Can we control health costs without rationing?

Robert Brook, MD, health services researcher extraordinaire, wrote a provocative commentary in JAMA – as he is accustomed to doing – entitled “What If Physicians Actually Had to Control Medical Costs?” In his piece, Brook challenged physicians to take a lead role in addressing the cost dilemma and called on physicians to find alternative strategies to rationing.

No matter how spot on Brook was in his call to physicians to lead these efforts, his use of the “R word” will not engage them in this important issue.  Telling physicians that they must be involved in explicit rationing will always be a nonstarter.  Rationing is the extreme view; there is a lot that can be done to control costs without having to resort to rationing.

For starters, let’s address waste, unnecessary care and care of marginal benefit and see what that produces in terms of better quality and lower costs. In addition, solving the cost issue must be seen as a shared responsibility by all stakeholders – including patients, payers/purchasers, government and communities. Physicians will rise to this challenge when they are being supported and aided by all of these constituencies. If physicians feel it’s a shared responsibility with shared accountability, they are more likely to become engaged in this mission and their patients will benefit from their engagement.

Patients need to take an active role in their care, be encouraged by their physicians and get involved in decisions related to medical decisions.  They need to recognize that some care may be harmful and more is not always better. The public at-large needs to recognize that overuse of health care resources has an impact on other vital community services like education.

The more we can equip physicians with evidence, decision support and IT support, the more we relieve physicians of the need to make bedside rationing decisions.  We don’t need to return to the political firestorms we saw last summer about what to do with my 89-year-old mother when she becomes gravely sick. What my mother and I don’t need is an unnecessary test.

Daniel Wolfson is COO of the ABIM Foundation and blogs at The Medical Professionalism Blog.

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  • Edward Pullen

    We ration already.  Some get care, some don’t.  As long as patients bear little direct responsibility costs will skyrocket.  

  • Kevin Windisch

    Yesterday I saw a kid whose mother ignorred my warnings that kids get fevers after the 2 month vaccines.  That evening she called the hospital advice nurse who suggested that mom take the child to the ER (notice that the advice nurse is paid by the hospital that owns the ER).  Mom went in.  They got a CBC which was normal and blood culture, a chest x ray which was normal  and a urine via in and out cath for urinalysis but no culture which was also normal.  Then the ER doc gave a dose of rocephin and sent the child home.  After the ER fees, Radiology fees, lab fees and doctor fees over $2000 was spent and nobody told the mom that this was an EXPECTED event after the first DTAP.  The amount of money wasted here would have paid for the kid’s vaccines for the rest of her life.

  • Kevin Nasky

    Who is knowingly providing care that is “unnecessary” or “of marginal benefit”? Very few, I would guess.
    That’s the issue here, right? As long as there’s no true consensus on what defines unnecessary care,  then there’s no way to ameliorate it, right? (An argument could be made that consensus on this would mean that we’ve gone to complete “cookbook” medicine, and the art of medicine would be lost, as well as medicine tailored towards individuals versus guideline-based medicine that stems from imperfect studies of populations…I digress.)

    I find this whole argument somewhat insulting, as if this whole problem would be solved if physicians woke up one day and said, “I’m going to stop practicing unnecessary medicine!”

    • Margalit Gur-Arie

      The argument is as insulting as it is futile. Those who provide care that is “unnecessary” or “of marginal benefit”, do so knowingly and for a well defined purpose. This type of appeal will have no effect other than amuse them.
      Yes, probably very few independent doctors, but plenty hospitals and “health care” corporations do the same thing (see comments above and below).
      The correct appeal should be to the medical profession to police the rotten apples in its midst, because if they don’t, the door is left open for governments and private interests to step in and police all apples as though they were rotten. May be a bit too late already…..

