Maybe the national conversation about the rationing of health care finally is moving to a more thoughtful plane. Maybe, instead of incendiary language, half-truths and mistruths, Americans, with the help of the medical establishment, are beginning the think rationally about rationing.
As widely reported last week, a panel of physician groups representing the American Board of Internal Medicine Foundation officially recommends that doctors cut back on the routine use of 45 common medical tests and procedures, deeming them often unnecessary and thus more prone to cause harm than good.
As regular readers know, we’ve walked this path many times.
Rationing is neither a new idea nor, necessarily, a bad one. It all depends on context. Doctors and patients who communicate well ration care all the time. One example is “watchful waiting” in the case of a 70-year-old man with prostate cancer, for whom the practice of holding off on treatment in favor of monitoring the status of the disease makes sense unless and until the cancer grows to the point where it would be dangerous to let it continue. Often, these patients live a long life and die of something else, and treating the cancer would cause side effects much worse than living with the disease.
A patient with a sinus infection who wants her doctor to prescribe an antibiotic might be denied because sinus infections often are caused by viruses, which, unlike bacteria, don’t respond to antibiotics, and because even a bacterial sinus infection usually resolves on its own. So the “rationing” of prescription medicine is wholly appropriate in this case.
As medical costs spiral out of control, as insurance premiums match that ascent, rationing makes sense when such care won’t improve someone’s condition, or only incrementally, and with the potential for negative side effects.
As the New York Times explained, the panel, composed of nine medical specialty boards, recommended that doctors perform 45 common tests and procedures less often. It also said patients should question such services if they are offered. Eight other specialty boards, the paper said, are preparing additional procedures their members should perform far less often.
“The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients,” said The Times. “By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.”
Removing the discussion of overused and overpriced tests and treatments from the realm of politics and/or commercial interests (insurance and pharmaceutical companies) and staging it instead on a platform of science confers a welcome sense of authority. Of course, The Times adds, it also reflects the fact that insurers and other entities that pay these costs want to shift more of them to providers, including hospitals and physicians. So, sometimes, it’s in their best interest to rethink a treatment.
To promote critical thinking about what’s necessary and what’s habit, the nine medical boards have created Choosing Wisely in partnership with Consumer Reports. The educational initiative speaks to both medical professionals and patients.
According to the panel, among the overused tests that should be called into question are such procedures as EKGs performed during an annual physical examination when the patient has no symptoms of heart problems, and MRIs or X-rays whenever someone complains of back pain. For the complete list of the initial 45 tests and treatments, link here.
Of course, this isn’t the first time elements of the medical community have suggested reining in the desire to test, test, test. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, and the ongoing debate about the wisdom of regular and invasive prostate cancer tests (see our post here) have caused concern about government interference in personal health-care decisions and the rationing of treatment.
As The Times noted, “Some of the tests being discouraged – like CT scans for someone who fainted but has no other neurological problems – are largely motivated by concerns over malpractice lawsuits…. Clear, evidence-based guidelines like [these] will go far both to reassure physicians and to shield them from litigation.”
We’ve broached the topic of “defensive” medicine as well, concluding that malpractice lawsuits in the wake of a medical error are much less likely if the practitioner takes responsibility, apologizes and assists in rectifying a bad situation.
The solution to too many patients receiving too many tests and costly treatments isn’t about government control, restricting care from people who need it or protecting practitioners against lawsuits. It’s about the thoughtful use of medical resources and putting individual patients’ conditions into context to make informed instead of reflexive decisions. Call it rationing if you want; we call it wisdom.