Rationing Influenza Vaccine
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《新英格兰医药杂志》
It was two days after the presidential election and only a week after the Red Sox won the World Series, but all anyone could talk about at my Boston hospital was influenza shots. I saw 12 outpatients and 1 inpatient that Thursday morning, and all but one asked whether they could get the influenza vaccine.
I told them all no. Our hospital, which logged more than 200,000 outpatient visits for primary care last year, had only 2000 doses for primary care patients, and there was no way we could come close to covering all our patients who were part of the priority groups designated by the Centers for Disease Control and Prevention (CDC). We were still working out how we were going to choose among the elderly, the sick, and the not-so-sick. I told the patients who inquired to call back next week, when we could tell them whether we had a flu shot for them. To three of them — elderly patients with heart failure or cancer — I said I was optimistic that they would qualify, but I was careful not to offer a guarantee.
Outside my office, I could hear other physicians, nurses, and secretaries at the hospital having the same conversation. I realized that we were doing something new — performing a clinical function that we had, until now, only heard about and feared. We were rationing.
In the past, with incentives from various kinds of managed-care contracts, we had made earnest efforts to become more efficient — but this was different. Before, we had tried to eliminate care that was likely to offer no value to our patients. Now, we were withholding care that we knew to be beneficial for the patient in front of us, because there was another patient out there who would benefit even more.
We had some encouragement from the Commonwealth of Massachusetts, which, like many other states, instructed physicians to withhold flu shots from patients who do not meet the criteria outlined in the CDC guidelines. Just in case we missed the point, our state issued a notice that "whoever violates any provision of this Order shall be punished by a fine of not less than fifty dollars nor more than two hundred dollars or by imprisonment for not more than six months, or both."1
The threat of prison time (presumably minimum security) wasn't really necessary. We were so far short of an adequate supply that we needed to be far more restrictive than the CDC guidelines permitted. At some of our practices, physicians are being asked to identify their 10 highest-risk patients and let them know that they can come in for their vaccination.
Now here is the first surprise of this experience: hardly anyone is complaining. Some physicians mutter that someone somewhere should pay for the incompetence that created this shortage — after all, we know that people are going to die unnecessarily this year because they didn't get flu shots. Nevertheless, most doctors are focusing on the work at hand, aware that we are doing something important — trying to care for our overall population, not just the person before us.
Surprise number two is how natural the work seems. As hard as this triaging is, most physicians understand that they are better trained to do it than anyone else. Prior research has shown that, when we have to do it, physicians are amazingly effective at figuring out which patients really need scarce resources.2 We quickly learned to tell patients, "The good news is that you are too healthy to get a flu shot this year."
We already joke about the personality types associated with flu-shot requests. There are the Optimists ("I think I'll have my flu shot today"), the Ashamed ("I hate to ask, but my wife is insisting . . ."), the Fatalists ("I don't qualify for a flu shot, do I?"), and the Survivors ("Tell me what I have to do to get one").
Are there lessons about rationing to be learned from this experience that might be relevant to our longer-term challenges in health care? For as medical progress races ahead, resources remain constrained. We are sure to face more and more situations in which we cannot provide treatments such as implantable defibrillators and high-cost chemotherapies or antiviral agents to all who could benefit from them.
With the flu-shot crisis, everyone — including the patients — knows that the shortage is not artificial. The problem is not some company's unwillingness to pay for care or society's reluctance to suffer a tax increase. Patients are not questioning physicians' financial motives. And most patients say they want their flu shots to be saved for patients who are sicker than they are.
The flu-shot shortage may never be repeated, and we may never again be as successful in persuading doctors and patients that the rationing of care is appropriate. After all, the American Way is for each person to try to get everything that might be beneficial. However, this season's experience suggests that, if the need is genuine and clearly understood, physicians and patients can deal with limited resources and unlimited demand with grace and dignity.
References
Revised order to establish rules and priorities for the distribution and use of influenza vaccine. Boston: Commonwealth of Massachusetts, 2004. (Accessed November 10, 2004, at http://www.mass.gov/dph/cdc/epii/flu/flu_order.htm.)