  • Terence Ivfmd Lee

    How is the word “rationing” strictly defined in this context? Anything at all that has scarcity is automatically subject to rationing. That is a law of nature. Suppose you say that all women have the right to hysterectomy if they want. Well, unless there are enough doctors to do hysterectomies on every single woman who wants them THIS WEEK, then there must be rationing, at least in a temporal fashion. OK, so some get them done this week, some get them done next week and so on down the line until the bottom of the list get them done next year. You could also look at it from the perspective of the surgeon performing the surgery. If the world’s top #1 Gyn surgeon can only do 40 cases this month, then some people will have to settle for the #2 doctor, while others will have to settle for the #3 so on down the line until the patients at the bottom of the list will have their case down by the one graduate of the worst residency program who has the most horrendous complication record. So, because there is ALWAYS going to be some type of scarcity, whether temporal or provider-specific, there must ALWAYS be some rationing in the strictest definition of the word. So the trillion dollar question is WHO gets to decide which patients get access to which providers at which times? Well, in the free market, no single person decides. It’s a dynamic self-correcting process based on incentives where people who contribute more to the world get more voice in the decision process. This drives people to work harder and produce more. Therefore, it actually increases the total amount of goods and services that all can share and benefit from. In contrast, in a central planning model, committees, bureaucrats or politicians decide who gets firdst dibs. The preference for which individuals or special interest groups get priority access to care is determined by the amount of political favor or clout they have. It should be easy to deduce which model is the more ethical and which is the more efficient. The good news is that it’s the same one, meaning the more ethical model is also the more efficient model. The bad news is that it’s the OTHER one which is dominating our health care system today. And THAT’s why we’re in the state we’re in.

    • Alice Robertson

      Good post, Terence.  One wonders in this world of relativeness….and hypersensitivity… why everything has to be brushed under the carpet.  Is that where the word “rationing” will be, even though it’s a given…always has been.  I subscribe to tons of magazines from different political worldviews….it is the only way I can piece all the truth together…it feels like writers are creating tapestries that portray their inner agendas….some create veils to hide us from the persuasive truth…..writers take liberties to weave together the truth eclectically to suit their own ideology….it is frustrating….even the debates last night were set up to smear the GOP candidates.  You read and ponder why the word “terrorist” is eliminated from Reuters….yet, the word “death panel” is met with denialism and ignorance about the consequences of what will become the next reinvented meaning for a word like…OMG….”rationing” :).  We can’t redefine reality……but we can bear the consequences of our own denialism.  Let us look at the real meaning of situations and words…the truth….not make decisions out of ignorance.  Ideas have consequences…but when the ideas are’s as if we are being protected from ourselves… our own ideals….which are not fully vetted….and that’s a real problem.

  • James deMaine

    There are no incentives to control costs in the current system in the USA.  Patients with insurance don’t pay much.  Those without insurance often don’t get much.  Docs bill by the procedure.  Hospitals and ER’s run lots of tests, MRI’s, etc.  Administrators said to one specialty eye group here, “You’re not billing enough.  If a patient’s in the office and you can do a billable procedure, do it.”  (about half of the group later resigned, but the culture didn’t change).  Hospitals boast and duplicate the latest equipment in order to pad their bottom line and market their services.  Hey, if you wanted to design the most expensive and inefficient system, we’ve got it!.  Insurance companies routinely deny coverage, thus driving up administrative costs.  One large hospital here has 7 administrators making over a million dollars.  It’s big business running these glass and steel palaces.

    I have a relative who’s a general surgeon in Montreal.  He’s happy with his income though it doesn’t compare well with the USA surgeons.  The single payer “socialized medicine” is so popular there (despite the horror stories we sometimes hear about wait times), it’s not about to change.

    Given our current structure in the USA, cost control seems to be an oxymoron!

  • Margalit Gur-Arie

    “It’s a dynamic self-correcting process based on incentives where people
    who contribute more to the world get more voice in the decision
    process. This drives people to work harder and produce more.”

    Who do you think contributes more to the world, a home-care RN or an ambulance-chasing attorney? And how is the world benefiting from each one of these people working harder and producing more?

    • Terence Ivfmd Lee

      Exactly! Thank you. In a truly free market, where I have free choice, I would much rather give money to the home-care RN to care for me and my loved ones than to the ambulance-chasing attorney to shuffle papers around and use the coercive power of the state to take away some innocent person’s money by force.

