Rationing and regionalisation of health care services: a critical care physician's opinion.

It is becoming apparent that we have created a demand for medical goods and services that threatens to overwhelm our health care system. Present fiscal policies for financing health care such as excluding a large portion of the population are clearly unacceptable to the public. Current reimbursement policies for health care providers are so murky and, in some cases, so conflicting that they could have been designed only as a method of rationing by inconvenience. Some improvements in the cost effectiveness of health care delivery are needed without increasing the administrative and regulatory bureaucracy currently feeding on itself. Regionalisation of medical services has proven to be cost-effective in the specialties of trauma and neonatology. There is accumulating evidence that this same concept, using severity of illness scoring as an objective marker of potential benefit, may maximise cost/benefit for medical and surgical critical care patients. However, multifaceted deterrents to the concept of regionalisation must be addressed, including reimbursement problems, logistics of bed occupancy and physician incentives to participate.