Rational Rationing

"Healthcare has to be rationed. The only question is how best to do it."

So writes Dr Crippen in his latest post is on the subject of, well, rationing healthcare.

Dr Crippen believes that one of the causes for the long waiting time in the NHS is abuse of healthcare by "people who do not understand that health care is expensive", and advocates a front-end charge for healthcare.

"There needs to be a front end charge for health care. Yes, a “charge” at the point of entry. That charge needs to be a percentage of the costs of care that each patient needs. And yes, that means that some will pay more than others; that those with poor health will pay more. The system must be properly safety netted by means testing so that none will be denied health care because of cost but all must pay something."

It's a controversial idea for those used to the 'free at the point of delivery' NHS, but here in Singapore we are already familiar with the concept of co-payment.

Unfortunately, in angry doc's experience, co-payment does not always eliminate abuse; it merely imposes a fee for abusing healthcare.

People will continue to use the healthcare system inappropriately as long as they can afford it, and means testing will not be a satisfactory tool in discouraging people from abusing the system.

Let's look at a couple of hypothetical scenarios.

Mr A makes $4500 a month. He lives with his elderly mother who had a stroke, his wife, and their two children.

Mr A wants to bring his family for an overseas trip for a week, but does not want to bring his bed-bound mother along. He brings her to the emergency department and 'requests' that she be admitted. As his monthly per capita household income is $900, he passes the means test and his mother is warded into C-class.

Mr B makes $2200 a month. He is unmarried and lives with his elderly mother, who also had a stroke. His bed-bound mother gets a urinary tract infection. He brings her to the emergency department, where the doctor advises her to be admitted for treatment. As Mr B's monthly per capita household income is $1100, he fails the means test and his mother is warded into B2-class.

Is that fair?

But what if Mr A pays B2 rates for his mother's admission?

What if Mr A pays A-class or non-subsidised rate? Does that mean he is not abusing healthcare?

angry doc believes what determines abuse of healthcare is not whether one pays for it, but whether one actually needs it. Setting arbitrary income-levels to decide who gets how much subsidy is not going to change the fact that fundamentally, most of us feel that given a situation where resources are limited, they should go to those who need them most.