Rationing of Care: Conceptual Ambiguity and Transparency in Data Collection and Synthesis
Rationing of Care: Conceptual Ambiguity and Transparency in Data Collection and Synthesis
Rebekah J. Walker 0 1 2
Leonard E. Egede
0 Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina , Charleston, SC , USA
1 Center for Health Disparities Research, Medical University of South Carolina , Charleston, SC , USA
2 Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Medical Center , Charleston, SC , USA
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R sial issue, with great disagreement over not only whether
ationing continues to be a hotly debated and
controverrationing is acceptable, but what it means to ration care. In this
issue of JGIM, Sheeler et al. present findings of a
crosssectional study that aims to describe physician rationing
behaviors and characteristics of rationing in the United States.1
Surveys mailed to physicians randomly selected from the
American Medical Association master file asked about
frequency with which they Bpersonally refrained, because of cost
to the health care system,^ from using ten different
interventions, including laboratory tests, magnetic resonance imaging
(MRI), referral, or prescription drugs. They found overall that
53 % of respondents reported refraining from using services in
the past 6 months.1 Prescription drugs and MRI were most
frequently reported at 48 % and 45 %, respectively.1 Surgical
and procedural specialists, medical school settings, and
physicians who self-identified as very or somewhat politically
conservative reported higher frequency of refraining from
using at least one of the ten services than primary care, small
or solo practice, and those identifying as very or somewhat
liberal.1 In addition, the survey asked respondents one of three
randomly assigned questions to gauge perceived responsibility
for containing costs, phrasing questions either as responsibility
to Bexercise wise financial resource stewardship,^ Bpromote
cost consciousness^ or Bration in my daily care of patients.^
Compared to 88 % agreeing with the Bwise-stewardship^ and
81 % agreeing with the Bcost-conscious^ statements, only
22 % agreed with the Brationing^ statement.1
As seen in the results reported by Sheeler et al., the phrasing
used to ask about rationing has an impact on responses. As a
result, it is necessary to be clear regarding the definition of
rationing. Ubel and Goold suggested in 1998 the use of a
broad interpretation Bencompassing any explicit or implicit
measures that allow people to go without beneficial health
care services.^2 They argued that this would highlight the
frequency with which rationing occurs, and remove the de
facto negative connotation.2 However, discussions of
rationing over the past 5 years consistently note there is no
agreed upon definition, and point out that the term is often
used synonymously with ideas such as ‘resource allocation,’
‘priority setting’ and ‘cost containment.’3–6 The political
processes surrounding the Affordable Care Act in the United
States, and the National Health Service in the United Kingdom
have added to the conceptual and methodological struggle to
measure and understand clinician attitudes and willingness to
accept rationing either in their own practice or through policy
measures.3–5 Even what is considered rationing is unclear; for
example, limitations on services by ability to pay, or lack of
care resulting from lack of health insurance, is seen as implicit
rationing by some definitions, but not others.2, 5, 6 By not
directly asking about rationing, Sheeler et al. avoided possible
reactions to the term itself, and stated this could prompt more
professional discourse on the topic.1 However, given the
widespread disagreement on what does and does not constitute
rationing, the conclusions drawn could be inadvertently
misleading and may be inconsistent with the intent of survey
participants at the time they answered the questions.
Previous studies have investigated the willingness of
physicians to ration health care as well as their perceptions of
rationing. Hurst et al. used a similarly phrased questionnaire in
Norway, Switzerland, Italy, and the United Kingdom, and
found a similar overall response, with 56 % of physicians
refraining from at least one of the ten interventions in the past
6 months.7 When asked more detailed questions regarding
criteria for rationing, respondents most often reported a small
expected benefit (82 %) and low chance of success (80 %).7 A
national survey of intensive care units (ICU) in the United
States found that a majority of respondents perceived
questions about specific situations or practices that may be
associated with rationing occurred Brarely^ or Bnot at all.^8 Few
ICUs perceived rationing as occurring Bfrequently^; however,
46 % of respondents felt Btoo much care^ was provided
Bsometimes or frequently.^8 In this study, the word rationing
was used, but not until the end of the survey in an effort to
minimize bias resulti (...truncated)