By Andrew Hantel, Gregory Abel, Mark Siegler
Few people would consider rationing to be a positive concept. When confronted with restricted access to something we want or need, we inevitably react with negative feelings. Such a reaction belies the overall concept of allocating a scare resource and distracts from the good that can come from that process. When concentrating on the restrictions inherent in rationing, we discount the expansion of access, as well as fairness, that rationing can bring to a previously haphazard and unjust situation. When addressed objectively, our response becomes: does the expansion of access (for some) and concerted distribution provided by systematic rationing outweigh the restriction of access (for others) and imperfections inherent in that distribution?
For several healthcare goods that have significant differences in supply and demand, such as transplantable organs, the communal answer to this question has been a qualified ‘yes.’ In these instances, supply is relatively fixed and one can assume that the expansion and diminution of access for the eligible population as a whole is zero-sum. For these scarce healthcare goods, the question turns on whether or not the medical community can create a system of distribution that is fair enough to be worth the effort of redistributing access from an ad hoc approach.
In our article, “A Practical Allocation System for the Distribution of Specialized Care during Cellular Therapy Access Scarcity,” we argue that such systems can, and should, be utilized during chronic personnel shortages such as those encountered in cellular therapy for cancer. In these instances—which can be thought of as expansions on emergency medicine triage—the scarce resource is subspecialty treatment itself. Unlike a material good, however, this resource is less fixed and therefore not zero-sum. First, the limitation of access for a one time-intensive case may yield treatment for two or more others. Second, and more importantly, the consideration and implementation of such an allocation system can spur innovations in care delivery, and with those innovations, an overall expansion of access.
When a scare resource is not fixed, its supply is more difficult to measure, and its scarcity more opaque. As a result, the leap from endemic personnel shortages to allocation or triage is taken only when shortages are egregious, longstanding, and there is little hope for their resolution. With cellular therapy specialists, shortages are not yet dire or longstanding, but even a small difference between the number of patients needing therapy and the number of therapies that can be given leads to patient deaths. To date, the groundbreaking advances of cellular therapy have been met by a relatively stagnant specialist workforce. If expected expansions of these highly morbid but highly successful treatments continue with little forethought regarding how to triage this care, denials of treatment will begin in an ad hoc and unjust manner.
This does not have to be case. First, new capacity assessments of cellular therapy programs must occur on a national scale in order to determine how many patients each program can care for. Second, cellular therapy experts and ethicists must consider how to create systems of allocation by which patients can be justly prioritized for these life-saving interventions. Our article outlines such a framework and methods for implementation. Third, innovative care strategies during both treatment and survivorship must be considered in order to reduce the burden of patients being followed by this scarce workforce. Established models of care transitions between oncologists and primary care physicians can be used as a basis for this strategy. Fourth, ongoing measures of programmatic outcomes for both patients treated with cellular therapy and those unable to receive these treatments must be obtained to understand where improvements can be targeted and triage systems refined. Finally, the perspective of those involved in these systems—patients and cellular therapy providers—need to be assessed to understand the impact of personnel shortages on their care or ability to provide care, quality of life, and understanding of the issues impacting care delivery. Such a strategy will to ensure that the system places patient care and care equity at its fore.
Authors: Andrew Hantel*, Gregory Abel^, Mark Siegler*
Affiliations: *The University of Chicago Medicine, ^ Dana-Farber Cancer Institute
Competing interests: None