Rationing surgery: rules or constraints?

As U.S. health care expenditures climb, the need to set limits on surgery is becoming more generally accepted. If limits are necessary, how should they be established and by whom? This article considers two fundamental approaches, rules and constraints.

With rules, payers or policymakers ration care by prioritizing and then restricting specific procedures. Although they have the advantage of explicitness, rules based on treatment prioritization are limited by patient heterogeneity and the lack of outcomes data necessary to rank many procedures. Rules are unambiguous and free the surgeon from the obligation to set limits, but they do not accommodate clinical judgment or patient preferences. With constraints, limits are set on surgical resources (e.g., the number and distribution of surgeons), but individual surgeons determine which procedures are provided to which patients. Although constraints are more feasible than rules, it is difficult to establish an "adequate" supply of surgical resources and to ensure that limits set by the individual surgeon are based on treatment efficacy. While preserving clinical autonomy, constraints require the surgeon to assume the responsibility of rationing care.

Surgeons should consider carefully the approach to rationing that best serves their professional interests, their patients, and society.