As purchasers, providers and health plans grapple with the best ways to deliver quality, cost-effective care, they are going beyond discussions of method to a broader principle.
That underlying principle is "an ethic of population-based care," terminology coined by David Eddy, senior adviser for health policy and management at Oakland, Calif.-based Kaiser Permanente.
Population-based care is another way of saying "healthcare rationing." But because that's such a loaded term, its advocates emphasize that what they're talking about is responsible, scientifically based rationing, similar to the Oregon Health Plan.
In that pilot Medicaid expansion program, funds freed up by not covering procedures judged by experts to be of little medical benefit are used to expand basic health services to more of the state's poor.
Responsible rationing has three hallmarks, Eddy said: It's scientifically based; it's a response to the desires of a health plan's enrollees to emphasize cost-control and prudent use of resources, but not for the sake of increased profits; and "every instance of rationing in fact improves the overall quality of care offered to the population for which the health plan is responsible because it involves a switch from no-value or negative-value activities to high-value activities."
But it's rationing nonetheless. While purchasers, providers and health plans are nervous about saying it out loud, the time to do so appears to be here.
Moving beyond talk.It's not just a matter of ethicists making provocative speeches about rationing anymore. While the word wasn't heard often, rationing was the topic earlier this month at a town-hall-type meeting of more than 300 Kaiser Permanente Southern California physicians and managers.
"That's what the meeting was all about," Eddy said. The conference was officially titled "Ethical Issues in Clinical Decisionmaking and Resource Allocation."
Rationing is considered necessary because of healthcare's relentless appetite for dollars-with much of the money spent on futile or wasteful treatments, experts say. The United States may spend 14% of its gross domestic product on healthcare, but 41 million Americans still have no health insurance.
"(Healthcare) is the Pac-Man of every public and private budget," former Colorado Gov. Richard Lamm told the Kaiser conference. All other efforts to control spiraling health costs have failed, he said.
Eddy said the meeting "was designed to initiate a group process wherein the organization as a whole will develop a policy and a coordinated approach" to resolving the cost and access problems by moving toward population-based care.
It was the first time Kaiser managers and physicians were assembled regionwide to consider the issue, said Oliver Goldsmith, M.D., medical director and chairman of the board of Southern California Permanente Medical Group.
At the conference, John Golenski, president of Bioethics Consultation Group, Berkeley, Calif., urged Kaiser physicians to take the lead in supporting population-based care.
"Payers are already there, providers are getting there, but patients are just beginning to figure it out," he said. Golenski said Kaiser physicians educate their patients on the goals of population-based care.
That means helping patients understand that they're not talking about denying care, just avoiding unnecessary use of resources and medically unproven treatment. "It is better for all of us to shift to what is good for all rather than what is good for the individual," Golenski said. "This is the best model for providing the best medical care."
But Helen Darling, manager of healthcare strategy and corporate benefits for Xerox Corp., who represented purchasers at the conference, had an ironic warning. She said Kaiser Permanente and other HMOs need to be careful leading the way toward such a cultural shift because managed care-with its image of being bottom-line oriented-has become a "negative shibboleth" that could taint the concept of population-based care.
The challenge is to educate people. "We underestimate what society will do" if properly informed about outcomes, she said.
Although the issue is crucial to healthcare delivery, Goldsmith also was nervous about airing it. "Kaiser Permanente's image in the U.S. and in California has been tarnished by the managed-care issue. We've got a whole host of problems in quality-of-care issues and in perception and image, and we've spent a lot of money to educate people," he told the conference. "We've got to be very cautious about what else we embrace that can affect our image."
Putting it in practice. How exactly will a visit to the doctor reflect an ethic of population-based care? In one example, Kaiser is moving toward a goal of biennial mammograms for all female enrollees between the ages of 50 and 75. Guidelines ask physicians to "discourage its use in (other age groups) in which either there is no evidence of benefit or where the magnitude of benefit, if there is any, is very, very small," Eddy said.
Giving mammograms to women who are most likely to benefit from them will result in a healthier patient population and will save money-and lower costs-for services other enrollees need, Eddy said.
But if a woman outside the target age group requests a mammogram, the role of the physician is to explain the lack of evidence of benefit or the probability of harm-such as false positives that might require biopsies.
"If after thinking about all of that she still feels strongly that she wants it, we will provide it to her for free," Eddy said.
The key to responsible rationing and population-based care-even 10 years down the road-will always be conversation between physician and patient, Eddy said.
"I realize all of this is fuzzy," he said. It will be clearer in 10 to 15 years, but this is "a period of transition."