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Sunday, June 28, 2009

Health care- needs vs. wants

Sometimes it is the simplest questions which needs to be asked to address the most complicated problems. The health care reform debate has a dizzying array of elements; economic, legal, moral, and practical. At the heart of the debate is a moral question- "is health care a right?"

In order to define whether health care is a legal right, it is essential to define what health care is. One can approach this question using general rules or by developing extensive menus of what and what does not fall under the category of health care. Either way, creation of a legal right to health care creates the requirement to standardize a menu of included and excluded services and context where the rules apply.

In order to develop such lists, we need to come to grips with a very fundamental issue. Does the right to health care confer the right to what patients want or does it confer the right to what someone else believes that they need? It is relatively easy to define what people want since their desires are self defined. It is much more difficult to define other people's needs.

Within the context of clear acute life and death issues, it may be possible to make such a call.
However, much of health care occurs under more mundane circumstances. There are about 30 million hospital admissions each year in the US. However, there are over 1 billion ambulatory visits annually in the US. These ambulatory visits are frequently focused on the management of chronic conditions which may be uncomfortable and function limiting. What do patients in these circumstances need and can these needs be separated from their wants? Are "expensive" interventions which have no impact on life expectancy but improve patient quality of life in the realm of needs or wants?

If definition of the scope of a health care right is based upon patient needs, who makes those decisions and upon what criteria? Creation of entities which measure effectiveness of interventions relies upon defining what constitutes effectiveness. Obviously use of life or death metrics use clear and unambiguous endpoints. However, such endpoints have only limited utility when trying to assess the vast majority of interventions which occur in more mundane, non-life or death settings.

Given these ambiguities, what do patient have the right to? Who draws the line and upon what criteria? How often do the criteria change?

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