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For Doctors, Rationing Care Is Standard Practice

By Manoj K. Jain
Special to The Washington Post
Tuesday, August 4, 2009

A seasoned pulmonologist shakes his head. "Let's face it, we already ration care." And, pausing ever so slightly, he begins his story. "This family of an 80-year-old gentleman came to me a few days after he was admitted into the ICU. He had end-stage emphysema. 'We had a family conference last night,' they told me, 'and we have decided that we want our father to have a lung transplant.' " The doctor shakes his head again. "They were dead serious," he says. "I took them aside and tried to explain the situation: He is 80 years old and a smoker. He can't get a lung transplant."

Organs are a precious commodity, their donation strictly regulated by national guidelines. About 100,000 patients are on the waiting list for a transplant at any given time, and last year about 6,700 died while waiting. Some 28,000 were fortunate enough to receive an organ in 2008; the rest simply remained on the list. Because donors are scarce, it seems appropriate to ration their organs on the basis of need and other ethical and medical considerations.

This spring, a few weeks after arriving in Boston from a vacation in India, my mother complains of itching. At first, it is a "sweet" itch, relieved by a scratch, but over days she scratches to the point that there is blood on her fingernails. Initial blood tests are unrevealing, and the earliest appointment she can get to see a dermatologist is 26 days later.

My mother was fortunate. A 2009 survey by Merritt Hawkins & Associates, a Texas-based physician-recruiting firm, showed that in major cities the average waiting time ranges from 11 to 50 days -- it's 23 days in Washington. Are we not rationing care, just like the Canadians and the British, with long wait times?

A patient at my clinic doubles over in pain. I order a CT scan of the abdomen, but the insurance company will not approve it right away. I haggle. Is the insurance company not rationing care?

As a second-year resident with only one bed available in my intensive care unit one winter night years ago, I had to decide whom I would admit: a 30-something woman with fever, rigors -- which is the shaking brought on by high fever -- and a dropping blood pressure because of a urinary-tract infection, or a nursing-home patient who was demented with shortness of breath that was worsening.

The unspoken truth among doctors is that we objectively or subjectively ration care, and often don't tell patients or their families.

Last fall, a patient of mine on a successful HIV treatment regimen came to the clinic with a wrinkled white paper bag full of medicine bottles. He displayed the contents like Halloween candy: the blue pill, the round pill, the big pill and others, and asked me to decide which five drugs he should take. "Doc," he said sadly, "that's all Medicaid will pay for." We ration care due to limited state funds.

This summer the health-care debate has heated up in Washington. Over lunch, the former chief executive of the Mayo Clinic says to me, "We ration health care 47 million times each day." That's the approximate number of uninsured Americans, and every uninsured patient is an admission by society that we don't commit the money to provide care to people.

In its broad definition, rationing is the allocation and prioritization of scarce resources. It is one of the strategies for cost containment. The paradox of rationing is that it seems fair, just and equitable, and it makes sense when applied to a population. But when it applies to my patient or my mother, it makes me uncomfortable. That said, rationing is necessary and inevitable.

True, the word "rationing" brings memories of gas-station lines in the 1970s. President Obama tries to distance himself from the word, while his Republican opponents try to evoke it in the public's mind when they talk about his reform plan. So rationing has become a dirty word, and I believe it is best to drop it from the debate.

To put it more neutrally, we allocate health care based on patient need and the available resources. The supply of organs is limited by the number of donors, but the supply of drugs, beds and doctors depends on the choices we make as a society about how much we want to spend on each person. My wife is visibly upset by this thought: "You can't put a price on a person." "Sadly," I answer, "though MasterCard would have us believe it, we are not priceless." In fact, when the benefits of a drug or a device are being evaluated, economists commonly agree that $50,000 is a reasonable cost for adding one year of quality life to a patient. To me this seems a good figure.

A deeper question for health care in America is how to best allocate limited financial resources. This requires us to be cost-effective and to be clear about who decides what is allocated.

Take the case of the artificial heart machine, or LVAD (left ventricular assist device). Many of my patients have had an LVAD implanted, at a cost of $200,000 the first year, a figure that includes continuing care. The LVAD keeps dying patients alive. It serves as a bridge, until they receive a heart transplant. It is also being used as destination therapy, which is to say that, just as a dialysis machine replaces a kidney, the LVAD replaces a heart.

Some 400,000 people develop heart failure each year. Nearly 200,000 will die within a year but can be kept alive a little longer with an LVAD. Should we put an LVAD in each one of these patients -- at a cost of $40 billion?

The cardiac surgeon at our hospital who installs the LVADs in the chest wall says, "Don't put me in the middle. Don't make me decide who does or doesn't get a heart transplant or LVAD. Create policies and criteria, and I will follow." Patients, too, don't want their doctor to be their gatekeeper; rather, they want their doctor to be their advocate.

In ways, we need a national independent institution that will look at cost-effective and cost-efficient treatments and procedures and decide what to pay for. A practical experience of allocation of resources will come this fall, when the influenza H1N1 virus -- otherwise known as swine flu -- comes out in full swing. If the demand for the vaccine exceeds the supply, we will have to allot and prioritize, as we decide who will receive the first 100 million doses available for the first mid-October round of vaccinations.

That is rationing, but we are better off calling it "appropriate allocation of resources."

Manoj Jain is an infectious-disease specialist in Memphis, and an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. Comments: health@washpost.com.

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