Rationing and health care reform: not a question of if, but when

Evidence-based medicine and rationing have been increasingly discussed in the context of health care reform recently. Both concepts are frequently the source of heated debate, leading to polarization of different health care practitioners and public parties. In some public arenas, rationing has become a dirty word. The term evidence-based medicine is perceived as being used as a "cover" for rationing. However, rationing is widespread, whether explicit or implicit, and exists within health care. Evidence-based medicine (or imaging) and rationing overlap considerably, and it looks like both are here to stay, given the current state of developed-world health care systems and the proposed reforms. The authors review these entities and argue that evidence-based medicine (or imaging) is one form of health care rationing. Rationing already occurs, and it is important that it be done in a way that provides the greater good for the majority. This article reviews the history of rationing and evidence-based medicine, the reasons evidence-based medicine and rationing are necessary, examples of rationing that already exist (economic), proposed forms of rationing (age based), the need for physicians (radiologists) to be at the forefront of any rationing efforts, and the basis (cost and comparative effectiveness research and evidence-based medicine) and principles of physician decision rationing (optimum outcome-based rationing) in the context of proposed health care reforms.