Education And Debate

Dilemmas in rationing health care services: the case for implicit rationing

BMJ 1995; 310 doi: (Published 24 June 1995) Cite this as: BMJ 1995;310:1655
  1. David Mechanic, visiting fellowa
  1. a King's Fund Institute, London W2 4HT
  • Accepted 21 March 1995

With tension between the demand for health services and the cost of providing them, rationing is increasingly evident in all medical systems. Until recently, rationing was primarily through the ability to pay or achieved implicitly by doctors working within fixed budgets. Such forms of rationing are commonly alleged to be inequitable and inefficient and explicit rationing is advocated as more appropriate. Utilisation management in the United States and quasimarkets separating purchasing from provision in the United Kingdom are seen as ways of using resources more efficiently and are increasingly explicit. There is also advocacy to ration explicitly at the point of service. Mechanic reviews the implications of these developments and explains why explicit approaches are likely to focus conflict and dissatisfaction and be politically unstable. Explicit rationing is unlikely to be as equitable as its proponents argue and is likely to make dissatisfaction and perceived deprivation more salient. Despite its limitations, implicit rationing at the point of service is more sensitive to the complexity of medical decisions and the needs and personal and cultural preferences of patients. All systems use a mix of rationing devices, but the clinical allocation of services should substantially depend on the discretion of professionals informed by practice guidelines, outcomes research, and other informational aids.

Medical care has always been rationed by the supply available, by its distribution, and by the public's ability to pay. As medical care has become more important in people's lives, and as its capacity to impact on health has grown, government has taken increasing responsibility either for providing medical services directly or for mandating them through an insurance system. Governments in all nations seek means to limit public expenditure and mandates for health services. Explicit approaches include fixed global budgets and limits on the benefit package and eligible providers. Rationing also …

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