There are many demons in the popular lore on American healthcare – bean counting hospital administrators, greedy doctors and sleazy malpractice lawyers – but the most infamous evil doers of all are probably the heartless insurance companies who are criticized for denying needed services to their subscribers to feed the corporate bottom line. In reality, drawing the boundaries on what medical services to cover is a very difficult and thankless decision. Everyone knows the anecdotes – like saying no to a mom of three who has metastatic breast cancer when there is an expensive new protocol that might offer hope. But there are other variations on the theme – what “non-traditional” therapies ought to be “covered” by private or government payers: acupuncture, chiropractic therapy, infertility treatments may be ok but what about aromatherapy or cosmetic surgery or chelation?

The other challenge to coverage decisions is that the healthcare universe is constantly moving forward. Around the edges of current practice there are innumerable alternative approaches pushing to enter the mainstream, often backed by industry, specialty medical societies and patient advocacy groups. Many are advances or at least have the potential to be, and we want these new answers, sometimes desperately. The problem is we can’t afford them all and, if we could, many wouldn’t turn out to be worth the money.

The US public votes a split ballot when it comes to healthcare – everyone thinks it should cost less but we also want every treatment to be available for ourselves and our families, regardless of cost. Although no one wants to talk about it, any effective approach to managing healthcare costs will eventually have to confront the issue of which kinds of care should be covered. The word that describes the allocation of limited resources is rationing.

Rationing happens every day – if three people eat a pizza together and there are no slices left, the pizza has probably been rationed. In US healthcare the word rationing is akin to profanity and is rarely spoken. Rationing is happening anyway; it’s just covert, controlled via access to care, most often defined by geography or socioeconomic status. In the UK, where healthcare is nationalized and a fixed budget must cover all services, the rationing of care is an explicit decision. The agency that makes this call is the National Institute for Health and Clinical Excellence or NICE.

There is a growing call for the US government to create a similar agency to examine the effectiveness of therapies and diagnostics, not just on the basis of whether they work but also on whether they add enough benefit over the existing technology to justify the extra cost. The knowledge base exists on how to do this. It is not as clear that there is the will. This sort of enterprise would cost millions to set up properly and will generate ongoing controversy and opposition from many sectors. In spite of the name, NICE is not very popular with the British public and it won’t be popular here either. The alternative that is worse is to do nothing and continue to covertly ration, irrationally.

David F. Torchiana, MD
Massachusetts General Physicians Organization