Implications of the New Ethics: The Transcendent Importance of Retainer Medicine
Posted on February 9, 2010
Filed Under Medical ethics, Primary Care in America, Wonkonian Rationing |
In his past few posts, DrRich has offered a substantive criticism of the new code of medical ethics which has now been formally adopted by over 120 physicians’ organizations across the globe. (See here, here and here.) Fundamentally, the New Ethics abrogates the physician’s classic obligation to always place the welfare of their individual patients first, by adding to it a new and competing ethical obligation (called Social Justice), which requires doctors to work toward “the fair distribution of healthcare resources.”
The New Ethics was explicitly born of the frustration felt by physicians as a result of the multitude of coercions the payers have thought up to force them to place the needs of the payers (the proxy for “society”), ahead of the needs of their patients. Thanks to the New Ethics, doctors can now bend to this coercion without violating their ethical standards.
Coercion by the payers was, of course, quite effective even before the New Ethics made capitulation ethical. This is because the third party payers - both private insurers and the government - have long had a stranglehold on the individual physician’s professional viability. Nonetheless, the fact that the New Ethics now formally divides the physician’s ethical obligations between their patients and society has very practical implications. By eliminating the remaining (relatively low) hurdle of ethical nicety, the New Ethics clears the way for even more sophisticated, more “official,” and more enforceable methods for achieving bedside rationing. (We have even seen the phenomenon, DrRich submits, of professional organizations going along with - and even assisting with - the development and implementation of such methodologies.)
As DrRich has described before, it is the primary care physicians who, so far, have borne the brunt of payers’ efforts to force bedside healthcare rationing. And to the very great credit of PCPs, despite the New Ethics aimed specifically at “curing” their sense of guilt and frustration, a majority of them remain very disturbed by the increasing pressure to make the needs of their patients their secondary concern.
Indeed, if anything, their frustration has grown. In the past, when they were torn between laying out an expensive but likely beneficial medical option for a patient, and not offering it because doing so would anger (say) the government, they could at least rely on classic medical ethics to back them up if they chose the less expedient path. Today, they have ethics as well as expediency pushing them, in such a case, to remain silent about that more expensive option.
To many PCPs with a strong sense of obligation to their patients, the coercive nature of the payers, combined with new ethical standards that virtually obligate them to give in to the coercion, have made modern primary care medicine a nearly untenable proposition.
Thus has the New Ethics rendered the practice of retainer medicine a matter of transcendent importance.
DrRich here uses the term “retainer medicine” as shorthand for any practice arrangement in which the doctor is paid directly by the patient, and not by third party payers. In some of these arrangements, patients actually do pay their physician a retainer fee of a few hundred to several thousand dollars a year. Such formal retainer arrangements - often called “boutique” or “concierge” practices - first began to pop up a decade or so ago. More recently, practices have begun appearing in which there is no actual retainer fee, but instead, patients pay their doctors the same way they pay their plumbers - on a fixed payment schedule according to the time the doctor spends with them. These pay-as-you-go practices generally are inexpensive enough to be affordable to any family that can afford cable television, or cell phone service.
Many retainer practices also provide amenities you often don’t get when your doctor is paid by Medicare or an insurer, including access to the physician’s cell phone, e-mail correspondence, same-day appointments, and plenty of face time during appointments. But whatever the specifics of a particular practice may be, the key that defines “retainer medicine” (as DrRich is using the term here) is that the doctor works for the patient, and nobody else.
Retainer medicine has been under steady attack, from the moment it first appeared, as being elitist, unethical, and divisive. The argument goes: While retainer medicine may be good for individual selfish doctors, and individual wealthy patients, this style of practice threatens to do much harm to the greater good. Critics maintain that retainer medicine threatens to create a two-tiered healthcare system (one for the wealthy and one for the poor). Plus, they say, if any substantial number of physicians were to adopt this odious new style of practice, there wouldn’t be enough PCPs to go around. Many critics have even called for making retainer practices illegal, and some states have already taken action to do so. The rationale for banning retainer medicine, boiled down, is: It is bad for doctors, patients and the public good.