Singer DE, Carr PL, Mulley AG, Thibault GE. Rationing intensive care -- physician responses to a resource shortage. N Engl J Med 1983;309:1155-1160.(Thomas H. Lee, M.D.)
I told them all no. Our hospital, which logged more than 200,000 outpatient visits for primary care last year, had only 2000 doses for primary care patients, and there was no way we could come close to covering all our patients who were part of the priority groups designated by the Centers for Disease Control and Prevention (CDC). We were still working out how we were going to choose among the elderly, the sick, and the not-so-sick. I told the patients who inquired to call back next week, when we could tell them whether we had a flu shot for them. To three of them — elderly patients with heart failure or cancer — I said I was optimistic that they would qualify, but I was careful not to offer a guarantee.
Outside my office, I could hear other physicians, nurses, and secretaries at the hospital having the same conversation. I realized that we were doing something new — performing a clinical function that we had, until now, only heard about and feared. We were rationing.
In the past, with incentives from various kinds of managed-care contracts, we had made earnest efforts to become more efficient — but this was different. Before, we had tried to eliminate care that was likely to offer no value to our patients. Now, we were withholding care that we knew to be beneficial for the patient in front of us, because there was another patient out there who would benefit even more.
We had some encouragement from the Commonwealth of Massachusetts, which, like many other states, instructed physicians to withhold flu shots from patients who do not meet the criteria outlined in the CDC guidelines. Just in case we missed the point, our state issued a notice that "whoever violates any provision of this Order shall be punished by a fine of not less than fifty dollars nor more than two hundred dollars or by imprisonment for not more than six months, or both."1
The threat of prison time (presumably minimum security) wasn't really necessary. We were so far short of an adequate supply that we needed to be far more restrictive than the CDC guidelines permitted. At some of our practices, physicians are being asked to identify their 10 highest-risk patients and let them know that they can come in for their vaccination.
Now here is the first surprise of this experience: hardly anyone is complaining. Some physicians mutter that someone somewhere should pay for the incompetence that created this shortage — after all, we know that people are going to die unnecessarily this year because they didn't get flu shots. Nevertheless, most doctors are focusing on the work at hand, aware that we are doing something important — trying to care for our overall population, not just the person before us.
Surprise number two is how natural the work seems. As hard as this triaging is, most physicians understand that they are better trained to do it than anyone else. Prior research has shown that, when we have to do it, physicians are amazingly effective at figuring out which patients really need scarce resources.2 We quickly learned to tell patients, "The good news is that you are too healthy to get a flu shot this year."
We already joke about the personality types associated with flu-shot requests. There are the Optimists ("I think I'll have my flu shot today"), the Ashamed ("I hate to ask, but my wife is insisting . . ."), the Fatalists ("I don't qualify for a flu shot, do I?"), and the Survivors ("Tell me what I have to do to get one").
Are there lessons about rationing to be learned from this experience that might be relevant to our longer-term challenges in health care? For as medical progress races ahead, resources remain constrained. We are sure to face more and more situations in which we cannot provide treatments such as implantable defibrillators and high-cost chemotherapies or antiviral agents to all who could benefit from them.
With the flu-shot crisis, everyone — including the patients — knows that the shortage is not artificial. The problem is not some company's unwillingness to pay for care or society's reluctance to suffer a tax increase. Patients are not questioning physicians' financial motives. And most patients say they want their flu shots to be saved for patients who are sicker than they are.
The flu-shot shortage may never be repeated, and we may never again be as successful in persuading doctors and patients that the rationing of care is appropriate. After all, the American Way is for each person to try to get everything that might be beneficial. However, this season's experience suggests that, if the need is genuine and clearly understood, physicians and patients can deal with limited resources and unlimited demand with grace and dignity.
References
Revised order to establish rules and priorities for the distribution and use of influenza vaccine. Boston: Commonwealth of Massachusetts, 2004. (Accessed November 10, 2004, at http://www.mass.gov/dph/cdc/epii/flu/flu_order.htm.)
Singer DE, Carr PL, Mulley AG, Thibault GE. Rationing intensive care -- physician responses to a resource shortage. N Engl J Med 1983;309:1155-1160.(Thomas H. Lee, M.D.)