Rationing Intensive Care Today's Boston

Rationing Intensive Care

Today's Boston Globe has a story by Liz Kowalczyk on the rationing of care in intensive care units (ICUs), here: "Rationing of medical care under study"

Rationing methods now

When people face prices for a good below market clearing prices, people will want more of the good than will be supplied. You need another way to decide who is going to get the good, that is, another way to ration access to the good. Kowalczyk's medical contacts described a wide range of current mechanisms for rationing for access to ICU treatment:

• witholding "care from patients who would benefit the least"
• "rationing decisions based on their [the doctors - Ben] own biases or their hospital's financial condition"
• "In an informal national poll of 620 intensive care physicians last year, 55 percent of doctors said they've withheld medication, tests, or services because they felt the cost outweighed the potential benefits to the patient..."
• "Some hospitals, for example, deny Xigris, which costs about $7,000 for several days of treatment, to patients with less than three months to live. But Charles Inlander, president of the People's Medical Society, a national nonprofit medical consumers' organization, said he disagrees with that approach. "What if the person is an official who has a huge and important foreign policy decision to make in the next three months," he said. "Should you still make the decision not to treat them even if they don't have long to live?"
• "...hospital executives shouldn't be the ones to decide how to ration care. Since they must earn a profit, they have an inherent conflict of interest. "My fear is that care will go to people who can pay," he said. "Rationing these days is built around age, race, and economic status. It's done under the table. It's a very important issue to face head-on. But any standards they set up still have to be accepted by the public."
• "...He said that often the most care goes to the patient whose family "pushes the hardest." "
• "...they acknowledge that they do consider cost when patients don't have long to live."
• "...Should a patient's age matter? Should doctors use more resources on a terminally ill 12-year-old than on a terminally ill 80-year-old?"

Although she doesn't mention it, it seems to me that doctors would be only human if they sometimes made decisions partly on the basis of who they liked.

The rationing work group

Kozalczyk reports on a new working group of doctors and medical ethicists (the Values, Ethics, and Rationing in Critcal Care Task Force) that is trying to develop a set of national guidelines for rationing ICU care. The effort is being supported by a $1.8 million grant tof Eli Lilly and Co.

"The group is gathering data for a series of journal articles, to be published within the next year, defining rationing and discussing models for it. The task force will also conduct focus groups with doctors and nurses and develop a computer program that will allow hospitals to plug in various treatments and compute how many lives their expenditures will save...

"But the second step will be far more difficult: How does the group decide how much money saving a life is worth? Levy said that question will be answered by ethicists, economists, physicians' patients groups, and politicians at a series of conferences. Hospitals and doctors can develop rationing policies on their own and don't need federal approval.

"Federal officials, debating whether Medicare should cover dialysis, first assigned a dollar figure to a year of life during the 1970s, said Peter Ubel, author of the pro-rationing book "Pricing Life." They arrived at $50,000, the cost of a year's worth of dialysis for a patient with advanced kidney disease. As a result, policy-makers and researchers have used this number to advise doctors, hospital administrators, and state and federal Medicaid and Medicare officials about whether particular treatments are worth paying for.

"Ubel, who is at the University of Michigan, believes that number is too low. Based on public opinion surveys, he thinks a year of life is worth closer to $150,000 to $200,000. But, he said, using a hard and fast number is "just so cold." Society should consider emotional factors too, he said, such as whether we want to provide all possible care to veterans because they defended the country."