To DrRich, the vociferous objections being raised against retainer medicine strongly suggest something deeper. DrRich believes that critics would simply find it far too “inconvenient” to have a bunch of wild retainer practitioners running around, disclosing to patients ALL their healthcare options, when the more well-behaved doctors are disclosing to patients only the healthcare options approved by government-assembled panels of experts. Retainer practitioners, in other words, will make covert rationing much more difficult. However, this is not a point of view which critics have been willing to express publicly, so DrRich will let it lay.
But even the publicly-expressed objections to retainer medicine - the notion that it is bad for doctors, patients, and the public good - are wrongheaded. Indeed, thanks particularly to the New Ethics, the opposite is true. Retainer medicine is perhaps the only pathway toward rescuing patients and the medical profession - and thus for best serving the public good. For PCPs to continue practicing under what has become the “traditional,” third-party-payment system is, in fact, the far greater threat.
It has become impossible - both in practical terms and now, in ethical terms - for “traditional” PCPs to fight the pervasive pressures being visited upon them to ration healthcare at the bedside. To escape this fate, they must either become specialists, deep-sea fishermen - or a retainer practitioner. That is, PCPs must choose between remaining in a system that ruthlessly pushes them toward a practice of bedside rationing (which many find an unethical, demeaning, and harmful style of practice), or, one way or another, getting out of traditional primary care medicine altogether.
To argue that retainer medicine is unethical is completely backwards. Retainer medicine restores the professional integrity of medical practice, and re-establishes a doctor-patient relationship in which the physician can again assume the duty of a true advocate. It is perhaps the only remaining means to restore the foundational (but now officially obsolete) medical ethic of always placing the patient first.
To argue that retainer medicine somehow threatens patients completely ignores reality. Retainer medicine may be the only remaining viable pathway toward restoring protections that patients are supposed to have when facing a healthcare system that is utterly bent on avoiding spending money on them.
To argue that retainer practitioners are creating a two-tiered healthcare system is ridiculous on its face, in a society that gives mere lip service (though, to be sure, plenty of it) to the problem of 47 million uninsured, and in which physicians already cannot afford to care for patients on Medicaid (or increasingly, on Medicare), because they lose money each time such a patient walks in the door.
To argue that retainer medicine will create a subpopulation of elites (because it provides a mechanism by which some individual patients can escape the deadly obstacles that have been intentionally laid before them), is as absurd as arguing that George Washington was wrong to free his slaves upon his death (or even that New York State was wrong to abolish slavery at about the same time), because it created a subpopulation of “elite” (i.e., free) African Americans; that until all slaves were freed, no slaves should have been freed. Rather, freeing at least some slaves - and forthrightly stating why it needed to be done (see: Declaration of Independence) - was not only ethical, but also showed what was possible, and over time created an expectation that eventually could no longer be ignored.
Finally, we should recognize that any innovation that can potentially spare patients from some of the harm the healthcare system has in store for them will necessarily be applicable to only a minority of patients at first. That’s how disruptive processes work. They begin as niche products or services, attractive only to a few high-end users; too expensive or too marginal for the vast majority; ignored, ridiculed or castigated by current providers and by most experts. But if at their core they’re offering something fundamentally useful, they will slowly demonstrate their worth - and eventually all the potential users will see the light, and demand for the product will become explosive. When that happens, the means are found to make the new product affordable and available to meet the demand - often by making significant “adjustments” to the original concept, that nonetheless preserve the core benefits. And when that happens, the traditional providers (who never saw it coming) are suddenly out of business.
It may not be that retainer-style medicine plays the personal computer to the traditional healthcare system’s mainframe. But it is inarguable that what retainer medicine offers to patients - at its core - is every bit as vital and every bit as indispensable. And if a critical mass of the public can be made to understand what is really being offered here, there will be no holding it back.
There never has been anything even slightly unethical about retainer medicine. The arrangement by which patients pay their doctors directly was, after all, how Marcus Welby practiced medicine, and how nearly every PCP practiced until the 1970s.
The problem began when third party payers were interposed between doctors and their patients, and it became progressively more difficult for doctors to honor their primary ethical obligations. The New Ethics has escalated the problem, however, from one where basic ethical precepts were merely being violated, to one where the precepts themselves were abandoned.
And by so doing, the New Ethics has elevated retainer medicine from something that was merely an ethically justifiable curiosity, to the last refuge for classic medical ethics, and the last best hope for patients, the profession of medicine, and the doctor-patient relationship.
