Can You Ration Health Care in a Just Society?

Health care costs in the United States are an unsustainable expense. In 2014, the United States’ gross domestic product (GDP) was about $17 trillion, and of that, close to $2.7 trillion was spent on health care. Per capita, we spend more money on health care than any other country in the world. Yet, health care disparities in the United States abound.

Addressing the Problem of Waste

One reason we spend so much money on health care is that 33 cents of every dollar we spend — close to $1 trillion a year — goes to waste. For example, clinicians order tests that are not indicated, patients are hospitalized when they could also heal at home, medications are prescribed for conditions that don’t require them, preventable mistakes prolong hospitalizations, cesarean sections are performed to fit someone’s schedule and services are provided even when science tells us that they will provide limited or no benefit. Short of arbitrarily deciding that some procedures or medications are too expensive and as such will not be offered, we need a system of cost containment that is both ethical and self-sustaining.

As suggested by Buyx and Buyx et al., Clinical Effectiveness is a just and ethical model aimed at reducing health care expenses. This model is meant to make the practice of medicine more evidence-based with the goals of improving the success, efficiency and value of health care. Clinically effective care uses evidence as the basis for assessing and evaluating the quality of care.

While at face value it would appear that information for the implementation of clinically effective care could only be derived from scientific studies, such is not the case. Evidence also comes from professional consensus, experts’ views, patient experiences, incidents or complaints, near-misses and quality improvement projects.

While clinically-effective care and cost-effective care have common foundations, the former has the advantage of being blind to the cost of a specific treatment. That is not to say that clinically-effective care ignores expenditures; its benchmarks are applied to any treatment, be it costly or inexpensive. When it comes to providing health care services to over 318 million Americans, the cost of “inexpensive” care adds up.

For example, we know that antibiotics are not effective against the common cold, and as such, clinicians shouldn’t prescribe them. One may think that saving a few dollars on inexpensive antibiotics would not amount to much, but that conclusion is wrong. In 2010 we spent about $1.1 billion on unnecessary antibiotics — not exactly pocket change.

Saving Patients — And the Bottom Line

A good example of clinically-effective care is described in an article that appeared in the Fall/Winter issue of Pediatrics Nationwide. Around 2009, Richard McClead, MD, a neonatologist and associate chief medical officer at Nationwide Children’s Hospital, recognized that babies in the hospital’s neonatal intensive care unit (NICU) were hospitalized longer than at comparable institutions. One of the reasons for long hospitalizations was feeding difficulties. Around the same time, Sudarshan Jadcherla, MD, principal investigator in the Center for Perinatal Research at Nationwide Children’s, developed a program aimed at improving feeding in the NICU. The program, which is based on evidence, has enhanced the success and efficiency of the feeding program in the NICU and has improved the value of the health care dollar.

The results have been impressive. Dr. Jadcherla’s program has shortened lengths of stay in the hospital’s NICU by as much as two weeks, without compromising quality of care. A rough estimate would suggest that Dr. Jadcherla’s program saves, without compromising babies’ health, $35,000.00 per child.

Establishing Thresholds for Effective Care

The goal of clinically-effective care is to provide medical treatments that offer measurable success, improve efficiency and add value to medical care. In other words, medical treatments should offer a positive causal effect on health and measures of health-related quality of life. And all interventions should be assessed with these expectations in mind.

How does one identify interventions that satisfy those premises? By establishing “minimum effectiveness thresholds.” According to Buyx et al., a minimum effectiveness threshold might be “…increasing an aspect of health related quality of life by at least 10%, or prolonging patient survival by at least three months as compared to established treatments or placebo.”

It is important to highlight that clinically-effective treatments must provide measurable improvement over existing treatments or placebo. Dr. Jadcherla’s feeding program is clinically effective because by decreasing days of hospital confinement it improves babies’ quality of life.

Implementing the Model

So what do we need to do to make this work? The model requires we all participate, through funding, shifting our mindsets and advancing research.

Funding for the model, in the short term, would come from the public in the form of taxation. In a sense, we already have taken steps in that direction. In 2009, Congress allocated $1.1 billion in funding for comparative effectiveness research (CER). The Institute of Medicine defines CER as “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care.” In the long run, the savings generated by this model will pay for itself — think of Dr. Jadcherla’s feeding program saving about $35,000.00 per child.

The model requires sacrifices. Making decisions based on clinical effectiveness requires that we accept that “doing everything” is no way to practice medicine. In fact, it is one of the factors that brought us to this crossroads. Models of cost-containment are meant to allocate goods that are in short supply. For that reason, we need a vehicle to decide what is covered and what is not — boards of consultants who can make decisions unencumbered by the doctor-patient relationship.

Is this a new and revolutionary idea? Not at all. All medical insurance plans — Medicare included — have lists of procedures that are considered to be “medically necessary.” Those lists are derived from high-quality evidence-based data (e.g., Milliman Care Guidelines, The Cochrane Library) and clinical guidelines put forth by professional medical organizations (e.g., American Medical Association, American Academy of Pediatrics). The National Guideline Clearinghouse lists over 2,500 clinical practice guidelines published by associations providing a solid foundation for what is considered to be medically necessary and appropriate.

The model requires investment in research to identify “minimum effectiveness thresholds.” Some might believe that rationing by clinical effectiveness could curtail research and development of new treatments as those are usually more expensive than existing alternatives. Nothing could be farther from the truth. The clinical effectiveness model stimulates discovery of therapies that reach the minimum effectiveness threshold, thus making existing and less effective therapies obsolete.

Finally, the model requires we accept uncertainty. Medicine is an inexact discipline. Diagnostic doubt is commonly encountered in clinical practice. Although uncertainty in practice cannot be completely eliminated, and we do not have “gold standard” treatments for every human illness, the Clinical Effectiveness Model can be used in many instances to provide uncompromised, yet fiscally responsible, medical care.

References:

1. Buyx AM, Friedrich D, Schöne-Seifert B. Ethics and effectiveness: rationing by clinical effectiveness. British Medical Journal. 2011;342:531-533.
2. Buyx AM. Personal responsibility for health as a rationing criterion: why we don’t like it and why maybe we should. Journal of Medical Ethics.2008;34:871-874.
3. Weisleder P. Healthcare rationing in a just society: The clinical effectiveness model. Seminars in Pediatric Neurolology. 2015;22:202-205.
4. Ghose D. Better care and better business. Pediatrics Nationwide. Fall/Winter 2015:16-19.