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The painful prescription: rationing hospital care.

The Painful Prescription: Rationing Hospital Care.

By Henry J. Aaron and William B. Schwarz. Washington, The Brookings Institution, 1984. 161 pp. $22.95, cloth; $8.95, paper.

This is a comparative study of the American and British health care systems that combines both the skills of an economist from the Brookings staff, Henry J. Aaron, and of a physician, William B. Schwarz, of the Tufts Medical School faculty.

As a result, interested readers--even if they have special knowledge in one of these fields--are likely to gain some new understanding in the other. Moreover, because of the successful blending and interlacing of the two kinds of information and concerns in identifying and analyzing the problem areas, and the generally nontechnical presentation, readers will find the book stimulating and rewarding regardless of their professional background or lack of specialized knowledge.

Health care, for some years, has been a timely and urgent subject and is certain to remain so for years to come because of the continuing progress of medical science and technology and the ensuing trend toward their utilization both in more sophisticated diagnostic and treatment methods, at ever increasing costs.

Sooner or later, this trend was bound to raise questions as to whether the successes achieved in (1) early recognition and correct assessment of patients' morbid conditions, and (2) healing them or, at least, alleviating the ill effects and suffering they cause were sufficient to warrant the ever greater share of money from all sources, especially public expenditures allocated to financing medical, hospital, and related services, both in absolute amounts and in the percentage of a nation's total expenditures for all purposes combined. What are the appropriate criteria for answering this question? How can one identify and define the limits beyond which greater expenditures no longer seem to produce beneficial results of like value? This is what the book is all about, with special emphasis on hospital care, notably for serious, often life-threatening diseases, in contrast to emergencies requiring hospitalization for the care of physical conditions that are not normally serious or of extended duration, or in the case of an accident victim.

After an exposition of the methodological problems of comparing health care and costs in Britain and the United States and stating initial hypotheses as to British attempts at cost containment (ch. 1), there follows a fairly comprehensive summary of the structure and working of the British National Health Service and the supplementary role of the private sector (ch. 2). More specific descriptions, highlighting the differences between British and U.S. uses of new technological aids, follow in the next three chapters. For example, life and death syndromes involving kidney dialysis and transplantation, and radiotherapy as well as chemotherapy to treat cancer are discussed in chapter 3; hip replacement and heart-bypass surgery in chapter 4; and diagnostic fine tuning through the use of CT scanners and the extensive diagnostic use of x rays in chapter 5. The last three chapters focus on rationing techniques and appraisals of efficiency in both the British and American settings.

What are the findings of this comparative study? Starting from what the authors deem to be the norm for hospital care in the United States--and with important exceptions-- namely, the near-maxim "if it will help, do it,' they view health care in this country "usually close to what would be provided if costs were no object and benefits to patients were the sole concern.

Add to this tradition the "deliberate goal of public policy in recent decades,' namely to insulate the patient from the cost of care (with private insurance, government programs, or payments from someone other than the patient) and the cost increases brought about are bound to suggest that some limits be placed on the excessive growth of these expenditures. Hence, the authors do expect (more) Federal and State efforts to keep costs down. With this prospect in view, British experience is likely to prove instructive, for "Britain has drastically curtailed the real growth of medical expenditures for an extended period. As a result, per capita hospital expenditures are now less than half as large as those in the United States.'

The core of the book lies in the authors' observations and interpretations of their field studies of the British National Health Service (NHS) and the ways in which its institutions and procedures, its medical and ancillary personnel and, not least, its patients, have managed to realize and to accept such cost containment. These passages are, for the most part, insightful and sometimes fascinating--most of all in raising various aspects of the hard-to-achieve compatibility of clinical freedom with budget constraints, or in assessing the role that traditional national mindsets play in providing different answers to this dilemma.

The authors leave it to the readers to judge whether their own conclusions and interpretations seem plausible in light of the evidence. In this reviewer's opinion, most of them do, especially the concluding generalizations that "the choices we face [in the United States] are clear and painful,' and that "rationing will inevitably be a painful prescription.' On the other hand, which of the authors' findings "persuaded' them "that the United States is not interested in creating a national health service on the British model'--unless, surprisingly, state planning is viewed by many Americans in the way the authors claim it was in Great Britain at the time of the NHS's conception, namely that ". . . the war was widely regarded as a triumph for state planning . . .'
COPYRIGHT 1987 U.S. Bureau of Labor Statistics
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1987 Gale, Cengage Learning. All rights reserved.

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Author:Rohrlich, George F.
Publication:Monthly Labor Review
Article Type:Book Review
Date:May 1, 1987
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