Letters to the Editor

Rationing vs. Free Market? Readers Debate

I read with interest, and then concern, your article "Is it time to embrace rationing of care?" in the August issue. Although you opened with a tellingly prescient quote from Donald Berwick, MD, which told us all that he, as head of CMS, intends to ration health care, you discussed the choice of antibiotics for your patients. It appears to me that you have confused "rationing" with "free-market choice"—two diametrically opposed concepts.

Rationing classically means the controlled distribution of scarce goods and/or services. However, rationing as Berwick has more likely referred to it is controlled distribution for purposes of equalization — a way of "spreading the wealth around" medically. Motive aside, the key is controlled distribution.

You, however, discussed generic vs. latest-generation brand name drugs. These goods are not scarce, their prices are free-market driven and their distribution is not controlled.

Your patients select what they want based on economically driven free choice — all the time, every day. The insurance companies do the same thing when they choose to only cover the low-cost item. It's not that your patients can't have the more expensive drug (controlled distribution), it's that they probably choose not to pay for it (free market choice). Furthermore, those same patients have probably chosen to purchase a less expensive insurance plan with limited drug coverage instead of one which had a more generous drug benefit. Indeed, some patients may have chosen not to purchase insurance altogether.

People do this all the time. When we buy tires for our car, we have several price options to choose from. At the grocery store, we can buy what we want. Just because we don't buy the most expensive thing available doesn't mean we were rationed; we exercised free market choice. Our patients may choose not to pay for premium IOLs and opt for the "standard" implant instead. You are not "rationing" them; patients are freely choosing.

Rationing is the opposite. During WWII, one couldn't buy as much sugar, gas, rubber tires or penicillin as one wanted. The government limited what someone could have.

Don't be concerned about what people choose in the free market — be concerned about a government that sees controlled distribution as a tool for social engineering.

Stephen H. Johnson, MD
Newport Beach, Calif.

■ Rationing is a subject that only an MD/MBA could love. It is interesting that in no other industry would ration ing be considered.

Rationing is a failure of imagination and intellect. Every industry outside of medicine addresses limited resources with improvements in productivity and innovation. Those who state that business solutions do not apply in medicine refuse to accept that medicine is a service. I believe that medicine would embrace change if allowed. I have used my office as a laboratory and have proved that change can create value. Yes, there is an alternative.

Mark H. Nelson, MD, MBA
Winston-Salem, NC

■ I think you have misstated the question. We already have rationing. Always have. Everything that has greater demand than supply is rationed in some manner. Patients already must get "prior authorization" before getting certain tests or medications. That is rationing by the insurance plan. It is loosely based on ability to pay. I think you meant to say, "Should we now allow rationing by the government?"

The answer is no, hell no! At least with insurance rationing, there is some tie to money paid into the system through insurance premiums. It is not nearly enough of a connection, but it is still present. When government rations, the situation becomes intolerable because of the complete disconnect between the supply and demand.

What if we apply your example to cars? Is it "unfair" that everybody cannot afford a Mercedes? Do we force everyone to drive a Yugo because it is a cheaper alternative? All would agree that Mercedes and other cars need to be rationed by ability to pay.

What is so special about medical care? It is a commodity like all others. Some have framed the argument that medical care can't be treated as such because it is a necessity. But food, clothing and shelter are far more important than medical care, yet no one is speaking of universal food coverage, universal clothing insurance, and so on.

Medical care is being used as a tool for gaining power and control. Should we embrace rationing? In a marketdriven system, of course. But by government employee, I hope never.

Dan Eisenberg, MD
Las Vegas

■ I just read your Viewpoint concerning rationing. I have been doing the same thing that you wrote about in your column. I joke with my patients by saying that we used to greet them by asking, "How are you?" but now we have to ask, "What is your insurance?"

We also ask if they have a prescription plan. If they do, I write for the "good stuff" and if they do not, I write for the generic "equivalent." For those who need the brand name, I will try to obtain samples. Actually, I do hoard some samples in anticipation of these patients. In this sense, unfortunately, we are rationing, as you say.

I also like the definition of generic. Officially, it means the drug contains the same "active ingredients." My own definition states that it is either more than 17 or 20 years old, depending on when the patent has lapsed. Consider going to a ski slope and finding that it has rained. Would that be considered "generic snow" and would that be equivalent to your expectations?

David S.C. Pao, MD
Southampton, Pa.

■ I agree completely that medication costs and our inability to get samples lead to difficult decisions. Gauging the added clinical benefit of branded drugs over generics is a challenge. I'd like to share my experiences, after building two ASCs and tracking our numbers very closely.

In over 25,000 cataract surgeries performed, I have had zero endophthalmitis cases. I have switched drops frequently over the years and found no difference if endoph thal mitis is the endpoint. The conventional wisdom is to use the most powerful drop for prophylaxis with cataract surgery, but our general surgery colleagues don't use the most powerful IV antibiotics for prophylaxis; rather, they reserve them for when there truly is an infection — and they get a lot more infections than we do.

I am finding my patients' insurance companies are denying a huge number of branded drops, so the patient gets what is covered under their plan. Thus far it has not impacted my infection rate, although newer products do offer advantages such as dosing convenience and improved ocular comfort that patients may appreciate.

Regarding anti-inflammatories, I have used generic prednisolone my entire career. For me, it is standard except when we use samples of newer medications. For NSAID use, I do feel the branded drops are worth prescribing after cataract extraction. I moved away from generic flurbiprofen due to corneal decompensation reports and went to Acular LS, but I have never personally seen a corneal melt. I also moved to BID dosing of NSAIDs because of convenience, but our postop CME rate has stayed the same regardless of which drop we use.

Being nine years into my career, you could say that we should have seen my CME rates drop as skills improved in my first few years and the drops improved as well. Instead, my CME has been stable at under 1%.

My practice is conducting a study of generic drops in which we don't control the medications our patients receive; we let their insurance or lack thereof decide. We will then compare clinical outcomes (visual acuity, CME, endophthalmitis and subjective reports of comfort/dryness) between the two.

I do feel that NSAIDs dosed BID help with comfort vs. QID dosing. But is a little less irritation from drops worth the extra cost for patients? Or should we give cheaper NSAIDs and then discontinue or switch to BID dosing if we discover irritation or dry eye? We as clinicians need to answer thorny questions such as these.

These challenges are magnified when you also include surgical costs in the analysis of how much out-ofpocket money a patient is willing to spend on their cataract surgery. If drops are pushing $400, my opinion is that the money would achieve a better clinical outcome if the patient puts that toward a toric lens or LRIs, or other noncovered services that would truly improve outcomes.

Unfortunately, today's medical economics pit the cost of branded drops against upgraded surgical procedures which give a definite improved outcome, and force patients to choose.

T. Hunter Newsom, MD
Tampa, Fla.

■ I learned during residency that generic maxitrol worked as well as the brand-name drugs used for postop cataract care at that time. My patients have shown me over the years that postop drops don't matter much; sometimes they don't start Pred until they have finished the antibiotics. That made me miss the "use Tobradex QID and see me in a week" days.

Experts suggest that it is standard of care to use the latest drops; for practicing surgeons, this is hard to justify. We spend more on drops than what some insurance companies pay for the surgery.

If we were given $1000 to do the surgery and supply the drops, generic use would skyrocket.

Anonymous