Original communication| Volume 113, ISSUE 5, P491-497, May 1993

Rationing surgery: Rules or constraints?

  • John D. Birkmeyer
    Reprint requests: John D. Birkmeyer, MD, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756.
    From the Dartmouth Medical School, Hanover, N.H., USA

    From the Department of Veterans Affairs Medical Center, White River Junction, Vt., USA
    Search for articles by this author
  • H.Gilbert Welch
    From the Dartmouth Medical School, Hanover, N.H., USA

    From the Department of Veterans Affairs Medical Center, White River Junction, Vt., USA
    Search for articles by this author
  • Author Footnotes
    a A fellow in the Program in Medical Information Science, which is supported by a training grant from the National Library of Medicine (NIH 5 T15 LM07044).
    b Recipient of a Department of Veterans Affairs Career Development Award for Health Services Research and Development.
      This paper is only available as a PDF. To read, Please Download here.


      Background. As U.S. health care expenditures climb, the need to set limits on surgery is becoming more generally accepted. If limits are necessary, how should they be established and by whom? This article considers two fundamental approaches, rules and constraints.
      Results. With rules, payers or policymakers ration care by prioritizing and then restricting specific procedures. Although they have the advantage of explicitness, rules based on treatment prioritization are limited by patient heterogeneity and the lack of outcomes data necessary to rank many procedures. Rules are unambiguous and free the surgeon from the obligation to set limits, but they do not accommodate clinical judgment or patient preferences. With constraints, limits are set on surgical resources (e.g., the number and distribution of surgeons), but individual surgeons determine which procedures are provided to which patients. Although constraints are more feasible than rules, it is difficult to establish an “adequate” supply of surgical resources and to ensure that limits set by the individual surgeon are based on treatment efficacy. While preserving clinical autonomy, constraints require the surgeon to assume the responsibility of rationing care.
      Conclusions. Surgeons should consider carefully the approach to rationing that best serves their professional interests, their patients, and society.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Schwartz WB
        The inevitable failure of current cost-containment strategies. Why they can provide only temporary relief.
        JAMA. 1987; 257: 220-224
        • Evans RW
        Health care technology and the inevitability of resource allocation and rationing decisions. Part 1.
        JAMA. 1983; 249: 2047-2053
        • Welch HG
        Should the health care forest be selectively thinned by physicians or clear cut by payers?.
        Ann Intern Med. 1991; 115: 223-226
        • Fuchs VR
        The “rationing” of medical care.
        N Engl J Med. 1984; 311: 1572-1573
        • Reagan MD
        Health care rationing. What does it mean?.
        N Engl J Med. 1988; 319: 1149-1151
        • Himmelstein DU
        • Woolhandler S
        Cost without benefit. Administrative waste in U.S. health care.
        N Engl J Med. 1986; 314: 441-445
        • Roper WL
        • Winkenwerder W
        • Hackbarth GM
        • Krakauer H
        Effectiveness in health care. An initiative to evaluate and improve medical practice.
        N Engl J Med. 1988; 319: 1197-1202
        • Barry MJ
        • Mulley Jr, AG
        • Fowler FJ
        • Wennberg JE
        Watchful waiting vs immediate transurethral resection for symptomatic prostatism.
        JAMA. 1988; 259: 3010-3017
        • Butler SM
        A policy maker's guide to the health care crisis (part II): The Heritage consumer choice health plan.
        in: Heritage talking points. Heritage Foundation, Washington, D.C1992: 1-28
        • Aaron HJ
        • Schwartz WB
        The painful prescription: rationing hospital care.
        Brookings Institution, Washington, D.C1984
        • Weinstein MC
        • Stason WB
        Foundations of cost-effectiveness analysis for health and medical practices.
        N Engl J Med. 1976; 296: 716-721
        • Welch HG
        Health care tickets for the uninsured: first class, coach, or stand-by?.
        N Engl J Med. 1989; 321: 1261-1264
        • Eddy DM
        What's going on in Oregon?.
        JAMA. 1991; 266: 417-420
        • Hadorn DC
        Setting health care priorities in Oregon: costeffectiveness meets the rule of rescue.
        JAMA. 1991; 265: 2218-2225
        • Daniels N
        Is the Oregon rationing plan fair?.
        JAMA. 1991; 265: 2232-2235
        • Stason WB
        Oregon's bold Medicaid initiative.
        JAMA. 1991; 265: 2237-2238
        • Eddy DM
        The individual vs society: is there a conflict?.
        JAMA. 1991; 265: 1446-1450
        • Welch HG
        • Larson EB
        Dealing with limited resources: the Oregon decision to curtail funding for organ transplantation.
        N Engl J Med. 1988; 319: 171-173
        • Wennberg JE
        Innovation and the policies of limits in a changing health care economy.
        in: Modern methods of clinical investigation. 1985 ed. Medical innovations at the crossroads. vol 3. National Academy Press, Washington, D.C1992: 9-33
        • Lewis CE
        Variations in the incidence of surgery.
        N Engl J Med. 1969; 281: 880-884
        • Paul-Sheehan P
        • Clark JD
        • Williams D
        Small area analysis, a review and analysis of the North American literature.
        J Health Polit Policy Law. 1987; 12: 741-809
        • Roemer M
        Bed supply and hospital utilization: a natural experiment.
        Hospitals. 1961; 35: 36-41
        • Wennberg JE
        • Freeman JL
        • Culp WJ
        Are hospital services rationed in New Haven or over-utilised in Boston?.
        Lancet. 1987; 1: 1185-1189
        • Wennberg JE
        • Freeman JL
        • Shelton RM
        • Bubolz TA
        Hospital use and mortality among medicare beneficiaries in Boston and New Haven.
        N Engl J Med. 1989; 321: 1168-1173
        • Mulhausen R
        • McGee J
        Physician need. An alternative projection from a study of large, prepaid group practices.
        JAMA. 1989; 261: 1930-1934
        • Center for Health Services Research and Development
        • American Medical Association
        Physician characteristics and distribution in the United States.
        1985 ed. American Medical Association, Chicago1984
        • Fisher ES
        • Welch HG
        • Wennberg JE
        Prioritizing Oregon's hospital resources. An example based on variations in discretionary medical utilization.
        JAMA. 1992; 267: 1925-1931
        • United States Graduate Medical Education National Advisory Committee
        The Report of the Graduate Medical Education National Advisory Committee.
        in: 3rd ed. Dept. of Health and Human Services publications [HRA] 81-651 through [HRA] 81-657. Health Resources Administration, Hyattsville, Maryland1980: 1-7
        • Schwartz WB
        • Sloan FA
        • Mendelson DN
        Why there will be little or no physician surplus between now and the year 2000.
        N Engl J Med. 1988; 318: 892-897
        • Leape LL
        • Park RE
        • Solomon DH
        • Chassin MR
        • Kosecoff J
        • Brook RH
        Does inappropriate use explain small-area variations in the use of health care services?.
        JAMA. 1990; 263: 669-672
        • Roos NP
        • Roos LL
        • Henteleff PD
        Elective surgical rates—do high rates mean lower standards? Tonsillectomy and adenoidectomy in Manitoba.
        N Engl J Med. 1977; 297: 360-365
        • Sulmasy DP
        Physicians, cost control, and ethics.
        Ann Intern Med. 1992; 116: 920-926