Viewpoint

Is It Time to Embrace Rationing of Care?

FROM THE CHIEF MEDICAL EDITOR
Larry E. Patterson, MD

“The decision is not whether or not we will ration care; the decision is whether we will ration with our eyes open.”

—Donald M. Berwick, MD
Obama appointee for Administrator of the Centers for Medicare and Medicaid Services

I think most intelligent people, which obviously includes the three of you who read my column every month (a special thanks to Mom and Dad for boosting my numbers), realize there actually is a limit to how much medical care can be provided to any society. A colleague of mine told me 22 years ago that people want their medical care free, they want painless perfection and they want it now. We know that having all that simultaneously is increasingly unlikely.

So I come to the conclusion that we will see open rationing of care in the future, in some form, whether we like it or not. To a certain extent, we already see it — those individuals who have limited or no insurance often self-ration by simply avoiding or delaying medical care.

Which brings me to my own small experiment with rationing.

For years, I've been able to provide all my cataract surgery patients the same high level of pharmacological care. They all got the latest-generation antibiotics, the very best brand-name steroid as far as corneal penetration is concerned and also a brand-name nonsteroidal anti-inflammatory agent that wouldn't melt their cornea. I usually obtained enough samples here and there to help out those who couldn't afford the good stuff.

My friend and the previous medical editor to this publication, Paul Koch, has eloquently written about the dilemma of the rising costs of ophthalmic drugs. It's finally hit the fan here with me. Drug companies are no longer providing samples at the rate they used to (not that I can blame them), insurance companies are balking at paying for the better drugs and more and more of my patients are coming in with no insurance or Medicaid, which severely limits our choices.

So I've started my own rationing program. People who can afford it get the good stuff. The rest are given the option, but will likely get older drugs and/or generics. It's a simple two-tier system, and I'll be the first to admit it feels unfair. But I don't know what else to do. I could make it more simple — and more equitable — by giving everyone the generics, but I do believe that the newer drugs really are better. How much better? I don't know. But if I were having surgery, I know I 'd like the best stuff available.

Don't get me wrong. While this is a form of rationing, it's not like deciding whether or not a 75-year-old gets a life-saving heart transplant.

Still, it concerns me. I'd like to hear your ideas. Please write to me with your thoughts (larryp@ecotn.com). How are you handling this problem? Is my rationing plan the way to go? Do I really have any other choice?