Professional judgment and the rationing of medical care.

Changes in knowledge and technology, the growth of the elderly population, and rising public expectations will continue to increase medical care costs. Due to these trends, more stringent rationing of medical care is inevitable. Future rationing must involve a blend of approaches, including: cost-sharing with patients (price rationing); administrative limits on technological expansion, reimbursable services, and provider remuneration (explicit rationing); and discretionary allocation of services within the constraints of established budgets (implicit rationing).' Each approach has advantages as well as liabilities. The health care rationing debate focuses on what relative weight each of these approaches should receive. Dependence on price rationing approaches is likely to deter appropriate as well as inappropriate medical care procedures with a larger deterrent effect on the poor. Also, while some explicit administrative constraints are essential to set the parameters of care and to avoid uncontrollable escalation of costs, dependence on explicit rationing approaches is likely to result in insensitivity to the complexity of clinical care, to the rapidly changing character of medical knowledge, to the uncertainties of the care process, and to the wide range of situations, needs, and preferences of patients. In contrast, an implicit rationing approach offers the most realistic and appropriate way to allocate services. Because patient populations are heterogeneous, many medical interventions involve uncertainty, and the clinical decisionmaking process is iterative (using information obtained from the relationship between professional and patient), an effective health care rationing system must take into account the need for flexible physician response to numerous unprovided-for circumstances. Implicit rationing allows for needed sensitivity to variance by relying on clinical discretion,