1. Health

What Is Healthcare Rationing?

From Denial of Care to Healthcare Reform, Rationing Is a Consideration

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Updated April 05, 2012

If you’re old enough to remember World War II, or if you studied it in school, then you remember what rationing is. Butter, sugar, gasoline and many more basics were rationed to ensure that soldiers would have the food and support they needed while they fought the war overseas.

At home, Americans sacrificed everyday necessities for the greater good.

It may surprise you to learn that rationing takes place even today, but not in foodstuffs or fuel; rather, it takes place in healthcare. Healthcare rationing is used by health insurers, the government and individuals to save money. Some would even argue healthcare rationing supports the greater good.

How Does Healthcare Rationing Work?

Most of us believe that if there is a treatment available, no matter what it costs, and no matter what chance there is for a positive outcome, it should be made available to us. We get frustrated when we are told we can’t have it or we’ll have to pay extra for it.

However, since funds are limited, then our options are limited, too, in a variety of ways.

Self-Rationing

Sometimes we limit ourselves. Suppose you develop a rash. You have two choices. You can go to the doctor, pay a co-pay, or pay cash from your pocket. Then you'll still need to pay for whatever prescription your doctor writes for you, too.

Or, you may choose an over-the-counter rash treatment instead -- much less expensive, not to mention the time you saved by not making an appointment, even waiting for heaven-knows-how-long to see the doctor. If you choose the no-doctor-visit route, then you have self-rationed your care, and saved money for something you believe is more important.

Health Insurer Rationing

Health insurers ration care, but they don't call it rationing, and they don't even want you to realize that it is rationing. Dr. Rich Fogoros, the About.com Guide to Heart Disease gave this its own term. He calls it "covert rationing."

When insurance companies ration care, it's a money-saving measure, in part for the greater good, but also to preserve profits or raise salaries or other reasons that their customers disdain.

Rather than dwell on the reasons that frustrate us, suffice it to know that some of their rationing does keep premiums from getting any higher than they do, and does allow insurers to stay in business.

Health insurers ration your care by limiting the doctors you may visit because they negotiate fees with those doctors. They will only pay for you to visit the ones they have negotiated the lowest fees with.

Health insurers ration care through co-pays, deductibles and caps. In fact, what they are really doing is encouraging you to self-ration. Knowing that a certain amount of your care will have to be paid from your pocket, you may choose not to get the care or drug you need.

Health insurers deny services or reimbursements for services. Denial of care is perhaps the most understood form of rationing, because it causes outrage and frustration. What most patients don't understand is that this is also the aspect of rationing that is most affected by laws and regulations, too.

In many cases, those denials may be based on science or evidence that a treatment won't work, doesn't work well enough, or is too new. For example, many patients get frustrated that insurance won't reimburse for an alternative treatment. What the insurer will tell you is that there isn't enough evidence to prove that treatment will work.

In other cases, experimental, off-label drugs or new surgical approaches are too new to show enough evidence of success, so the insurance company will not reimburse for it.

In still other cases, a doctor may recommend a treatment that is shown to only benefit a small percentage of the people who have used it (usually in very difficult medical cases), and may also be very expensive, so the insurance company will decide it's not worth the high cost for so small a probability of success.

Remember, of course, the insurer isn't denying permission for the treatment. Rather, payment for the treatment is being denied. The patient can still participate in the treatment if she can pay for it herself.

Government Healthcare Rationing

Even the government rations healthcare. The difference between the government's rationing and the rationing conducted by health insurers is that there is no profit motive. The government, through Medicare or state Medicaid or other programs, keeps costs lower as much as possible in order to keeps taxes lower, or to expand care to others, both considered to be the greater good.

A good example of government rationing is Medicare’s donut hole. Seniors know they are limited on the amount they can spend on prescriptions, because if they spend more, it comes from their own pockets.

Why Do We Need to Understand Healthcare Rationing?

There are several reasons why understanding healthcare rationing will help you.

First, should you run into a denial of care, you'll know why it's been denied, and will better understand how to go about combating it, should you want to do so.

Second, in the coming years you will hear more and more about healthcare reform and why it will, or won't, affect how you receive care. The biggest arguments center on how payment should be handled; whether it should be handled as it is now with both government and private payers, or whether the United States should move to an all-government, single payer system.

Some experts in healthcare rationing will tell you that private health insurer rationing means that the insurers are the ones determining who is getting what care. They cite the fact that which treatment you receive has more to do with whether or not your insurer gives permission than what you and your doctor think would be best. Private insurers argue that if the government takes over all cost coverage of all healthcare, then the government will make healthcare decisions for patients.

Patients will have to decide for themselves how they feel about the bigger picture. But understanding today how rationing works will help them figure out how to get the care they need and want.

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