Is parsimonious medicine only about avoiding wasteful care?

walker
Jon Tilburt and Christine Cassel
make a distinction between parsimonious medicine and rationing:

parsimonious medicine is not rationing; it means delivering appropriate health care that fits the needs and circumstances of patients and that actively avoids wasteful care—care that does not benefit patients.

I agree with Tilburt and Cassel that parsimonious care is ethical care. But I am not sure that it is only a matter of avoiding waste. I would defend a form of parsimonious medicine where only certain kinds of care were covered by a public system, even though a more expensive form of care did provide additional benefit.

There are considerable savings in health care that could be achieved by not delivering expensive care that does not benefit patients (Tilburt and Cassel cite the example of routine screening with cardiac computed tomography or chest radiography in an asymptomatic patient). I agree that doctors should not supply care that has well-demonstrated lack of benefit. Of course, this is not the modal case. It is far more common to have little or no evidence, or doctors may have reason to doubt existing studies that do not demonstrate benefit.

However, there are other care decisions where there is a choice between expensive care that benefits patients and inexpensive care that delivers less benefit. If you spend time in both the US and Canada you notice far more elderly people on walkers and canes in Canada. A total hip replacement costs $20,000 to $40,000 in the United States. The cost of a walker is $100 – $500 and a few years of over-the-counter pain medication might be another $1000. Let’s stipulate that even including a small surgical risk and 6 weeks recovery time, the quality of life improvements of a new hip exceed those of a walker and pain meds. But the new hip costs thirty times as much.

Here is something else you notice if you are well-off and get medical care in both the US and Canada. In the US, the facilities are often nicer. A few years ago, my wife had a procedure in a US orthopedic speciality hospital. The lobby was a three-story atrium that included a waterfall from the ceiling to a central pool. The architecture was beautiful and would not have been out of place in a hotel in Aspen, but the medical justification was not clear to me. However, our insurance covered it and this is where her surgeon practiced. In Canada, there is far less gold-plating of the amenities. That said, spending time in a hospital that is a nicer hotel is a benefit. Moreover, it is a benefit that many patients value.

In these cases, I believe that the Canadians are making better choices. They are asking people to make do on walkers while waiting for hip replacements and to forego hospital decorations so that more people can be cared for at a lower overall cost. This is rationing. But it is also parsimony in the everyday meaning of the word: frugality, the unwillingness to expend resources unnecessarily. Americans should stop paying for care that doesn’t work. However, providing decent care to all US citizens while simultaneously  limiting the growth of medical spending will also require frugality and parsimony for those not able to pay out of pocket. Tilburt and Cassell have defined parsimony in a way that makes it an objective matter of science and evidence. That sense of parsimony is easier to defend. But it won’t get us out of arguing about what we value in medical care.

See also Austin Frakt.

About Bill Gardner

A health care researcher and a child and quantitative psychologist by training. I am an American living in Canada and am Professor of Paediatrics, Obstetrics & Gynaecology, and Community Health & Epidemiology at Dalhousie University; and Professor of Pediatrics, Psychology, and Psychiatry at The Ohio State University. I also blog at The Incidental Economist (theincidentaleconomist.com) and you can follow me @Bill_Gardner on Twitter.
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