University of York.
J Health Polit Policy Law. 2013 Dec;38(6):1103-27. doi: 10.1215/03616878-2373157. Epub 2013 Aug 23.
All public and private health care systems ration patient access to care. The private sector rations access to consumers who are willing and able to pay. The poor and disadvantaged have limited access to care and inadequate income protection. In public health systems, care is provided on the basis of "need," that is, the comparative cost-effectiveness of competing treatments. This results in patients being deprived of care if treatments are clinically effective but not cost-effective. Rationing health care is ubiquitous. In both types of systems physicians have discretion to deviate from these rationing principles. This has created inefficient variations in clinical practice. These are difficult to resolve because of the lack of transparency of costs and patient outcomes and perverse incentives. The failure to remove universal inefficiency in a period of economic austerity sharpens awareness of rationing. Hopes of greater efficiency are largely faith based. Competing ideologues from the left and the right continue to offer evidence for free solutions to long-established problems. Inefficiency is unethical, as it deprives potential patients of care from which they could benefit. Reducing inefficiency is essential but difficult. The universal challenge is to decide who shall live when all will die in a world of scarce resources.
所有公共和私人医疗保健系统都对患者的医疗服务进行配给。私营部门对有意愿和有能力支付费用的消费者进行配给。穷人和弱势群体获得医疗服务的机会有限，收入保障不足。在公共医疗体系中，医疗服务是基于“需求”提供的，即对竞争性治疗方法的相对成本效益进行评估。这导致如果治疗方法在临床上有效但不具有成本效益，患者就会被剥夺治疗机会。医疗服务配给是普遍存在的。在这两种类型的系统中，医生都有自由裁量权来偏离这些配给原则。这导致了临床实践中的低效差异。由于缺乏成本和患者结果的透明度以及不良激励，这些差异难以解决。在经济紧缩时期，未能消除普遍存在的低效现象，使人们更加意识到配给问题。对更高效率的希望在很大程度上是基于信仰。来自左右两翼的竞争意识形态者继续为长期存在的问题提供免费解决方案的证据。效率低下是不道德的，因为它剥夺了潜在患者可能从中受益的治疗机会。减少低效是必要的，但很困难。普遍的挑战是，在资源稀缺的世界中，当所有人都将死亡时，应该由谁来决定生存。
