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Wednesday, May 23, 2012

Waste avoidance and "rationing" in health care: how much money can we actually save?

Two articles in today's New England Journal of Medicine address waste and rationing. Rationing in health care is an emotion fraught term meant to awaken visions of long lines of people waiting for loaves of bread in grainy black and white photographs, but bearing the faces of sick loved ones instead of long dead strangers. Arrrgh. The first article, entitled "From an Ethics of Rationing to an Ethics of Waste Avoidance" is written by Howard Brody MD, an infectious disease specialist who was in clinical practice for many years and now is known as an ethicist. He makes the point that we need to pull ourselves away from the issue of rationing truly valuable medical care to focus on realizing that the procedures and treatments that we do that are truly not helpful are not only expensive but harmful and therefore unethical. He further suggests that using population studies to decide what works or does not work for an individual is inherently in error, and that if we successfully cut most of our truly wasted medical costs, real people will suffer who presently make their livings off of our health care behemoth. His bottom line, as I read it, is that it would be easy, using the evidence we now have and our own good sense, to do many less useless things and save lots of money, but that we need to be very aware of our patients' individual needs and also of how vulnerable our economy is to major changes in medical spending.

The other article, by Dr. Gregg Bloche MD, JD, seems to be another article about how there is really no easy way to save money in medicine unless we make major painful changes. He cites the statistic that 30% of medical spending is wasted, then goes from there to estimate that perhaps 3% per year could reasonably be saved by cutting waste and that since medical care just naturally gets more expensive every year that means we could just about break even. I really dislike this 30% number. It comes from nowhere. It might be right, but is based on no actual figures and so extrapolating to an invented 3% per year from the invented 30% per year is one of the most flagrant examples I can imagine of the truism that 73% of all statistics are made up on the spot. It is interesting that this article is written by a professor of law who also happens to be an MD, rather than someone who has practiced much medicine. The people who write articles in the New England Journal who say that there is no easy way to save money in the practice of medicine usually don't practice medicine. Most of us who do practice medicine feel like huge and avoidable waste is right there, within easy reach and that with some small changes in culture and incentives we could realize it.

Dr. Bloche goes on in his article to say that we really do need to realize that we can't afford all of the expensive and actually helpful things that medicine has to offer or will have to offer in the future and that we eventually do need to think of rationing in some way. I probably agree with him on this, though I think it is truly out of order to talk about cutting back what is actually useful before making changes that drastically reduce real waste.

Links to the two articles are:

http://www.nejm.org/doi/full/10.1056/NEJMp1203521?query=TOC
http://www.nejm.org/doi/full/10.1056/NEJMp1203365?query=TOC

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