Friday, December 13, 2013

Fwd: qotd: Alan Maynard on rationing in public and private health care systems

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Subject: qotd: Alan Maynard on rationing in public and private health
care systems
Date: Fri, 13 Dec 2013 14:30:12 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

Journal of Health Politics, Policy and Law
December 2013
Health Care Rationing: Doing It Better in Public and Private Health Care
By Alan Maynard


All public and private health care systems ration patient access to
care. The private sector rations access to consumers who are willing and
able to pay. The poor and disadvantaged have limited access to care and
inadequate income protection. In public health systems, care is provided
on the basis of "need," that is, the comparative cost-effectiveness of
competing treatments. This results in patients being deprived of care if
treatments are clinically effective but not cost-effective. Rationing
health care is ubiquitous. In both types of systems physicians have
discretion to deviate from these rationing principles. This has created
inefficient variations in clinical practice. These are difficult to
resolve because of the lack of transparency of costs and patient
outcomes and perverse incentives. The failure to remove universal
inefficiency in a period of economic austerity sharpens awareness of
rationing. Hopes of greater efficiency are largely faith based.
Competing ideologues from the left and the right continue to offer
evidence for free solutions to long-established problems. Inefficiency
is unethical, as it deprives potential patients of care from which they
could benefit. Reducing inefficiency is essential but difficult. The
universal challenge is to decide who shall live when all will die in a
world of scarce resources.

From the Overview

In all countries there is a reluctance to use the word "rationing."
Policy makers and politicians prefer terms such as "prioritization" and
"resource allocation." Call it what you will, rationing in health care
is ubiquitous in public and private health care systems. The latter
ration by consumers' ability to pay, and "success" is related to
physicians and other providers making a good living. Public health care
systems, in principle, ration in relation to need or comparative
cost-effectiveness; in practice, prioritization is determined by
physicians' providing treatments that most satisfy the physicians.

Productivity variations exist throughout the manufacturing and service
industries. Indeed, these variations drive innovators to act smarter and
capture market share from rivals. Public and private health care markets
are remarkable in that innovation tends to increase costs rather than
reduce them, as has happened in information technology and other
industries. The causes of this difference are debated and include the
power of the medical profession (physicians' monopoly of many areas of
activity where efficient substitutes exist), third-party pays (weak
budget caps), and perverse incentives confronting providers and
consumers (moral hazard). Mitigating problems such as these could ease
rationing constraints but would not remove them.

The failure of health care systems to measure and manage these problems
with greater transparency and improved incentive structures will result
in rationing becoming more explicit. The hope is that the consequent
debate about who will die and who will live in what degree of pain and
discomfort will not be dominated only by emotion (e.g., hysteria about
"death panels") but by evidence of cost-effectiveness produced by robust
HTA programs (health technology assessment) and the transparent
judgments of clinicians using this information. The policy priority, as
efficient HTA and P4P (pay for performance) schemes increasingly
influence rationing choices, will be to ensure that this is seen by the
public as improving patient safety and value for money for insurers and
taxpayers, and not merely seen as depriving patients of care from which
they might benefit marginally but which societies choose not to fund,
either by NHS rationing or US rationing by restrictive benefit packages
and poor access.

Comment: "All public and private health care systems ration patient
access to care." Professor Alan Maynard of the University of York, with
his characteristic academic objectivity, describes the differences in
public and private approaches to health care rationing.

Public health care systems ration access in relation to medical need,
whereas private systems ration access based on willingness and ability
to pay. In public systems, success is measured by the satisfaction of
physicians with their ability to meet the medical needs of their
patients, whereas in private systems, success is measured by the ability
of physicians to make a good living.

Both public and private systems experience inefficiency. Since the
rationing that results from inefficiency deprives some patients of care
that they should have, tolerating inefficiency is unethical. When you
compare the public British system with the largely private system in the
United States, it is clear that our much greater inefficiency results in
an insufferable level of ethical compromise. We do ration far more than
the British; we just don't see it since our victims of rationing are not
even allowed a position in the queue.

Why do we tolerate this? A clue might be found in Alan Maynard's words
in "The Public-Private Mix for Health" (The Nuffield Trust, 2005):

"As societies spend increasing proportions of their rising GDP on
healthcare, more realism about its productivity in terms of improving
the health of the population is needed. But this is not in the interest
of the media, politicians and commerce. Promising miracles increases
their income and power!"

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