The belief that we need rationing is driven by two interlinked
assumptions: 1)
demand is insatiable; and 2) more treatment is better. Both of these are
probably wrong.
The trouble with these assumptions is that they are plausible enough
that
they are accepted as axioms and never questioned. Sure, the population of
western countries is getting older so demand is bound to increase; sure
there
are plenty of people waiting for treatment, so we could make things better
by
providing more.
But there is surprising evidence that both are just wrong. Worse they
are
directing policy makers to focus on the wrong problems.
The best evidence that undermines the myths is from Wennberg's work
on
The Dartmouth Atlas of Healthcare (www.dartmouthatlas.org). The project
uses the
highly variable rates of spend on Medicare in different states in the USA
to
ask what more spending achieves. While there are some areas (mostly about
prevention and primary care) where many areas under-treat their
populations, the dominant pattern is of over-treatment. The Dartmouth work
convincingly demonstrates that high-spending states get nothing for their
extra spending except more activity. In some cases outcomes are worse as
the side effects of excessive treatment dominate any potential benefits.
Outcomes for patients are no worse in frugal states.
What seems to drive the activity in the USA is not the needs of
patients but
the capacity of providers. Wennberg's term is "provider driven demand".
And
it is this, not the real healthcare needs of patients that is pushing up
activity
and budgets.
In fact, once we acknowledge that more is not better we undermine the
first
myth as well. At the very least we should investigate whether budgetary
and
activity inflation is driven by patient need or by provider need.
It could be argued that the USA is a uniquely bad example. As far as
I know
there have been few definitive attempts to replicate something like the
Dartmouth atlas work in other economies. But some preliminary analysis I
conduced suggests that even the UK (historically centrally planned which
in
theory should offer some counter weight to the power of the provider
lobby)
suffers from similar patterns of provider-driven demand (at least if we
use
hospital beds as a proxy for provider capacity).
The two biggest problems, i believe are not about rationing as such
but about
curbing the power of providers. We need to stop over-treatment, because it
is bad for patients. And we need to curb their power over prices
(especially in
the USA, but to some extent everywhere else). There is plenty of scope for
both and the extent of the gains are such that we should be able to
postpone
severe rationing in the foreseeable future. Consistent clinical thresholds
for
treatment can curb volume growth and improvements in provider efficiency
can curb cost inflation.
We don't have to accept the myths; more isn't always better: an apple
every 8
hours won't keep three doctors away.
Rapid Response:
Do we need rationing?
The belief that we need rationing is driven by two interlinked
assumptions: 1)
demand is insatiable; and 2) more treatment is better. Both of these are
probably wrong.
The trouble with these assumptions is that they are plausible enough
that
they are accepted as axioms and never questioned. Sure, the population of
western countries is getting older so demand is bound to increase; sure
there
are plenty of people waiting for treatment, so we could make things better
by
providing more.
But there is surprising evidence that both are just wrong. Worse they
are
directing policy makers to focus on the wrong problems.
The best evidence that undermines the myths is from Wennberg's work
on
The Dartmouth Atlas of Healthcare (www.dartmouthatlas.org). The project
uses the
highly variable rates of spend on Medicare in different states in the USA
to
ask what more spending achieves. While there are some areas (mostly about
prevention and primary care) where many areas under-treat their
populations, the dominant pattern is of over-treatment. The Dartmouth work
convincingly demonstrates that high-spending states get nothing for their
extra spending except more activity. In some cases outcomes are worse as
the side effects of excessive treatment dominate any potential benefits.
Outcomes for patients are no worse in frugal states.
What seems to drive the activity in the USA is not the needs of
patients but
the capacity of providers. Wennberg's term is "provider driven demand".
And
it is this, not the real healthcare needs of patients that is pushing up
activity
and budgets.
In fact, once we acknowledge that more is not better we undermine the
first
myth as well. At the very least we should investigate whether budgetary
and
activity inflation is driven by patient need or by provider need.
It could be argued that the USA is a uniquely bad example. As far as
I know
there have been few definitive attempts to replicate something like the
Dartmouth atlas work in other economies. But some preliminary analysis I
conduced suggests that even the UK (historically centrally planned which
in
theory should offer some counter weight to the power of the provider
lobby)
suffers from similar patterns of provider-driven demand (at least if we
use
hospital beds as a proxy for provider capacity).
The two biggest problems, i believe are not about rationing as such
but about
curbing the power of providers. We need to stop over-treatment, because it
is bad for patients. And we need to curb their power over prices
(especially in
the USA, but to some extent everywhere else). There is plenty of scope for
both and the extent of the gains are such that we should be able to
postpone
severe rationing in the foreseeable future. Consistent clinical thresholds
for
treatment can curb volume growth and improvements in provider efficiency
can curb cost inflation.
We don't have to accept the myths; more isn't always better: an apple
every 8
hours won't keep three doctors away.
Competing interests:
None declared
Competing interests: No competing interests