Can a just society ration healthcare?

The gross domestic product (GDP) of a country represents the dollar value of all goods and services produced by that country over a period of time, usually a year. One can think of the GDP as the size of the economy. In 2014, the United States’ GDP was about $17 trillion. And of that $17 trillion, some $2.7 trillion was spent on healthcare. Per person, we spend more on healthcare than any other country. One of the many reasons why we spend so much money on healthcare is that 33 cents of every dollar – close to $1 trillion a year – goes to waste. For example, doctors order tests that aren’t needed, patients are hospitalized when they could get better at home, medications are prescribed for conditions that don’t require them, and services are provided even when science tells us that they will not provide benefit. Short of arbitrarily deciding which services or medications will be covered, we need a system of cost containment that is both ethical and self-sustaining. One such method is called the “clinical effectiveness model.” This model is meant to make the practice of medicine more science-based so as to improve the success, efficiency, and value of healthcare. One might ask the question, isn’t that already being done? The answer is “yes,” but given that we waste about 33% of each healthcare dollar, we aren’t doing it too well.

What is “clinical effectiveness”? This is a system that uses the best available scientific information, the opinion of experts in a field, the experiences of patients, and lessons we learn when mistakes are made to guide the practice of medicine. This information is put together to evaluate the quality of medical care, and decide what works and what doesn’t. The authors of the “Clinical Effectiveness” model suggested that we identify what they call “thresholds of minimal effectiveness.” These are realistic goals that are based on a patient’s illness and treatments available for that illness. For example, we know that antibiotics effectively treat of most forms of pneumonia, as such we prescribe them. We also know that antibiotics are not effective against the common cold, as such clinicians shouldn’t prescribe them. It may seem that saving a few dollars on antibiotics would not amount to much, but that conclusion is wrong. In 2010 we spent about $1.1 billion on unnecessary antibiotics – not exactly pocket change.

What do we need to do to make this work? The model requires we all participate. In the short-term, funding for the model would come from taxes. We need to invest money to generate information regarding improved patient results while at the same time maximizing the value we obtain for every dollar we spend – a bigger bang for our buck. In the long run, savings generated by this model will pay for itself – think of the antibiotics example. The model requires sacrifices. Making decisions based on clinical effectiveness requires we accept that “doing everything” is not a way to practice medicine. We are not talking here about rationing healthcare based on cost. We are talking about rationing healthcare based on whether the treatments are effective or not. Finally, the model requires we accept uncertainty. Medicine is an inexact discipline. Although uncertainty in medicine cannot be completely eliminated, and we don’t have “silver bullet” treatments for every illness, science-based medicine can still be used to provide clinically effective care. In the title I asked “Can a just society ration healthcare?” The answer is “yes,” if we use clinical effectiveness as cost containment model.



Health Care Rationing in a Just Society: The Clinical Effectiveness Model.
Weisleder P
Semin Pediatr Neurol. 2015 Sep;22(3)


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