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The Covert Rationing Blog has been chosen as a finalist in the 2009 Medical Weblog Award Competition, in the category of Best Health Policy/Ethics Blog. Voting continues here through Feb. 14.
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18 Responses to “Implications of the New Ethics: The Transcendent Importance of Retainer Medicine”
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I agree with your new ethic, patient and physician autonomy both unfettered by the restraints of society.
Should physicians then be allowed to refer to facilities where they have financial interests and set prices for their diagnostic recommendations.
Remember a sick patient may find financial negotiation difficult
Much of what you’ve written about “covert bedside rationing” etc. has bothered me, but only now am I able to clearly articulate why you are full of shit:
The problem has never been “expensive but likely beneficial medical options.” This is a straw man. If a medical option is clearly beneficial to the patient, I recommend it regardless of cost, old ethics, new ethics, middle-aged ethics be damned. The issue is procedures that a patient wants — or that a specialist has deemed “beneficial” in the context of disease-specific guidelines without regard to the given patient’s actual situation — that are prohibitively expensive.
Even before the promulgation of what you’re calling the “New Ethics”, I always made a point of including cost in the risk/benefit analysis for a particular patient. Seems to me the only thing that has changed is that internists are now being urged to take their heads out of the sand and face the reality that there is a difference between what they CAN do for a given patient and what they SHOULD do. What these new ethical guidelines really do is give physicians permission to consider cost issues in their decision making.
AD,
The fact that there are ethical standards does not obviate the need for laws to “back up” the ethical standards. Robbing a bank is unethical; but I’m still glad there are statutes making it illegal.
If all doctors who owned diagnostic facilities strictly adhered to the ethical precept of always doing what’s right for their patients, then I would see nothing wrong with it. However, the abuses in actual practice have been many, so I have no problem with rules (or laws) that prevent it.
Rich
# 1 D,
Both you and the Chair of the ACP’s Committee on Ethics &c. have both now carefully considered the evidence, and have found me to be full of shit. And for the same reason, too! (That there is no difference between the patient’s best interests and society’s best interests).
I should probably inform my wife that the question she has been asking for 35+ years has now been definitively answered, by at least two eminent authorities.
In the meantime I will cling to my own poor, deceived retainer physician until they drag his sorry butt off to jail - or, more mercifully, to a rehabilitation camp.
Rich
#1 Dinosaur, you should read DrRich’s numerous articles on implantible defibrillators (a device with which he is intimately familiar) for an example of an extremely expensive procedure with undeniable benefits that many are trying to stamp out or at lest severely curtail.
I wrote a long response - and the computer ate it before I sent it. So here’s a shorter version. I think the ICD issue is a good example of how *not* to approach expensive medical procedures/devices (which gobble up a lot more health care dollars than PCPs).
My late FIL got one (when he had 2 kinds of terminal cancer and CHF) after an episode of syncope. We asked the doctor who did the procedure whether an ICD had ever saved any of his patients’ lives - or whether any had even been activated. And he didn’t know. Which indicated to me that no one here is keeping score.
Now I don’t know if ICDs make sense for certain patients - but - if we’re going to put $35k devices in people - we ought to require all doctors who implant them to report all procedures and outcomes to a national database - and to do long term follow-ups. And then decide whether these things make sense for any patients - and - if so - which ones. I mean - it takes 30 seconds to vote on “Dancing With The Stars”. If a doctor does 300 of these a year - perhaps that is a few hours a year he will have to spend on his computer. But we will get very important data to help us to make very expensive health care decisions.
Note that I see this again and again - expensive stuff being done/used in patients on the basis of short term studies involving small numbers of patients. Since my husband has MS (was diagnosed over 25 years ago) - I follow all the extremely expensive MS drugs on the market and in the pipeline - and there isn’t a single study that has convinced me that it’s worth the money and - especially - the possible side effects - for my husband to take any of them - because all of the studies are too limited in terms of time and numbers of patients. After all these years that MS patients have been using the ABC drugs - why isn’t there a huge database showing how every user has fared using one of these $25K+ a year drugs? Is it perhaps because drug companies would rather stick with the 200 patients and 2 years that got them their initial FDA approval?
