Can We Say No? The Challenge of Rationing Health Care
http://www.100md.com
《新英格兰医药杂志》
More than 20 years ago, Henry Aaron and William Schwartz argued in The Painful Prescription: Rationing Hospital Care (Washington, D.C.: Brookings Institution Press, 1984) that the explosive rise in the cost of health care would eventually force the United States to find a way to ration care. By rationing, they meant saying no to care that benefited patients in cases in which that benefit was less than the cost. The past two decades have seen miraculous technical advances but little success in holding down costs, and the annual cost of U.S. health care is rapidly approaching $2 trillion. In this new study, Aaron and Schwartz again argue that medical spending will eventually have to be limited, and they look to Britain to see what sorts of tradeoffs and cultural changes rationing might require.
The book first describes the British health care system and shows how the rates of use in the United States and Britain differ for selected big-ticket diseases, procedures, and diagnostics. The National Health Service (NHS) provides about 80 percent of British health care, with general practitioners as the gatekeepers for specialist and hospital care. The main benefit of the small private sector is not higher quality but reduced waits for either visits with specialists or elective operations.
So how do the British manage to spend 60 percent less per capita than we do? Instead of our fragmented system with its enormous administrative costs and no effective ways to limit wasteful spending by insured patients, overall NHS spending is set by Parliament, with efficient allocation of resources as a policy goal. The gatekeepers use their authority as physicians to persuade a less demanding set of patients that aggressive treatment is not warranted. Deep support for the egalitarian NHS persists despite the stringent budget-constrained limits. Costs of inputs are lower: the average doctor in Britain makes less than half as much as the average doctor in the United States. Introduction of new therapies — especially those that require specialized equipment — is much slower. It is easier to tell patients that care is simply not available than to say they would not benefit enough from an available treatment for the NHS to provide it. Treatments such as dialysis, intensive care, and aggressive terminal care are generally much more limited than are such services in the United States; treatments with bigger potential gains of good health for patients are favored.
Ultimately, these comparisons are more interesting than helpful — we are not British, and in the end, when the authors discuss what rationed health care in the United States might look like, the British examples are left behind. Instead, they look directly at what would have to change for us to limit care of low value. Paradoxically, they suggest that enrolling the more than 40 million Americans with no health insurance would allow administrative constraints by insurers or the government to have more bite. In order to say no to care, we would need changes in the attitudes of both physicians and patients, as well as changes in medical ethics, malpractice law, and investment decisions. The consideration of whether and how such changes could occur is the most valuable part of the book.
Emmett Keeler, Ph.D.
RAND
Santa Monica, CA 90407(By Henry J. Aaron and Wil)
The book first describes the British health care system and shows how the rates of use in the United States and Britain differ for selected big-ticket diseases, procedures, and diagnostics. The National Health Service (NHS) provides about 80 percent of British health care, with general practitioners as the gatekeepers for specialist and hospital care. The main benefit of the small private sector is not higher quality but reduced waits for either visits with specialists or elective operations.
So how do the British manage to spend 60 percent less per capita than we do? Instead of our fragmented system with its enormous administrative costs and no effective ways to limit wasteful spending by insured patients, overall NHS spending is set by Parliament, with efficient allocation of resources as a policy goal. The gatekeepers use their authority as physicians to persuade a less demanding set of patients that aggressive treatment is not warranted. Deep support for the egalitarian NHS persists despite the stringent budget-constrained limits. Costs of inputs are lower: the average doctor in Britain makes less than half as much as the average doctor in the United States. Introduction of new therapies — especially those that require specialized equipment — is much slower. It is easier to tell patients that care is simply not available than to say they would not benefit enough from an available treatment for the NHS to provide it. Treatments such as dialysis, intensive care, and aggressive terminal care are generally much more limited than are such services in the United States; treatments with bigger potential gains of good health for patients are favored.
Ultimately, these comparisons are more interesting than helpful — we are not British, and in the end, when the authors discuss what rationed health care in the United States might look like, the British examples are left behind. Instead, they look directly at what would have to change for us to limit care of low value. Paradoxically, they suggest that enrolling the more than 40 million Americans with no health insurance would allow administrative constraints by insurers or the government to have more bite. In order to say no to care, we would need changes in the attitudes of both physicians and patients, as well as changes in medical ethics, malpractice law, and investment decisions. The consideration of whether and how such changes could occur is the most valuable part of the book.
Emmett Keeler, Ph.D.
RAND
Santa Monica, CA 90407(By Henry J. Aaron and Wil)