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Abstract
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.
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Article info
Publication history
Accepted:
October 9,
1992
Identification
Copyright
© 1993 Published by Elsevier Inc.
