “top-down” decisions driving intensive, burdensome, and yes, expensive care, the end-of-life care received in our studies is more powerfully influenced by patient and oncologist factors. These can include patient preferences for aggressive care, religious
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views and doctor-patient communication. Unlike economic models that assume supply of health care resources creates its own demand, while true to some extent, our studies show there are some important and modifiable psychosocial factors that could make a substantial difference in the health care choices patients, families and their physicians make. Having end-of-life conversations or informing patients of the pluses and minuses of different treatment options might be a way to promote rational decision-making that enhances patients’ quality of life while reducing health care costs. This seems more rational than a top-down plan to ration care. It has the same ends, but different means, that preserve patient, family and oncologist autonomy.
Holly G. Prigerson, PhD, is Director of the Center for Psycho-oncology and Palliative Care Research at Dana-Farber Cancer Institute.