Rationing Obesity Care

One of the big hot button issues of Obamacare, healthcare rationing, has faded from public debate. But rationing of bariatric surgery — arguably a life-saving procedure — was a fact of life long before passage of the Affordable Care Act, and it continues to this day. A new publication in Social Science and Medicine by Amanda Owen-Smith, Jenny Donovan, and Joanna Coast describes how this works in the UK’s National Health System.

They find that patients are well aware of the rationing, despite the fact that physicians mostly don’t discuss it. While outright denial of treatment is uncommon, subversive rationing is more routine, through practices of:

• Selection. Setting criteria for medical eligibility that raise the threshold of eligibility for treatment.
• Delay. Making patients wait serves to limit the numbers who ultimately receive care.
• Deterrence. Waiting time and barriers other than medical criteria that keep patients from receiving care.
• Deflection. Sending patients to other programs and providers.

 
Rationing by selection was the most common means employed to limit access to obesity surgery, but delay was also very common. Rationing by dilution — cutting resources so that the quality of care suffers — was not found to be common.

The situation in the U.S. is different because of fundamental differences between the the U.S. and UK healthcare systems. Limits are applied through different means. The most common means for rationing are outright denial of care and dilution. In 27 states, people who buy insurance themselves or get it through small employers are denied coverage for bariatric surgery. That’s because those states did not define bariatric surgery as an essential health benefit.

Dilution occurs when reimbursement rates under Medicaid and even Medicare programs are so low that providers find ways to avoid delivering care to patients in those programs.

So, rationing of surgical care for obesity is common in both the U.S. and the UK, even though the means for it are different. But as the burden of untreated obesity grows, it’s become increasingly clear that this implicit rationing is irrational.

Click here for the study of bariatric surgery rationing in the UK. Click here and here if you want to a broader perspective on how medical care rationing has dropped out of view in the U.S.

Off Limits, photograph © Kylie Jaxxon / flickr

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December 29, 2015