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Time for Physicians To Take the Lead in Health Care Rationing
by Peter A. Ubel, M.D.
Geriatric Times September/October 2003 Vol. IV Issue 5
In a perfect world, primary care physicians, such as geriatricians, would promote their patients' best interests without regard to financial costs. But this is not a perfect world. Resources are finite, forcing physicians to make difficult decisions about what services to offer their patients.
As a primary care physician, I am forced to set priorities every time I see a patient. Should I do a complete physical on this patient or a focused physical? Should I take time to ask about smoking habits, recent sexual behaviors, whether they are wearing seat belts regularly, what kind of exercise they have done lately? Should I spend time screening for anxiety, depression or spousal abuse? Should I order some screening blood tests to check for hypercalcemia, hyper- or hypothyroidism, or occult anemia? Or, should I spend my time doing a thorough review of systems to see if they are forgetting to mention any important bladder problems that might be developing?
I am repeatedly amazed to discover that many intelligent people still believe health care rationing is unnecessary. Of course, if rationing refers only to heinous acts by managed care organizations to withhold necessary therapies from their patients, then I am all in favor of avoiding such rationing. But if "rationing" refers to letting patients go without the best possible medical care (a much more plausible definition in my view), then I would contend that rationing always has and always will be a part of medicine.
Physicians have always been forced to decide how much time to spend with the patients in their exam rooms versus the patients in their waiting room (versus their families, even). Government officials have historically had to make health care rationing decisions, too--such as deciding how many ambulances to provide for their citizens. If health care rationing was really to be avoided at all costs, we would have a nearly infinite supply of ambulances. And most people would be able to call upon their own personal physical therapist whenever their low back pain kicked in. Practicing medicine and making health care policy have always required tough decisions about how much health care to make available to whom and how much of society's resources should be directed to health care versus other important social goals.
I am less amazed by (but equally opposed to) another common view held by many intelligent people--that if health care rationing is inevitable, then physicians "at the bedside" should not be the ones making the rationing decisions. According to this view, patients need to know that their physicians are pursuing their best interests without regard to anyone else's pocketbook; instead, rationing should be done at higher levels, by practice guidelines, formulary committees, utilization reviewers and the like.
One problem with this view is that things like practice guidelines do not relieve physicians of the need to make rationing decisions. For example, I was teaching medical residents recently about the cost-effectiveness of Pap smears. In low-risk women, annual Pap smears cost almost $1 million to save one year of life, because most of the benefits of Pap smear screening would still be gained by testing these women every three years. The residents said that this cost-effectiveness information should not influence physicians' decisions, because physicians should pay attention to what is best for their patients. They added that if the American Cancer Society or other organizations recommend Pap smears every three years in low-risk women, then physicians should follow that recommendation.
"But," I responded, "if you really have a moral duty to do what is best for your patients, then you should ignore the American Cancer Society guideline and test women annually." Physicians are kidding themselves if they think that following practice guidelines means that they have not rationed care at the bedside. As geriatricians are well aware, some cancer-screening guidelines set an upper age limit on when to screen patients. These guidelines implicitly recognize that screening is less cost-effective in elderly patients. The guidelines, therefore, encourage bedside rationing by physicians.
I also think that some amount of bedside rationing is necessary, because leaving all rationing decisions up to higher-level organizations would be a disaster. Any rationing rule--whether it be a formulary committee decision about an expensive drug or a utilization review decision to limit psychiatry visits for patients with depression--is an imprecise way of making medical decisions.
Suppose it was true, on average, that 10 psychotherapy sessions are adequate for most patients with moderate depression. Some patients would still need more therapy than this. For any rationing rule to work, there has to be enough inherent flexibility so that physicians can treat each patient appropriately. Once such flexibility is put into play, physicians who are determined to get their patients the best possible care without any regard to financial cost will ignore the rule, and higher level rationing rules will have to get even stricter.
By saying physicians ought to make rationing decisions, I am not suggesting that physicians should withhold necessary services from their patients. Instead, I am urging physicians to look for ways to trim benefits at the margin. For example, an experienced oncologist once told me that he did not have the time to check between all his patients' toes to see if they had melanomas. This is an example of a justifiable rationing decision. Physicians make rationing decisions like this all the time, and many know when not to make them. Indeed, my wife, a redhead with a family history of melanoma, should and does have her toes examined every year. But physicians need to be more aggressive in trimming marginally beneficial health care services if there is to be any hope of controlling medical inflation without transferring rationing authority to higher levels.
I am nervous about health care rationing, in general, and about bedside rationing, specifically. I worry that rationing will be done haphazardly or, even worse, in a biased manner. I fear that physicians will have longer visits with attractive, personable patients and shorter ones with unattractive, ornery ones. And I recognize that assertive patients are going to find ways to get themselves a larger slice of the health care pie than nonassertive patients.
But I am even more nervous about a health care system that discourages physicians from rationing at the bedside and, instead, leaves all rationing up to higher levels. Although we need formulary committees to make tough decisions about which medicines to add to the formulary, we also need to make sure that formulary committee decisions are flexible. Where I practice, for example, there is an appeals process through which most of us can get nonformulary medications for our patients. If, however, physicians were convinced that they need to pursue their patients' best interests regardless of cost, then the number of nonformulary drug requests would skyrocket and, pretty soon, the pharmacy would have to find a way to refuse our requests. Thus, the best way to ration is to have high-level groups make guidelines or, occasionally, rules, but in all cases make sure that these guidelines and rules are flexible. At the same time, physicians treating individual patients need to recognize that they cannot do everything for their patients, but must set reasonable limits on the care that they provide and be prepared to go to bat when patients are in dire need of important medical services.
Dr. Ubel is a general internist and bioethicist who has written extensively on health care rationing. He is author of Pricing Life: Why It's Time for Health Care Rationing from MIT Press.