      • Margalit Gur-Arie

        But you don’t…. You don’t give more money to the private nurse, or nanny who cares for the most precious things in life. You give orders of magnitude more money to accountants and attorneys and car dealers and investment bankers, who don’t work harder and don’t produce more and don’t contribute more to the world.
        There is no self-correcting process. We as a moral and ethical society must correct things purposely.

  • Terence Ivfmd Lee

    Are you claiming we live in a free market world? A world without coercion, where all interactions are voluntary? That’s where the fallacy lies. Well, we don’t. But the good thing is that you are staring to realize the benefits to everybody if we can work towards that type of system (assuming you, like me,  favor rewarding the nurse and nanny more than we reward the investment banker and attorney).

  • don peterson

    It’s really interesting to read everyone’s views on the issue of over-utilization or the converse action of rationing as if it were in the physicians hands to control this.  In another article recently on this site, a physician compared health reform to accident reform citing improved automobile safety features and improved infrastructure as a reason for a reduction in fatal car accidents.  He said something to the effect that healthcare is on the same trajectory…where improved technologies and better trained physicians will, in time, result in better health outcomes.  Yet, where his hypothesis fails is that most drivers actively avoid getting into accidents, while in healthcare we have patients playing chicken with their personal and family’s health at every turn in the road.  Look at the widespread and growing obesity problem, smoking or how so few choose to eat nutritious foods or exercise even occasionally.  When people get sick from all of these poor behaviors, they go to the doctor and expect to be cured. They are sick, their disease will progress and may languish for years, maybe decades. The only choice for a physician is to treat, period. If rationing healthcare were simply about saying NO to people whose poor choices become a drain on public health systems, then people would need to pay for what care they could afford and forego the rest.  If Medicare refused to pay for oxygen tanks for smokers who get COPD or pay for scooters for those with Type II diabetic peripheral neuropathy as a result of obesity, patients would ration their own care based on what they could afford or they would make better choices along the way knowing that staying healthy costs much less. Saying NO in our society seems like a radical and painful approach to cutting costs.  But something must be done to shift the perceived responsibility for health away from those who’s job it is to treat the sick.  It’s everyone’s job to keep themselves and their family’s healthy.  It’s the doctor’s job to treat us when we are sick. 

    • Alice Robertson

      Good points…but a bit of overlapping between rationing, responsibity, and reality. My daughter’s workplace penalizes smokers with higher monthly contributions…then out of five points you must pass three or pay about $30 a week extra…Cleveland Clinic does this too. It does seem fair….of course…if we get healthy via lifestyle choices we will not need as many docs, or drugs, or hospitals…..doctors will be victims of their own making. A job well done…and it is their job to educate us…..they should be into prevention….not just health janitors that clean up our man made health hazards.

  • Jim Jaffe

    rationing is really an unhelpful perjorative word here.  fact is nearly all of us prioritize in nearly all areas of life.  I don’t have a Rolls Royce or BMW because I choose to spend my money in other ways. question is how to make rational (same word) economic decisions.  Does a test that increases knowledge by 1% for a non-life threatening disease and costs $10,000 make sense.  Not for most of us.  Or a procedure that costs $1 million and extends life for a few weeks?  doctors regularly make decisions when they treat the young healthy and old failing in different ways.  and properly so.

  • Cindy

    I agree with Edward.

  • ninguem

    Is the ABIM Foundation related to the American Board of Internal Medicine?

  • ABIM Foundation

    The ABIM Foundation was established as a separate operating organization by the American Board of Internal Medicine in the 1990′s and works to improve the health care system through the advancement of medical professionalism. More information on the Foundation’s accomplishments in advancing professionalism can be found at

  • Robert Bowman

    With 50% of the workforce in 1000 zip codes in 1% of the land area, and with so many with low or no health care coverage we have already rationed health care and made it difficult for 50% of Americans to access. We don’t prosper health care by focusing on health care needed for a few years (or a few visits) at highest cost delivered in a few locations. A health design that is the foundation for better health is a design that results in basic health care delivery – the kind needed for nearly all people delivered in nearly all locations. Physicians are hostages of designs. Associations are key players in establishing the designs. Associations must act to change the design to establish a solid sustainable foundation.

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