Friday, October 30, 2009


I can see from the readership to the last article on rationing in healthcare that it is a very popular issue. There were many who read the article. I thought that I should write a few more ideas that all healthcare planners are grabbling with, be it President Obama, or NHS-UK, or the Australian Health Authorities, or our Ministry of Health.

How do we provide the best of care to all our citizens, with a fix amount of money. Afterall, a country's health resources can never be unlimited. If and when we overspend, that we go into a current accounts deficit ( like what may happen in USA if President Obama is not careful with his healthcare reform ). We have a fix amount of money, but we have to deal with either a growing population, or an aging population, a growing number of disease conditions, with an ever growing number of ways to treat those growing number of disease conditions. And sometimes these growing number of ways of treatment is not aimed at the basic of prolonging life, but is also aim at reducing discomfort ( improving quality of life ). As a healthcare planner, how do you balance all these issues. And also, I forgot, no one must be left out. All citizens ( and someimes non-citizens too, what with health tourism ), must have equitable healthcare, as healthcare is deemed as a basic human right.

How do we juggle all these and come out with a good healthcare system? I suppose to solve the last point ( equitable healthcare ) there must be a public option. That is why, I am very keen that the government must continue to be the main provider of basic healthcare. That will make sure, that everyone ( rich or poor or tourist ) will always be provided with healthcare at almost no cost. Obviously the public option cannot provide all forms of healthcare. There need to be some rationing. In our language, we call it " the healthcare that we must have ". I suppose this will be made up of basic healthcare, first aid, and emergencies and perhps infectious diseases, so that they do not affect the economy of the country. It must also include some palliative medicine and basic care for the terminally ill. If money allows, the public option may also include " healthcare for conditions that is good to have ". I suppose included in this would be investigative techniques to diagnose life threatening disease conditions, treatment and followup of chronic disease conditions, basic cardiac care including bypass-surgery and angioplasty using bare-metal stents. Of course the last option for public health service is " those healthcare that is nice to have ", by which I will include things like oncology treatment that will prolong life by 6-8 months, treatment for exotic conditions, complex angioplasty where CABG is an alternative, and of course all the cosmetic surgeries. As you can see, this strategy is one form of rationing.
However, being a free market economy, those pro-rich, will want better care. I believe that if they are paying out of their own pockets, or through their own health insurance with high premiums, then no one should begrudge them. Private insurance is one way of paying for healthcare, and they are getting more popular. Either the subject buys their own health insurance or many companies are also insuring their employees. Then, the level of care is in some way dictated by the insurance policy that you buy. Invarably, insurance will have their own way of rationing, sometimes rather arbitrarily I must add. We have always advocated that health insurance firms to survive and profit, must enroll more of the healthy who will not claim and less of the sick, who are likely to claim. We also advice them to go on well publicise drives to launch preventive disease programs, especially with lifestyle diseases and even better to reward those who do not claim ( a form of no claim bonus ), so as to encourage a more healthy populace. This is a win-win strategy.
In UK, there is a body called NICE ( National Institute for Health and Clinical Excellence ) who have decided that it is not cost effective to spend more than US$ 45,000 for a one year life extension. They calculated " Quality adjusted life year ", for all conditions and found that anything more than US$ 45K per year is not worthit. This approach has also been heavily criticised.
Looks like rationing healthcare is a rather emotional subject too, especially when your love ones is the subject. Politicians find it very difficult to draw the line. Yet we all know that the budget is finite. If you use up too much for one patient, you are actually depriving someone else, who may be more deserving.
I really do not know what the answer is. It is never nice or humane to deny someone some therapy which may help, but then sometimes we have no choice.
That choice is always a tough one. Rationing healthcare??

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