Let's get rational about health care 'rationing'

February 08, 2010|By John M. Freeman

Current medical practice is enormously expensive, often without clear long-term benefits. A few examples:

*End-of-life care at New York University averaged $105,000 per patient in the last two years of life, without evident improvement in mortality rates. Costs at other centers were nearly as high, also without evident benefits.

*Studies document that providing intensive care to infants born at 22-23 weeks resulted in more than 1,700 extra days in intensive care, with fewer than 20 percent of the infants surviving -- only 3 percent without profound impairment. Costs per day were approximately $3,400.

*New cancer drugs cost up to $100,000 for a single course of treatment and may prolong life only a few months. Among new treatments, monthly costs are $8,800 per month for Avastin; $10,000 per month for Erbitux; and $30,000 per month for Folotyn. Used only for late-stage cases, these drugs are taken only for a few months.

These cases and countless others raise an uncomfortable but necessary question: How much medical care can society afford?

As former Colorado Gov. Richard Lamm has written "everything we do prevents us from doing something else we also care about." What do we, as individuals or as a society, care about? Or rather, what should we care about? We all care about health care for ourselves. Many are in favor of universal health care. But we will not be able to continue our current coverage, let alone afford universal health coverage, without some constraints on costs and choice.

Among many reasons for the rising cost of care: Medicine and society overly respect the concept of autonomy and are reluctant ever to say "no" to requests for care from those who have health insurance. In recent debates about health care reform, potential constraints and choices were rarely discussed in a rational, non-alarmist fashion.

The failure to discuss the concept of constraint or rationing is all the more puzzling, because many things within the current system are already rationed. We ration care for all those without medical insurance, even though they tend to enter the system when their condition worsens and care becomes more expensive.

We ration preventive care. Some insurance policies permit only certain types of care for certain diseases, or permit the use of some treatments or medications but not others. Among other potential candidates for rationing: mammograms for women under 50, heart or liver transplants for some categories of patients, end-of-life-care for some and beginning-of-life-care for others. We are not talking about death panels or euthanasia but about sparing the comatose, intubated elderly and the most premature infants weeks and months of fruitless tests and procedures.

Americans demand the right to choose, but those choices must come with the responsibility to choose wisely. Oregon's plan of prioritizing diseases for treatment within a limited budget might be one approach, despite the fact that, for political and financial reasons, it was unsuccessful in containing costs. A thoughtful review of this plan emphasizes that "Health reform will never succeed if it doesn't ensure long-term affordability" and suggests that the Oregon Plan, even with its problems, affords a road map and a cautionary tale for the development of a national health plan.

Certain principles must be preserved in a system that limits choice. I suggest that universal health care be basic but cover only conditions and procedures necessary for health and productivity. Fringe benefits such as cosmetic surgeries and fertility treatments should be available but only paid for by the patient or by the patient's private insurance outside universal coverage. New medications and therapies should only be approved and covered when they have been shown to be superior and more cost effective than existing therapies.

The biggest immediate savings to any health plan, however, could come from a careful approach to curtailing care at the beginning and end of life, which account for disproportionate medical costs. One article noted that from 2001 to 2005, a national average of $46,412 per patient was spent on chronic illness in the last two years of life. Costs of end-of-life care vary greatly, with most of the money spent in acute inpatient settings. The volume of services provided, length of time in intensive care, number of specialists consulted and number of tests performed all influence costs -- without improving mortality rates.

"Having recently gone through this situation with my father," a friend confessed, "I can say from first-hand experience that we need badly a rational approach to these end-of-life decisions. Sustaining 'life' when there is absolutely no hope is not only wasteful and misguided, it's inhumane."

As we embark on a path leading to universal health insurance, as we must, we also must begin to discuss the constraints that must be applied on the care to be provided. We must "ration" health care and provide basic care to all that balances costs and benefits -- not only to the individual but also to society.

Rationing end-of-life care and elective procedures might be a place to begin, but we also need a public debate on prioritizing that care. Let the debate begin.

Dr. John M. Freeman is Lederer Professor of Pediatric Epilepsy (emeritus) of the Johns Hopkins Medical Institutions, and core faculty (emeritus) of the Phoebe Berman Bioethics Institute of The Johns Hopkins University. His e-mail is jfreeman@jhmi.edu.

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