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Rationing: coming to a hospital near you!

January 2009

Published in the January 2009 issue of Today’s Hospitalist

AS A SLOGAN, “Health care rationing: Coming to a hospital near you!” is no election winner. I’m sure none of us was surprised that this issue wasn’t raised during the recent presidential campaign.

But given the fact that health care is not recession-proof, this little slogan would have at least been truthful. Because I am not currently running for office (nor plan to, ever), I can state for the record that it is high time we figure out how to ration health care intelligently.

I base this call to action on my opinion that given the growing economic constraints on health care delivery, inaction will itself result in rationing that is far less equitable and effective. And who better to lead this charge? You guessed it! Assuming that you are a hospitalist, the answer is (drum roll, please): you. Even if we hospitalists don’t invent this wheel, we’ll be asked to make it turn by way of a mandate that we will have to figure out how to follow.

Heading off unintentional rationing
But let’s back up for a minute and review a few points we all agree on. We already ration health care, both intentionally and unintentionally; the former, we for the most part we do well, and the latter not so well.

Intentional rationing occurs, for instance, every time we discuss with a family when and how to place limits on end-of-life care. According to a study in the Oct. 8, 2008, Journal of the American Medical Association (JAMA), failure to have these discussions results in “aggressive care [that] is associated with worse patient quality of life and worse bereavement adjustment.” Walk into any ICU today, and most reasonable clinicians would agree that close to 50% or more of the care being rendered there is futile and therefore would warrant end-of-life discussions.

Unintentional rationing, on the other hand, occurs when lack of insurance or inadequate coverage blocks access to treatment. Numerous studies summarized last September by the Kaiser Foundation spelled out how this unintentional rationing leads to increased mortality for uninsured kids and adults.

How to get there
So how can hospitalists coordinate the rationing of care for the greater good when ethicists and the like cannot come close to defining what “greater” and “good” even mean in a complex, heterogeneous culture like ours? First, we need to keep doing what we are doing. Clearly, we are a field that understands the concept of health care as a limited resource. And given that we are not procedure-based, we may have less of a financial incentive to overtax the system by over-treating patients.

Second, I believe we need to have our voices heard so we can begin to affect health care reform. How can we do this? I am not entirely sure, but I believe the Society of Hospital Medicine is doing a superb job representing hospitalists and hospitalized patients.

At the individual level, we are witnessing hospitalists ascend through the hospital ranks, something that will undoubtedly increase our collective input. And because I’ve got the microphone, I’ll take this opportunity to voice my own support for this sensible change: aligning reimbursement with evidence-based guidelines.

This is the same recommendation made recently by researchers and an editorial in the Oct. 15, 2008, JAMA. These authors, based on their examination of the disconnect between evidence-based indications for heart catheterizations and their execution, recommend that all procedures and treatments be reimbursed based on the strength of the evidence that supports said intervention.

A start on reform
This is a terrific proposition, as no profession, not even the medical profession, can be expected to consistently act to its own financial detriment, particularly in a health care culture in which doing more is often assumed to be doing better. Our profession’s tendency to over-treat is best understood when medical-legal considerations, patient expectations and the current economy are factored into the equation. Importantly, this equation must also include meaningful tort reform, if true progress is to be achieved.

The suggestions made in JAMA about catheterization demonstrate great promise for genuine, useful reform. What a concept: little evidence for an invasive procedure, minimal payment; lots of evidence for good preventive medicine or a life-saving procedure, fair reimbursement.

As examined in this issue’s cover story and elsewhere, the recession is adversely affecting health care. And aligning payment with evidence, even if that can be done fairly, is no panacea for a health care delivery system as complex as ours. However, I would argue that one potentially productive outcome of the recession for hospitalists and our patients is the fact that economic strife accelerates the need for reasoned, rational reform. The well is drying up, and health care is not a limitless reserve.

It is time to start spending our resources wisely so everyone can benefit equally from the compassion and dedication of this country’s health care providers. Hospitalists are uniquely positioned to drive this change, and the stakes “for our profession and our patients “could not be higher.

Erik DeLue, MD, MBA, is medical director of the hospitalist program at Virtua Memorial Hospital in Mt. Holly, N.J. Check out Dr. DeLue’s blog and others on the Today’s Hospitalist Web site.