Health-Care Rationing: Bring it On

We already have it, so let's do it intelligently.

Since the debate over health-care reform has brought the problem—and threat—of rationing to the fore, let's give a tip of the hat to Dr. Henry Friedman, professor of neuro-oncology and codirector of the brain-tumor center at Duke University Medical Center. That's where Ted Kennedy had last-ditch surgery last year after he was diagnosed with glioblastoma. In an article last Friday in The New York Times, Friedman spoke of the extraordinary and expensive measures the senator and his medical team took, including the surgery. "If you have the insurance to come to Duke, no problem," Friedman told the Times. And if you are uninsured, if your insurance does not cover such surgery, or if Duke is not in your plan's network, and you do not have a few tens of thousands of dollars to pay out of pocket, then "we will work with [your] home physician to give them our expertise," said Friedman.

Translation: you don't get to have brain-cancer surgery at Duke.

And that, my friends, is the rationing we have today: determined by insurance companies and ability to pay.

I don't mean to single out Duke. It is the rule, not the exception, that doctors and hospitals provide care based on ability to pay. Nor do I mean to imply that with health-care reform we will all be able to go to the top medical centers and get any treatment we want. The point is simply this: rationing is already here.

It is time, then, to move beyond the ignorant and duplicitous debate over rationing—"ignorant and duplicitous" because many of those opposed to the health-care-reform bills wending their way through Congress pretend that rationing is not happening in the current system or, to be charitable, are not aware that it is—to an examination of what I'll call "smart rationing." That is, let's figure out what treatments and diagnostic tests make a difference to people's health and longevity, and which are insanely overused to no good end. The latter is what we need to ration, restricting their use to the patients and conditions where they can make a difference or abandoning them altogether.

Needless to say, there is no obvious hit list. That's part of why comparative-effectiveness research is so necessary. But there are certainly hints of things we could do with a lot less of. How about the PSA test for prostate cancer? No major medical group, including the American Cancer Society, recommends regular prostate-cancer screening, including the PSA, for men at ordinary risk. This isn't just about saving money: the PSA test is so crude that it leads to significant overdiagnosis, "finding" cancers that are not there but subjecting men to biopsies and other interventions anyway.

How about imaging? The use of CT scans has exploded in the last decade, with more than 62 million scans done per year, according to a 2007 estimate by scientists at Columbia University. Again, unknown millions of those CT scans produce no improvement in outcome but come at a cost that is both financial and medical: they expose people to doses of radiation that can be 50 times what you get from a standard X-ray. Radiation increases the risk of cancer, so overuse of CT scans is hardly benign.

There is a raging debate about why CT and other scans are overused, and a new study in the open-access journal BMC Health Services Researchprovides some clues, at least in one European country where overuse is a problem much as it is in the U.S. For the study, Kristin Lysdahl and Bjørn Hofmann of the University of Oslo polled 374 radiologists for their views on the causes of the increasing use of radiological imaging. Their top five answers, in order: new radiological technology (my translation: "Ooh, a new toy, let's use it"); patients' increased demands for certain knowledge about their own health (to which I must add that patients seem to have no clue that CT scans do not necessarily tell a doctor anything they can't figure out by other means, or anything that will alter the course of treatment); physicians' lower tolerance for uncertainty (a.k.a. "Let's be sure we cover our backsides so we don't miss something and get sued"); expanded clinical indications for radiology; and increased availability of radiological equipment and personnel ("We have it, so let's use it"). Note that the list does not include "it improves patient care" as a reason for the increased use of CTs.

We have all been bombarded with stories about the near magic of CT scans and other new diagnostics, thanks to the media's fawning coverage of medical advances. (Which I am tempted to call medical "advances.") Information about what real difference such diagnostics can and cannot make? Not so much.

The list of overused medical treatments is as long as your arm, and in each case the consequences are felt not only in our collective wallet but in our health. Overuse of antibiotics? Not only does it breed resistant bacteria, but it can camouflage a deadly brain infection in children. How about giving patients beta-blockers in the hours right after a heart attack? Also useless, found a 2005 study, but commonly done. Spinal-fusion surgery? Arthroscopic surgery for osteoarthritis of the knee? Pointless, and pointless.

At the risk of being a broken record, as my mother used to say, we are already rationing, on the basis of ability to pay. How about we start rationing useless interventions right out of medical practice?

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