Sunday, October 10, 2010

Health Care Rationing and the Role of Physicians In Its Design

Writing in the October 6 issue of JAMA, RAND physician-scientist Robert Brook ponders how physicians will react to the certainty that current efforts at bending the cost curve will fail and "sooner or later, health care will need to be explicitly rationed." Examples of more local explicit rationing include Oregon Medicaid’s experiment with selective coverage and the use of tiered economic incentives by pharmacy benefit plans.

According to Dr. Brooke, all that remains is a decision on whether the national plan to ration will be led or not be led by physicians. After all, they’re not only generally knowledgeable about health care, but they're trusted by a majority of the U.S. public. Unfortunately, he notes, there is little research on just how U.S. physicians would install "explicit" rationing. Rather, docs seem to prefer using “implicit” and "microsystem" approaches, such as queues (“we can give you an appointment next Tuesday”), subjective priority setting (“that rash sounds worse than the headache”) and networked relationships (“Fred’s referring another patient and I gotta keep him happy").

Dr. Brooke also cautions that the current mix of single specialty organizations, practicing physicians' distrust of ivory tower policy making, physician vs. physician jockeying over the SGR and the one-at-a-time Hippocratic devotion to the "here and now" of each patient make it unlikely that the docs will be collectively able to drive change. The only thing that is buying them time – for now - is that the chances of Washington doing anything about this in the near future is about as likely as witnessing a dermatologist successfully figure out which end of a stethoscope goes on the patient.

While this isn't a pretty picture, the DMCB points out that Dr. Brooks' original premise - that there aren't "systemic" changes that could bend the curve - isn't necessarily correct. As a society, we’ve only just begun to appreciate the interlocking synergies of ACOs plus medical homes plus disease management plus shared decision making plus bundled payment plus value-based insurance designs plus wellness/prevention plus smartly regulated market-based competition. If the premise is that it’ll be up to the vast Washington DC blob-collective to show how it can’t execute on these policy-options, the DMCB agrees that diktat-style rationing will be inevitable.

Plus, there’s another premise of Dr. Brooke’s that isn’t quite correct. Check out this 2006 JAMA article by Dr. Gruen and colleagues that shows that physicians are paying lots of attention, but their focus is on the local community and public health issues such as obesity, poor nutrition, immunizations, substance abuse, and seat belts. What’s more, recall that physicians not only helped lead the way in defanging health maintenance organizations (HMOs) but the AMA’s umbrella organizations were a positive force in the successful passage of the Affordable Care Act.

Last but not least, physicians’ participation in Medicare is not mandatory. Call that BATNA, leverage or a "nuclear option," the fact is that once physicians become actively engaged, they are quite capable of wielding considerable leadership and influence. They may not have a single public service union president, a trade association president or a sympathetic cable news channel that Dr. Brook can point to, but the DMCB suspects that rationing, at this point, is only a possibility. What's more, thanks to their track record, the DMCB is confident that any Central Committee-style planning will be dead in the water unless the docs have a major hand in its configuration.

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