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ON THE COSTS OF DENYING HEALTH-CARE SCARCITY

The following points are made by G.C. Alexander et al (Arch Intern Med. 2004;164:593-596):

1) Scarcity is increasingly common in health care, yet many physicians may be reluctant to acknowledge the ways that limited health care resources influence their decisions. Reasons for this denial include that physicians are unaccustomed to thinking in terms of scarcity, uncomfortable with the role that limited resources play in poor outcomes, and hesitant to acknowledge the influence of financial incentives and restrictions on their practice. However, the denial of scarcity serves as a barrier to containing costs, alleviating avoidable scarcity, limiting the financial burden of health care on patients, and developing fair allocation systems.

2) Almost two decades ago, Aaron and Schwartz(1) published The Painful Prescription: Rationing Hospital Care, in which they examined the dramatic differences in health care expenditures between the US and Great Britain. Their examination highlighted the role of rationing within the British system and explored the difficult choices that must be made when trying to weigh the costs and benefits of many health care services. They noted that British physicians appeared to rationalize or redefine health care standards to deal more comfortably with resource limitations over which they had little control.

3) Since that time, physicians in the US have been under increasing pressure to acknowledge and respond to scarcity.(2-4) To begin to learn more about how they respond to these pressures, the authors conducted exploratory interviews with physicians faced with scarcity on a daily basis: transplant cardiologists involved in making decisions about which patients to place on the organ waiting list; pediatricians who frequently prescribe intravenous immunoglobulin (IVIg), a safe and effective medical treatment that has been in short supply(2); and general internists who make cost-quality trade-offs on a daily basis. The interviews were conducted in confidential settings, included open-ended and directed questions, and were recorded and transcribed for subsequent analysis. During these interviews, the authors were struck by the vehemence with which the physicians they interviewed denied scarcity or, more commonly, the constraints that scarcity imposes on their practice. The authors were left with the impression that physicians' awareness of scarcity and its consequences lies under the surface.

4) The authors conclude: Physicians' limited time and energy will never suffice to fulfill the almost limitless needs of their patients. Similarly, the limited resources available to health care in the US guarantee that difficult choices must and will be made regarding the distribution of health care. Physicians are in a privileged position to help develop policies that promote fair allocation of health care resources. However, to do so, they must examine their own practices and those of the health care systems in which they work. Denial of the impact of scarcity limits physicians' abilities to play an active role in reshaping policies on a local and national level.

References (abridged):

1. Aaron HJ, Schwartz WB. The Painful Prescription: Rationing Hospital Care. Washington, DC: Brookings Institution; 1984

2. Tarlach GM. Globulin goblins: shortfall in immune globulin supplies looms. Drug Topics. 1998;142:16

3. Pear R. States ration low supplies of 5 vaccines for children. New York Times. September 17, 2002:A26

4. Morreim EH. Fiscal scarcity and the inevitability of bedside budget balancing. Arch Intern Med. 1989;149:1012-1015

5. United Network for Organ Sharing. Data. Available at: http://www.unos.org/data/default.asp?displayType=USData.

Archives of Internal Medicine http://pubs.ama-assn.org

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