Book Review

Pricing Life: Why it's time for health care rationing

N Engl J Med 2000; 342:1059-1060April 6, 2000

Article

Pricing Life: Why it's time for health care rationing
By Peter A. Ubel. 208 pp., illustrated. Cambridge, Mass., MIT Press, 2000. $25. ISBN: 0-262-21016-9

In this book, Peter A. Ubel discusses the important and controversial issue of health care rationing in a logical, carefully defined, and well-substantiated manner. He accurately points out that rationing of health care services is essential in any society in which resources are not unlimited. Simply stated, this means that not everyone can have everything he or she wants. Ubel skillfully deals with the ethical and moral dilemmas that result from these limitations. He points out that health care is rationed at many levels — for instance, by federal policy mandates, insurers' reimbursement policies, and physicians' decisions at the bedside. Ubel presents a lengthy description of cost-effectiveness analysis, accompanied by a discussion of the pitfalls of this method when it is applied to the rationing of health care services. He notes the frequent discordance between findings derived from cost-effectiveness analysis and those obtained by direct community interviews or surveys. His discussion of his own substantial and innovative research on people's preferences for the allocation of health care resources is excellent. Ubel has made important contributions to our understanding of how people make choices about health care and of the factors that enter into those decisions. In this book he notes that it is very difficult to predict individual responses to questions about resource allocation and that responses can be manipulated by subtle alterations of the frame of reference in which the data are presented. Ubel attempts to convince the reader that, by incorporating analyses of the quality of life and measured community preferences, cost-effectiveness analysis can be improved sufficiently to become a useful and dominant tool for guiding health care rationing. He makes a forceful case against rationing by the physician at the bedside.

Several aspects of this book detract from its high points. First, it gives the impression that the physician always knows the efficacy of a treatment or the value of a test in each situation. Second, it is assumed that the belief of the physician about what should be done in a specific situation is representative of the choice the patient would make, given the same information. Ubel neglects to discuss the physician as the patient's agent, who ideally would understand the preferences and wishes of the patient and thereby represent the patient accurately.

Ubel speaks of the added benefits of costly new developments in health care technology but ignores the reality that many less expensive approaches to care are extremely safe and effective. The added benefits of new techniques may be statistically significant for the population but may have no benefit for the individual patient. The unstated but consistent message of the book is that there are adequate data on outcomes to support therapeutic or diagnostic decisions firmly, when in reality we have barely enough data to make statistical recommendations. In his discussion of resource allocation and setting priorities for expenditures, Ubel does not mention disease prevention, such as the use of weight reduction and nutritional management to lower the risks of hypercholesterolemia and hypertension. He does mention early diagnosis and screening, but not how these techniques are to be supported.

Ubel inaccurately attributes much of the excess use of health care to insurance abuse (use of more resources by a patient than he or she pays for) and labels this problem a “moral hazard.” What he is actually observing is the perverse effects of subsidized insurance premiums, a phenomenon that blunts the elasticity of the consumers' response to increases in health care consumption and to actual increases in cost. The cost of health insurance for most employees is supported by tax incentives for their employers and is exchanged for a portion of employees' wages.

Even in the best sections of this book, no theoretical framework guides the author's research or recommendations. Part of the difficulty of making policy recommendations in the absence of a theory is the inability to generalize findings to situations outside the study environment. The only theories discussed were those of justice, which did not hold up well when tested in populations. The author notes that he is not an organization theorist or an economist, but this should not impede the use of sound theories as the foundation of research and eventual policy formulation.

Wallace F. Berman, M.D.
Virginia Commonwealth University, Richmond, VA 23298