Thursday, August 20, 2009

Rationing of Care

This is an editorial that I just published in the latest issue of PA Professional, as many of you likely do not GET that journal, I thought I would also post here.

Rationing of care, yep, it’s a scary term I know. Yet, while it’s an emotionally charged and difficult topic to discuss, it remains one of the most complex and pressing issues for a society heading rapidly towards health reform.
We ration care now. However, now it’s rationed simply on a financial basis, i.e. those who cannot afford insurance, and do not qualify for state assistance have little in the way of options for chronic medical treatment. Even those with Medicare and Medicaid can sometimes find it difficult to obtain appointments or a provider, as many do not accept those insurance plans.
I have had my more conservative friends tell me, that those without insurance can simply obtain care “in the ER”. Sadly, this observation plays itself out in reality more times than not. However, the care that is provided in the emergency department (ED) setting should, in no way, be compared to the comprehensive care, and management that an experienced and competent primary care provider could provide for chronic disease management.
I discuss health policy on a daily basis, and one of the frequent things that I try to tell people is that, discussing health care reform without discussing how to provide care for an increased number of people, while lowering costs at the same time, and not discussing rationing, is ignoring the 800 pound gorilla sitting in the corner of the room. It’s a difficult discussion because – unlike our European counterparts – there are cultural forces at work in the United States.
Many patients have a rather defiant attitude towards death. This is problematic when we realize that the majority of patient health care expenditures occur in the last months of life. For example, Taxol is used in the United Kingdom in the treatment of ovarian neoplasms, but it’s often withheld in advanced ovarian cancer. Elderly patients, who have multiple co-morbidities and develop conditions like renal failure, may not be eligible for services like dialysis. Their system has decided that the cost/benefit ratio is simply not acceptable.
Other industrialized countries, with more governmental control of health care, use similar methods to ration care. Now, ask yourself how you would feel if it were your loved one? Does that change your response? These are important questions, and I am not going to pretend to know the answers, but this is a necessary discussion, and there is a definite fiscal reality that we as a nation, are going to have to confront.
As provider’s, we all have the ability to influence the health care reform debate to some degree, and if we want to have any sort of real honest discussion about health reform, or universal coverage, we need to first be honest with ourselves, because it’s still the 800 pound gorilla, sitting there in the corner, staring at you.

For those interested, it is in Vol. 1, No. 2 of the PA Professional.

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