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January 2, 1991

Rationing by Patient Choice

Author Affiliations

Duke University Durham, NC

Duke University Durham, NC

JAMA. 1991;265(1):105-108. doi:10.1001/jama.1991.03460010105043

RESOLVING our conflict about health care costs will require connecting value to cost.1,2 Ideally, the connection should be made through individual decisions in the marketplace—each individual would be responsible for paying the financial cost of the health care services he or she chooses to receive. This would force each of us to weigh the value of those services (their benefits and harms) against the cost we would have to pay and would ensure that, both for the individual and for society as a whole, the value of health care would be worth its cost.

Unfortunately, in medicine the connection between value and cost has been cut by some basic flaws in the medical marketplace, most notably third-party coverage, third-party advice, and uncertainty. Individuals do make decisions, but they are based on imperfect perceptions of the benefits, without appreciation of the true costs. The inevitable result is what we see

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