Key Point

Resource allocation must be addressed in order to provide the greatest number of patients with the best possible care.

PHOENIX—At this year’s annual meeting of the Society for Critical Care Medicine, Mitchell M. Levy, MD, FCCM, Professor of Medicine at Brown University and Director of the ICU at Rhode Island Hospital—both in Providence—addressed the volatile issue of rationing care in the ICU.¹

In the United States, observed Dr. Levy, the subject of rationing medical care is extremely controversial. Why? “In part,” he said, “we want to preserve our health care system—the right to excellent health care, not rationed health care, the right to choose, the right to access any health care options, and,” he added, “the right to pay more and get less.”

Dr. Levy pointed out that the US spends more on health care than does any other developed country in the world. Yet, the quality of care is certainly nowhere near the best. The US ranks 26th in infant mortality, 24th in disability-adjusted life expectancy, and 9th out of 10 in patient-reported satisfaction with health care. It was ranked 37th by the World Health Organization.

Although the US pays more for its medical care than does any other industrialized country, there are still 43 million uninsured Americans. Discrepancies in access to adequate medical care can be seen in terms of ethnicity, age, insurance coverage, and even employment status. In fact, a 2003 study determined that whether or not a patient is actively employed can predict the likelihood of that patient getting a DNR order.²

WHAT DOES RATIONING MEAN?

Before rationing can be discussed, said Dr. Levy, the term must be defined: He and his colleagues from the Values, Ethics, and Rationing in Critical Care Task Force have defined rationing as “the allocation of health care resources in the face of limited availability, which necessarily means that beneficial interventions are withheld from some individuals.”

In the past 15 years, the number of ICU beds per hospital in the US has increased by 26%. Or to illustrate it differently, in 1985, 7.8% of hospital beds were dedicated for critical care. In 2000, that figure had risen to 13.4% of hospital beds, or 87 beds for a 654-bed hospital. In comparison, the mean number of critical care beds for a 600-bed hospital in Europe is about 11.

Furthermore, with the aging of the US population, the demand for care and the expenditure of resources for senior citizens have increased exponentially and will likely continue to do so.

“Can we ‘just say no’ to rationing?” asked Dr. Levy. “Can we provide all services to all patients that have any positive expected benefit—no matter how small and uncertain the benefits and no matter how high the costs?”

Never having to ration means making all resources available to all patients who need it, he said. Given the rate of health care cost increases cited above, it is inevitable that giving some patients all available treatments will prevent clinicians from providing care to patients who would benefit more from these treatments.

EXAMPLES OF RATIONING

In response to those who won’t consider the “R word,” Dr. Levy submitted that not only is rationing happening, it is both desirable and necessary. In fact, he said, not rationing could be unethical.

How is rationing happening now? Dr. Levy answered this by posing questions to his audience:

• How do you decide which patients get more of your time?
• Who gets that last bed in the ICU?
• Do you give an expensive diagnostic procedure to a patient who is not likely to benefit from it?
• How aggressively do you treat a patient?
• How do you decide who gets transferred out of the ICU?

All of these are fairly common examples of rationing, he explained.

A CALL FOR DEBATE

There is no question that rationing exists, said Dr Levy. “Now, we need to move the agenda forward and be able to ration effectively,” he argued. “We need to be willing to have a public debate and force the issue, so we can talk about wise, evidence-based resource allocation.”

“If we can start a public debate about resource allocation, the first thing people have to start talking about is the 43 million uninsured Americans whose outcomes are worse because they’re uninsured,” Dr. Levy stressed. “That’s part of the rationing debate. In order to ration wisely, we have to ask about the existing inequities in the health system. When I talk about rationing, it’s to get all of that on the table. So let’s start talking about where our resources are going, and where they aren’t going, and then start to look at a fair and equitable way to do it.”

It’s pie in the sky to think that politicians are going to accept any of this, admitted Dr. Levy, “but if we don’t start a public debate, they’ll never do it. Then all of the people with money and power will get the best care, and the inequities will continue.”

The challenge is to provide the greatest good for the greatest number—given the rising ICU costs and health care costs in general, Dr. Levy proposed. “This must be balanced with our moral obligation to act for the benefit of others.”

He cited the Oregon Health Plan, which demonstrated very clearly that rationing can occur. In Oregon, the public became involved in health-policy making and finally, said Dr. Levy, the use of cost-effective analyses came into the public mindset. “At the very least,” he pointed out, “the Oregon Health Plan demonstrated that these things could be talked about in public.”

—Gale Jurasek

References
1. Levy MM. Plenary: Rationing in the ICU. Presented at: Society for Critical Care Medicine’s 34th Critical Care Congress; January 15, 2005; Phoenix, Ariz.
2. Guyatt G, Cook D, Weaver B, et al. Influence of perceived functional and employment status on cardiopulmonary resuscitation directives. J Crit Care. 2003;18:133-141.

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