I periodically write about rationing.  While I believe I understand the issues, perhaps I do not really have a complete understanding, because my explanations do not always resonate.  Perhaps the subject is too emotionally charged to allow for a fair discussion.

My friends, David Meltzer and Allan Detsky, have a wonderful explanation of the rationing problem in JAMA  (subscription required)- The Real Meaning of Rationing.  Our ACP Advocate, Bob Doherty, places this paper into a very real context today on his blog – “Death Panels” redux

Meltzer and Detsky define rationing in thiis way:

The term rationing implies that goods and services are allocated to consumers in a way that is disconnected from the price. That is, specific amounts of goods and services are allocated to consumers on the basis of criteria other than their actual preferences, willingness to pay, and income or wealth. The party making that decision has to determine what the person really needs or what is fair. If demand exceeds supply at that price, the price is not allowed to increase.

As I understand this paragraph, unless you have cash, then the intermediary – insurance company, government – must use criteria to prioritize expenses.  The idea here is that we cannot afford everything.  We already have irrational rationing for many expenditures.  They favor making rationing explicit, based on societal values and data on effectiveness.

Doherty highlights this problem by discussing an Arizona decision to withhold transplants from certain patient groups:

Arizona Medicaid officials told the Times that they “recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.”

Now some experts (read those who do transplants) argue about the data that Arizona used.  But what Arizona is doing is making a decision of the relative use of $4.5 million each year.  Rationing makes sense when we have limited resources and we want the most bang for the buck.

As a medical student I rationed expensive meals.  One expensive meal could be replaced by 3-5 inexpensive meals.  Now many readers will argue that the examples do not parallel each other.  So let me try again.

You are the governor of a state that has a balanced budget restriction.  You cannot overspend your budget.  Thus, you must make trade-offs between desirable expenditures.  Thus, you must ration.  Really the only question here is how you decide to ration, not whether you will ration.

You are the king of liver transplantation for the US.  Let’s assume 1000 expected livers will become available this year.  You must prioritize the use of this scarce resource.  Clearly you should give the livers to those most likely to benefit.  Therefore you ration.

We can ration health care rationally or irrationally.  We can ration health care based upon emotionally appeals or based on data.  We must remember that a decision to pay for one treatment or diagnostic test may deprive someone else of a different treatment or diagnostic test.  Or even worse, one treatment may cost so much that many other patients will go without a vaccines or preventive visits.

Rationing exists, it will continue to exist, and we have an obligation to ration in a fair way.  We should not value some diseases over other disease.  We should avoid emotional appeals, but rather look at data to make the difficult decisions that must be made.

This strategy is not a strategy of death panels.  This strategy makes explicit that TANSTAAFL is an important concept. (there ain’t no such thing as a free lunch – Robert Heinlein).  If the Tea Party fans look at health care honestly, they must agree with this concept.  To complain of “death panels” shows a conceptual inconsistency.