No one wants to mention the R word – rationing. We ration health care. Of course we do not ration rationally. Why must we ration?
First, we do not have unlimited resources. Second, we do not have a capitalistic system at the patient level. Let me explain.
If I want to spend $100 on dinner, that is my decision. If I have the money, I can spend it. If I want to buy a $500 bottle of wine, I can find that wine, and buy it.
If I want a $1 million dollar house, that is my issue.
In neither case does my decision directly impact the cost of your food, wine or lodging.
However, every choice made in my health care impacts everyone else who has the same insurance carrier. That is the problem. I have no incentive to make rational financial choices about my health care.
The lack of financial decision making is one factor leading to increasing health care costs. When I as a physician want a CT scan, I do not have to justify that scan to the patient. If I choose to prescribe an expensive trade name medication, when I could prescribe a lower cost generic, many patients do not care.
Does money matter? Regularly I do prescribe generic medications to patients without insurance. For these patients, money really matters. The cost of the medications impacts adherence. People cannot take medications that they do not buy.
One reason health care costs continue to rise faster than other sectors of our economy is the problem known as the tragedy of the commons. Since individuals with insurance do not self ration, we should have rational rationing – for the good of all.
This editorial explains the problem well – Healthcare has rationing in abundance
But we do ration healthcare indirectly, in two ways:
First, we ration health insurance. We make affordable insurance available to some people but not to others.
Second, our insurers — insurance companies or the government, if you’re on Medicare or Medicaid — ration what they’ll pay for. They’ll reimburse some costs but not others.
These things aren’t “rationing” in the old-fashioned sense, but as far as patients are concerned (to quote Kyl), “it’s the same result.”
The worst thing about our current “system” is that it’s irrational; decisions are often based on seemingly whimsical standards. Who gets affordable health insurance? Full-time employees of big companies — but not many part-time workers, small-business employees or individual entrepreneurs (despite being heroes of the free market). Who decides what medical costs are paid? Not “the patient and the doctor”; that only happens in the utopia of Republican rhetoric. As every insured American knows, those decisions are actually made by a not-very-accountable hierarchy of insurance executives and Medicare bureaucrats. It’s not exactly rationing — but as far as patients are concerned, “it’s the same result.”
We cannot avoid rationing. Since we cannot, we must make rationing rational. Do not attack this problem objectively represents a failure of our health care delivery.
Money matters. We cannot buy everything we want. We cannot provide every test and every expensive medication without considering the true cost.
