Last week, I discussed rationing health care, using the intensive care unit to illustrate what happens when you use "compelling need" to decide who receives care that is in limited supply.
However, other criteria can be used to determine who will receive a medical resource.
We could, for example, allocate medical resources in equal shares, giving six days in the ICU to every person. At the end of six days, it would be someone else's turn.
While this seems eminently fair on the surface, healthy young people require virtually no health services while many elderly or chronically ill patients require substantial care.
We could decide who gets a limited resource based on the person's effort or value. But why does this make a person more deserving of an ICU bed or an organ transplant?
Certainly, some people have more advantages in life than others (prestigious professions, good genes, wealth, a nurturing environment). Should we reward someone who tries very hard but fails or someone who succeeds easily because of greater natural ability?
Or we could allocate resources according to ability to pay. That, however, does not necessarily reflect value, effort or need. If we allocated resources based on ability to pay, it could create a bidding war.
Other types of rationing decisions don't involve choosing one patient over another. Instead, doctors are forced to make a decision on whether a person gets access to a particular test or procedure.
Say, a 38-year-old man has no high-risk factors for heart disease but asks his doctor to order a $1,200 imaging study. The doctor explains that it would be far more useful to increase exercise and improve diet.
The patient then demands to know why the doctor feels the need to ration care. After all, he paid for his health insurance, and now he just wants to use it.
The doctor, however, sees his responsibility as including helping to limit escalating health care costs and manage limited resources.
Would this man have asked for the $1,200 test if he had to pay for it out of pocket? In the world of medicine, this situation often invites those with insurance coverage (health, life, auto, etc.) to behave differently than they would if they have no insurance. We describe it as a moral hazard.
Malcolm Gladwell, in a New Yorker magazine essay, provides an analogy: This summer, your office decides to give everyone free Pepsi for a month. We would expect that the average consumption of Pepsi would increase. After all, it is free.
Similarly, if you drive a huge sport utility vehicle, you may not drive as carefully as you might in a Mini Cooper.
As Gladwell explains, health insurance can have the paradoxical effect of producing riskier behaviors and creating wasteful requests. This is part of the reason that nearly all health insurance now requires a co-payment, reminding us that health care has real costs.
Individuals make rationing decisions because of the co-payment. Doctors, hospitals and communities make rationing choices all the time. Yolo County just decided to lay off drug and mental health workers instead of other types of county workers. Sacramento County made huge cuts in health care for the poor while preserving other programs that had more vocal advocates.
There is only so much money, and money saved on one program can be directed to another program that has a higher priority to someone.
Health policy often results in rationing, and these policy can be direct, transparent and upfront or sneaky and disguised.
Medicare completely covers health costs for people with end-stage renal disease (regardless of their age, income or insurance) but doesn't cover any other disease this way – not heart disease, emphysema or schizophrenia.
Such inconsistency may seem arbitrary and even unfair. If aggressive care is important for people with kidney failure, why not also provide it for people with other diseases like cancer?
Ultimately, in any health care system that is financially viable there needs to be a system for rationing.
Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality. Reach him at drwilkes@sacbee.com.
