Friday, May 2, 2008

Learning how to Ration

Over the years I have posed this question to physicians I respect in a wide range of medical specialties – “if you were the czar of your field and your orders were cheerfully followed, how much money could you save with no loss of quality?” No one ever said less than 25%. Lots said more. Many commented that quality could be improved at the same time.

Last month an article in the New England Journal of Medicine on “Options for Slowing the Growth of Health Care Costs” listed 12 approaches, 10 of which are familiar and widely discussed.

Given that we know how to contain costs, why have we been so powerless to do anything?

The last two options in the NEJM article – rationing - give a clue about our stunning inability to get a grip on costs. The authors write - “Should other options fail to provide sufficient cost reductions, policymakers may be forced to consider various forms of rationing.”

I think they have it backwards.

Cost containment hurts. We won’t make serious efforts until not doing it hurts more. That means being ready to start rationing in an explicit fashion. When we understand that the alternative to serious cost containment is more and more explicit rationing we’ll be readier to bite the bullet. As long as explicit rationing is off the table, cost containment will just get lip service and hand wringing.

A Wall Street Journal article – “Weighing Which Babies Get a Costly Drug” – shows how we can start learning how to ration despite the pablum our political leaders (always excepting Oregon) feed us about achieving painless cost containment through electronic medical records and magical market forces.

Synagis (Palivizumab), an antibody to protect against RSV (Respiratory Syncytial Virus) in children under two, is given as a series of monthly injections, usually five. A full course can cost up to $6,000. Synagis reduces the frequency of hospitalization, but not mortality, in vulnerable infants.

In 2003 the Committee on Infectious Diseases & the Committee on Fetus and Newborn of the American Academy of Pediatrics published a policy for use of Synagis, signed by 38 distinguished pediatricians. In a remarkably straightforward way, the first paragraph states:

…immunoprophylaxis should be reserved for use in infants and children at greatest risk of severe RSV infection because of the high cost of this intervention.

Three years later, RAND studied the cost-effectiveness of Synagis in premature infants without lung disease, one of the groups of concern with regard to increased vulnerability to RSV. The study concluded:

...the current recommendations for the use of palivizumab as RSV prophylaxis in premature infants without chronic lung disease are not cost-effective by today's standards. Our analyses support the implementation of more restrictive guidelines for RSV prophylaxis for these infants...

I can't offer expert assessment of the American Academy of Pediatrics guidelines or the RAND study. But I can say that that they are just the kind of studies and deliberations we would need to conduct explicit rationing in an ethical manner.

Major insurance coverage policies largely follow the AAP guidelines and associated studies. Aetna, for example, posts its coverage criteria on the web. As an ethics wonk I was impressed with the wording of the Aetna policy, especially the recurrent use of "Aetna considers Synagis medically necessary for..." rather than "Synagis is medically necessary for..." (emphasis added) By using "considers" Aetna acknowledges that it is making a policy judgment based on its assessment of when the value provided by Synagis warrants its use. That's rationing.

The bottom line is that without using the dreaded "r" word, our society is beginning to learn how to ration. When we become bold enough to say it out loud and practice it more widely we will be energized to work at cost containment in a serious manner.

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