Dilemmas in Rationing Health Care Services: The Case for Implicit Rationing
BMJ (British Medical Journal). 1995 Jun 24; 310(6995): 1655-1659.
With tension between the demand for health services and the cost of providing them, rationing is increasingly evident in all medical systems. Until recently, rationing was primarily through the ability to pay or achieved implicitly by doctors working within fixed budgets. Such forms of rationing are commonly alleged to be inequitable and inefficient and explicit rationing is advocated as more appropriate. Utilisation management in the United States and quasi-markets separating purchasing from provision in the United Kingdom are seen as ways of using resources more efficiently and are increasingly explicit. There is also advocacy to ration explicitly at the point of service. Mechanic reviews the implications of these developments and explains why explicit approaches are likely to focus conflict and dissatisfaction and be politically unstable. Explicit rationing is unlikely to be as equitable as its proponents argue and is likely to make dissatisfaction and perceived deprivation more salient. Despite its limitations, implicit rationing at the point of service is more sensitive to the complexity of medical decisions and the needs and personal and cultural preference of patients. All systems use a mix of rationing devices, but the clinical allocation of services should substantially depend on the discretion of professionals informed by practice guidelines, outcomes research, and other informational aids.
Accountability; Administrators; Aids; Comparative Studies; Costs and Benefits; Decision Making; Disclosure; Discrimination; Doctors; Economics; Forms; Guidelines; Health; Health Care; Health Care Delivery; Health Insurance; Health Services; Incentives; Insurance; International Aspects; Managed Care Programs; Medicine; Managed Care; Organizations; Patient Advocacy; Patients; Physician Patient Relationship; Physicians; Practice Guidelines; Remuneration; Renal Dialysis; Research; Resource Allocation; Review; Social Discrimination; Social Dominance; Social worth; Treatment Outcome; Trust;
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