In October, when I belatedly came upon Dr. Rich Fogoros's "Covert Rationing" blog, I knew I'd found a kindred spirit. Even though DrRich (his blogging name) identifies himself as a Milton Friedmanite, and I'm New England liberal, we agree that (a) our society has an ethical responsibility to ration health care, (b) that we ration all the time but do it covertly, and (c) our current political culture pretends that rationing is an avoidable evil, not an ethical requirement.
DrRich recently wrote about "Setting Limits Fairly" - the book Norman Daniels and I wrote. Not surprisingly, because we agree on so much, he praised it. Now I'm writing about his book - "Fixing American Healthcare." Not surprisingly, I think it's terrific, and encourage readers to go to DrRich's blog and to read the book.
DrRich presents a "grand unification theory of healthcare" in the form of a 2 by 2 table. The vertical axis goes from low quality decisions at the bottom to high quality decisions at the top. The horizontal axis goes from individual decisions on the right to centralized decisions on the left. This simple framework is very powerful for explaining the mess our system is in. DrRich shows how we've moved from quadrant III (low quality decisions made by individual doctors and patients), which led to chaos, highly variable quality, and escalating costs, to quadrant IV, in which centralized decisions lead inevitably to covert rationing.
What makes covert rationing inevitable is the collision between two incompatible pieces of belief - that access to health care is an entitlement and that limits are unacceptable. DrRich argues that because all members of society contribute to financing the health system the social contract requires that health care must be available to all. It's the delusion that limits can be avoided that has to go. He envisions a system in which a generous but limited package of benefits are available to all, with opportunity for purchasing a wider range of coverage with individual funds.
I especially like DrRich's emphasis on the role "empowered patients" play in the system he envisions. DrRich has practiced medicine (cardiology), written text books and done research. He conceptualizes medical care as a partnership between clinicians out from under the bureaucratic fetters the current system places on them and activist patients. It's a vision of the kind of health care the residents I teach want to practice. Unlike so many of the free marketeers who write about medicine he doesn't reduce caretaking to an arms length commercial transaction between wary "consumers" and chastened "providers."
While each of the ten chapters is replete with pearls of insight, I was especially impressed with chapter 9 - "How to Ration Healthcare." DrRich presents the best thought out practical framework for rationing that I've seen. He uses comprehensible mathematical formulae to show how clinical evidence and core values can be factored into decision-making in a systematic manner.
The most useful part of "Setting Limits Fairly" is its conceptualization of "accountability for reasonableness" - a societal process for fair, open and potentially socially acceptable rationing. If we combine that framework for process with Rich Fogoros's lucid analysis of how specific rationing decisions can best be made, we have the underpinnings of how a society and an actual health system could set clinically informed, ethically justifiable limits.
Now we need political leadership with the courage to tell us what we need to hear!