Is rationing necessary to reduce health care costs?

Healthcare costs keep rising. Your insurance premiums go up, your deductible and co-pays go up, pharmacy benefits go down. Despite the high cost you get little time with your physician, insurance statements are complex beyond belief and “customer service” seems to be a foreign concept. To combat high costs we are often told that rationing will be necessary. Is that true?

Why are costs so high in this very dysfunctional healthcare delivery system?

There are many reasons. New technologies and drugs are often cited as major culprits. There is some truth to this of course but the real culprit here is inappropriate use. Think of the stomach acid blockers for reflux (heartburn). Good drugs for sure but maybe some lifestyle changes such as less caffeine, less alcohol, raising the head of the bed and waiting a few hours after dinner before going to sleep will work just as well with no cost whatever.

Worst yet is when an expensive test is ordered when diagnosis could have been figured out through a careful history. Did you need an endoscopy with its negative results when the reflux would not abate? Or did you really need a careful history that figured out you were sensitive to gluten? A dietary change solved the entire problem; no pills or procedures needed.

Our lifestyles are a major reason for the escalation of costs. As a society we eat a non-nutritious diet and far too much of it, we are sedentary, we are chronically stressed and 20% still smoke. The results are complex chronic illnesses such as diabetes, cancer, heart disease and stroke. These are lifelong once they develop, difficult to manage and expensive to treat. The real answer is to adjust our lifestyles and to prevent the epidemic of obesity which is a precursor to many of these illnesses. But until we do, costs will escalate rapidly as more and more individuals develop these chronic illnesses – which are where about 70+% of health care claims paid go.

The population is aging as well and with aging come problems such as visual and hearing impairments, joint dysfunction and Alzheimer’s disease. These too incur substantial expense.

There remains in healthcare delivery far too many preventable errors with probably 100,000 individuals dying each year and an equal number dying of hospital acquired infections. Dealing with these two problems will not only markedly improve quality but will also save billions of dollars each year.

And at end of life, often there is a decision made by either patient (or patient’s loved ones) or recommended by the physician to “do one more thing.” All too often this is a mistake with no real benefit to the patient and often more time spend with distress. It is much better to have a realistic discussion between patient (and or loved ones) and the physician and from that a realistic plan for care. This, I hasten to add, is neither a “death panel” nor does it mean no more care and attention. What it does mean is that the care going forward will be just as complete and compassionate but with the more realistic goal of best quality of life possible for as long as possible. Here again, quality ends up costing less.

These are just some of the most notable reasons for rising costs. Many, perhaps most with the exception of those that come with aging, could be addressed with changes in lifestyle, good preventive medicine, attention to quality and more emphasis on patient-physician interaction rather than on testing and referrals to specialists. Add to this good palliative care at the end of life and a very substantial amount of money could be saved while providing better quality.

Physicians can take the lead by agreeing to eliminate those tests and procedures that are often done but which have not been found to add much to the care of the patient. A good approach to this has been presented by Dr. H Brody in the New England Journal of Medicine which was followed up in the oncology field by Smith and Hillner also in the NEJM . The basic concept was that each specialty society create a “top five list” of those tests or procedures that offer little or no benefit to most patients. In Smith and Hillner’s article they suggested – just one of their  examples to reduce costs in medical oncology -that no patient (other than certain well defined exceptions) should receive chemotherapy if he or she was unable to walk into the clinic unaided, there being good data that such patients rarely benefit but often suffer adverse consequences.

Rationing is not necessary. We need to correct the dysfunctional delivery system so it can offer higher quality care at a reasonable cost. It is not impossible to do and no rationing is required.

Is rationing necessary to reduce health care costs?Stephen C. Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the US Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery, published by Potomac Books. 

Comments are moderated before they are published. Please read the comment policy.

  • cmac611

    Couldn’t agree more, however, I’d emphasize that patients need to take more responsibility for their behavior. The motivation for change on the delivery side is (and always will be) profit driven … motivation for the recipients of our broken health care system will only come when affordability becomes enough of a personal issue so as to change ones behavior. Unfortunately, ‘preventative’ by definition implies action before something bad happens. That does require knowledge and discipline … sorely lacking in today’s society.

  • cmac611

    Couldn’t agree more, however, I’d emphasize that patients need to take more responsibility for their behavior. The motivation for change on the delivery side is (and always will be) profit driven … motivation for the recipients of our broken health care system will only come when affordability becomes enough of a personal issue so as to change ones behavior. Unfortunately, ‘preventative’ by definition implies action before something bad happens. That does require knowledge and discipline … sorely lacking in today’s society.

  • amolutrankar

    What do you define as ‘rationing healthcare’? Isn’t creating a ‘top-five list’ a form of rationing in itself?

  • Amy Staples

    Healthcare is already being rationed — especially for dialysis patients. Medicare and most insurance companies refuse to pay for more than 3 treatments per week. How did they arrive at that particular number? They put patients on 1 treatment per week, they died. Two treatments per week, they all died. Three treatments per week, BINGO, they stayed alive. Dialysis patients receive the bare minimum to stay alive, but suffer from built up toxins in their systems from high phosphorus and calcium imbalances causing high PTH which then causes severe bone disease and calcium lined vessels. Heart disease is the number one killer of those on dialysis. Is it any wonder why so many dialysis patients die within the first year and the five year mark is almost unheard of? So, if you think rationed healthcare is in the future, think again. Rationed healthcare is here now.

    • http://profiles.google.com/andeevb Andee Bateman

      Rationing is fine if, as in the UK, you START at 3 runs a week, and they are increased based on your lab values. In home daily HD, for 60-90 minutes results in much better outcomes, yet in America it is the treatment of the uber wealthy, not the average citizen with ESRD. Its not a case of patient care driven protocol. In the case of HD, it was the profitization of healthcare in 1973, when Nixon and Kaiser closed the door and decided HMO’s were a great idea for profitizaiton, except for HD which would cut into the bottom line far too much. Welcome to ‘Merica, where corporations are people and patients are profitzed.

  • Doug Capra

    The question will always be who gets rationed. The poor will always get rationed. Those with diseases that cost a lot of money to treat will get rationed. Children and those with no economic or political clout, will always get rationed. Those with money will always find a way to get the treatment they need.

    • fixkid

      You mean those with money will always get the treatment they want – not necessarily the same as whet they need.

  • katerinahurd

    Do you think that rationing is compatable with a patient centered medical care? Do you think that ratioing is synonomous with futile medical interventions? Do you think that the concepts of longevity and quality of life are highly medicalized?

Most Popular