Tuesday, November 23, 2010

The "R" word

There is a terrific two-page commentary titled "The Real Meaning of Rationing" in this week's issue of the Journal of the American Medical Association by Drs. David Meltzer and Allan Detsky. They point out that the price disconnect caused by health insurance leads insurers to attempt to allocate health "goods and services" based on actual need or effectiveness rather than the patient's desires. Of course, in contrast to the example of wartime rationing, any person who is able and willing to pay full price for an uncovered health service can typically receive it - be it a full-body CT scan, an "executive" physical, or an anti-cancer drug.

Because many Americans are deeply suspicious of the motives of government and health insurance companies, they tend to react negatively to perceived actions by "bureaucrats" to limit coverage for services, whatever the reason. "For example," the authors write, "the challenges of rational discussion of health care reform in the United States can be illustrated by typing the words 'mammography' and 'rationing' into a Google search." Noting that "deeply vested interests" often act to inflame the debate, they add:

What is needed is intelligent discourse on what approaches to rationing work best and what values Americans most wish to express as a nation to address this problem. ... Concerns about "death panels" and debates about rationing make better press than balanced discussions of who should or should not receive a mammogram, or the effects of co-payments on appropriate and inappropriate emergency department use. It is critical that Americans learn that rationing currently exists and is inevitable and focus their thinking on how its vagaries are best minimized, rather than use the word to instill fear.

I agree completely, though I wonder who will be the ones to teach ordinary citizens not to be afraid of the "R" word. Certainly not politicians, or disease advocacy groups, or for the most part, our most respected physicians and scientists. After all, as Josh Freeman noted today on his Medicine and Social Justice blog, the $250 million price tag for the National Cancer Institute's recently concluded lung cancer screening study would have paid for the entire 2008 budget of the Agency for Healthcare Research and Quality or the 2010 primary care workforce programs of the Health Resources and Services Administration. Instead, a year or two from now, when the U.S. Preventive Services Task Force examines the evidence on lung cancer screening, there will probably be lots of powerful, politically-connected groups urging them to give an "A" or "B" level recommendation to CT scans for smokers so that this service will automatically receive first-dollar coverage under the prevention provisions of the Affordable Care Act. And the "R" word will once again rear its ugly head.