Rationing is a compulsory measure ordered by the state (issuing of food stamps , etc.), which is normally only used in times of need (in wars , economic crises , famines , disasters , epidemics , etc.). Rationing can be carried out due to an actual shortage of certain products or preventively, if, for example, in times of political tension, hamster purchases by the worried population are to be feared.
In the economy, rationing can occur when the price mechanism or other reasons fail to balance supply and demand . If the demand is greater than the supply (excess demand), the consumers are rationed (and vice versa for excess supply). A rationing mechanism then ensures an appropriate distribution. An example is the allocation of scarce groceries in times of need through food stamps or the allocation of shares as a result of an oversubscription in the issue of securities or in the trading of securities on the stock exchange. Here the course addition “r” = rationed / repaired is used on the course table.
Health care rationing is a downstream decision in prioritizing medical services . Prioritizing creates a ranking that can be used to identify useful medical services and ration less meaningful services.
Financial restrictions or limited resources are often given as reasons for rationing in the healthcare system .
In the context of the discussion about the rationing of medical services, different types of rationing are presented:
Primary / Secondary: Due to financial constraints, the state is forced to set a fair share of total health care expenditure. This creates an intentionally accepted shortage of medical services, since the available budget is limited. This decision - made by the state and the health service - is known as primary rationing and involves determining the amount available. In some cases, this is also referred to as indirect rationing, since rationing is not meant based on people, but rather on resource-related rationing.
Secondary rationing then takes place within the health system. This is about the financial allocation to certain medical areas as well as the allocation of funds to the patients themselves. In this context, the direct form of rationing is also often used; the doctor decides on a case-by-case basis whether the respective patient receives a certain service.
Strong / Weak: Another differentiation is the word pair strong and weak. With heavy rationing, it is not possible to purchase additional medical services. It is forbidden by law to acquire additional services independently and with your own financial means.
In contrast, with weak rationing, there is a legal market for the procurement of medical goods that are not financed by the state. In Germany, this enables private supplementary insurance or self-financing of medical services. Critics complain about the weak rationing that not wealthy members of society are disadvantaged.
Hard / Soft: With hard rationing, it is not possible to increase the rationed amount. In the case of soft rationing, rationing takes place because the decision was made not to offer any more of this good. One case of hard rationing is donor organs, one case of soft rationing is the number of emergency ambulances.
Explicit / Implicit (open / covert): The explicit rationing results in the establishment of guidelines that are used to publish which services doctors are allowed to offer and which are not. The patients receive specific information about the criteria or rules that contribute to the decision on the rationalization question. This is why this form of rationing is also known as open.
In contrast to this, in the case of implicit or hidden rationing, the patient does not find out whether he is being deprived of resources due to rationing. The decision on this is delegated to the doctors without prior public debate, who are obliged to implement this decision.
Another, temporal form of rationing is queuing . With this form of rationing costs can be saved by the fact that a time-fluctuating demand can be satisfied with less capacities, since part of the demand is shifted from “peak times” to times of low demand.
In view of the growing contradiction between medical advances on the one hand and limited financial resources on the other, rationing has increasingly become a topic of scientific and public discussion. For example, in 2011 the outgoing President of the German Medical Association, Jörg-Dietrich Hoppe, said: “We will set up a working group in the German Medical Association to promote the subject of prioritization in medicine. The working group will work out proposals on how prioritization can be implemented. We doctors will take the issue of prioritization in hand because politicians have so far refused to tackle this issue. "
In particular, it is discussed about
- ethical and legal aspects of rationing,
- socially acceptable allocation criteria as well
- Procedure for prioritizing indications, procedures or patient groups
The rationing debate is more advanced in other countries, notably the UK, the Netherlands, Sweden and Denmark. The rationing or prioritization of some medical services is practiced there.
The Federal Joint Committee G-BA is discussing no longer offering services whose cost-benefit ratio (KNV) is too poor. Determining the KNV of a medical service for individual patients, case groups and / or for society ( economic benefit ) is difficult and often controversial.
A famous example of health rationing policy was in 1987 in the US state of Oregon . Health insurance should be introduced there to cover the entire population without increasing the overall cost of Medicaid . This was only possible with a reduction in the scope of services. Instead of z. B. Organ transplants in children were therefore funded in future preventive examinations in socially disadvantaged pregnant women and children - with the risk that some children were severely impaired due to not performed transplants. The holistic approach was laid down in a priority list for all medical measures.
There are only limited financial and human resources available to care for an aging population with increasing disease burden. In Germany, the statutory health insurance funds the care of around 70 million people with six percent of the gross domestic product (as of 2010). The physicians have capped budgets; if many practices close towards the end of the quarter (“vacation”), this is also a form of rationing.
Rationing is not to be confused with rationalization .
- Alexander Dietz: Just health reform? Allocation of resources in medicine from an ethical perspective. Campus-Verlag, Frankfurt am Main 2011, ISBN 978-3-593-39511-1 .
- H. Tobiska et al.: Rationing in the health system: expensive, unjust, ethically unjustifiable. Zurich 1999, .
- C. Fuchs: What does rationing mean here? In: E. Nagel, C. Fuchs (Ed.): Rationalization and rationing in the German health system, Symposium, Mainz May 6, 1998. Academy of Sciences and Literature. Thieme, Stuttgart / New York 1998, ISBN 3-13-105031-4 , pp. 42-50.
- Bernard Degen : Rationing. In: Historical Lexicon of Switzerland . August 2, 2010 .
- ARD report from October 18, 2006 about rationing in the health system with a terminally ill person whose life-prolonging therapy is not paid for by the health insurance company, and the G-BA chairman Hess ( Memento from November 29, 2009 in the Internet Archive )
- Rationing in the health sector Ärzteblatt
- H. Raspe: Prioritizing and Rationing. In: F. Breyer, H. Kliemt, F. Thiele (Eds.): Rationing in Medicine: Ethical, Legal and Practical Aspects. Berlin 2001, pp. 31-38.
- President of the Federal Medical Association Hoppe: We have secret rationing in the health system. ( Memento of the original from May 30, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Interview. on: rp-online , May 27, 2011.
- AOK Lexicon