Health care rationing is a politically charged issue that evokes deep emotional reactions from a variety of individuals and institutions: politicians, patients, payors and providers. Despite widespread agreement that resources to sustain current trends in health care spending are inadequate, the role of rationing in U.S. health care reform remains polarizing.
But what exactly is health care rationing?
Rationing is a term used to describe allocation of resources in the context of scarcity, which exists in health care when the need for services exceeds the resources to provide services. Thus, health care rationing involves decisions to withhold beneficial services for reasons associated with inadequate resources.
Rationing is best discussed in the context of health-care decision making, which is made at multiple levels within the system:
• the macro level, where policy is established by governments, health authorities, insurance plans, etc.;
• the meso level, where organizational budgets are established by organizational administrators; and
• the micro level, where care is delivered by clinicians.
Macro- and meso-level decisions are most commonly made by administrative authorities in the form of explicit policies and fixed budgetary allowances. Such policies are typically rule based and broadly applied. Decisions of this form that result in withholding health care are administrative and/or political in nature and are considered a form of explicit rationing.
In contrast, decisions about withholding care at the micro level are typically applied to specific patients and contexts based on the judgment of frontline clinicians. Decisions of this form are clinical and discretionary in nature and are considered a form of implicit rationing, also known as bedside rationing.
Most of the political rhetoric and media attention about health care rationing has centered on explicit rationing, while implicit rationing has received comparatively little attention. This is not surprising since policymaking is more visible to the public than bedside clinical decision making. Consequently, implicit rationing has been characterized as a form of hidden rationing that remains largely invisible to the public and possibly to patients themselves.
In essence, cost containment strategies shift the burden of responsibility for rationing decisions from policymakers to clinicians. Additionally, the decision-making process is shifted underground from the visible world of policymaking to the invisible world of clinical-decision making. Invisible decisions are inherently more difficult to measure and evaluate and invisible decision makers more difficult to hold accountable.
As prescribers of medical care, physicians are often viewed as gatekeepers for access to health care. However, health care extends beyond medicine to include multiple clinical disciplines, and access to medical care requires more than a physician prescription. Although medical care may be prescribed by physicians, it is largely accomplished through the interdependent and collaborative efforts of other disciplines, particularly nursing.
For example, physicians may prescribe medications, diets and procedures, but it is the nurse that must administer them. When the volume of care prescribed exceeds the available time among the nursing staff on duty, decisions must be made about which elements of care are completed and which are delayed or left undone. This might mean that, in order to administer all prescribed medications on time, a nurse may cut back on the amount of teaching provided, limit the frequency in which patients are assisted to the bathroom or skip a scheduled blood pressure assessment.
The frequency and patterns of implicit rationing of nursing care in the U.S. are not known. Furthermore, the practice of implicit rationing may not be generalizable across countries due to the variability in systems of health care delivery, health care reimbursement and nursing education. Given the U.S aversion to explicit rationing and the prevalence of cost containment initiatives among U.S. health care organizations, it is imperative that implicit rationing practices be more thoroughly explored and evaluated.
A study I recently completed provides evidence that implicit rationing may be a routine component of clinical decision making among medical-surgical nurses in at least one U.S. state. Moreover, it suggests that, when faced with time scarcity, medical-surgical nurses may favor completion of activities to address direct and immediate physiological health needs over psychological and future health needs.
The documented presence of implicit rationing of nursing care in the U.S. health care system has important implications for research, practice and education. Research is needed to determine if the relationships documented in other countries between implicit rationing and adverse patient outcomes are also present in the U.S. If these relationships are supported, then implicit rationing may serve as an important quality indicator.
A better understanding of the decision-making process is needed to guide quality assessment of rationing preference patterns and develop strategies to support “good” rationing decisions. Nurse leaders must create opportunities to learn more about the underlying rationale for rationing preferences and what information is considered when deciding among choice options.
Finally, more research is needed to assess relationships between specific preferences patterns; for example, completion of direct and immediate physiologic care activities and patient outcomes to support value judgments about the quality of rationing decisions.
Armed with this information, educators can better guide clinicians toward choice options associated with favorable risk-benefit profiles.
—Terry Jones, RN, PhD, assistant professor
Jones, Terry. (2014). Validation of the perceived implicit rationing of nursing care (PIRNCA) instrument. Nursing Forum, (early release online January 8, 2014). Doi:10.1111/nuf.12076
Jones, T. (in press). A descriptive analysis of implicit rationing of nursing care: frequency & patterns in Texas. Nursing Economic$