And good grief - if you’re going to implant an ICD that costs $35k in someone and he dies 6 months later - at least have a plan to recycle the frigging thing. My FIL was cremated - the ICD had to be removed so it didn’t explode during cremation - and then it was thrown in the garbage (or maybe sold on the black market - who knows). Robyn
Robyn, your rant suggest that there is a “we” that is of one mind in medicine and society. Indeed, nothing could be further from the truth.
As for spending only $35,000 6 months before we die… If that was all we were spending, we wouldn’t be in the mess we are in.
For what if you have MS AND cancer AND need a defibrillator?
And how do we compare that vs. spending more money on primary education vs. spending it on road safety, etc..?
The idea that we can somehow firewall/compartmentalize medical decisions because they are more life and death than other financial decisions we make in life is absurd.
All I can say is as long as some of the silly ways we spend large amounts of money continue, I am not going to loose all that much sleep putting an AICD (a defibrillator) in a 90 year old.
It is obviously my own opinion but looking at the poor ROI ways we spend money in medicine in isolation from every other poor ROI way we spend money is patently absurd.
To be fair I don’t put AICDs in people so I don’t have to worry about going to jail for such self serving selfishness.
I just have to worry about Triage decisions
Hi Red Baron - If you think what I wrote is a rant - you’ve never read non-moderated political chat boards (smile).
All I suggested is that before we use medical things on people - especially expensive ones (whether they’re surgeries - drugs - devices - etc.) - perhaps we ought to have some solid evidence that these things are effective - for what kind of patients (if fewer than all) - and a detailed understanding of the long term side effects (if any).
Just to give you a personal example. I’ve been on HRT for over 25 years (since a hysterectomy/BSO). Seems like there is an article every other day about one study or another. On one hand - on the other hand - etc. - ad nauseum. The studies are all very limited considering. Millions of women have been taking these drugs for decades. And we get a few extra gray hairs when we read one of the “scare” articles. Now wouldn’t it be nice if every woman in the US who took an HRT drug could register somewhere - and simply report once a year on her experiences. We’d have an amazing database. Women with all their plumbing who used the drug for menopause - women who used the drug for premature surgical menopause. Women who have gotten breast cancer. Women who haven’t. Their family histories of breast cancer. Women who know whether or not they have the BRCA1 gene - and women who haven’t been tested. Etc. I could actually make an informed decision about what to do. Perhaps continue taking HRT - stop - or maybe get genetic testing (although I have no family history of breast cancer - I am in an ethnic group with higher than average incidence of genetic problems). “Wouldn’t it be loverly” (smile - from My Fair Lady).
But what I got instead was being part of a study at the hospital where I got my operation. And when I moved from the city - I was out of the study (after being in it for 15 years). And when I dig into the details of most of these studies that get headlines - I find that they are similarly stupid.
I think the difference between today and 25 years ago is the internet. The ability to gather lots of information from huge numbers of people. Perhaps not all. But many people with specific medical issues/questions go on the internet. And - if spelling mistakes are any indication - you’re getting pretty broad based participation - maybe not from homeless people (although I wouldn’t be surprised if some used their local libraries for internet access - especially in the winter when it’s cold) - but from a broad range of people. I keep an old WSJ cartoon on my bulletin board. One doctor talking to another. Caption is: “With the internet, my patients come self-diagnosed, have second opinions and already belong to a support group.”
Anyway - I’d rather see 2 million women reporting themselves on their HRT experiences - even if I had to take some of what’s reported by lay people with a grain of salt - as opposed to what’s reported in the kind of very limited studies we see today. Heck - the NIH could probably set up a website for something like this for relative peanuts - following patients by SS numbers (surprisingly SS and Medicare have great websites - so I don’t think the government is totally incompetent when it comes to the internet).
Finally - I don’t buy your implied argument that because the government pisses away money in one area - it should piss away money in all areas. I will leave discussions about the propriety of spending money on things like the war in Iraq to other blogs. OTOH - Medicare is more likely to bankrupt our country than any war. And although a $35k ICD may seem like pissing in the ocean in terms of federal spending - none of our parents who has died (3 out of 4) has cost less than $500k in medical care in their last year or two of their lives (at least in terms of what “list price” are for what they got in terms of medical care). And that doesn’t include any money spent on skilled nursing facilities or in-home nursing care (paid out of pocket - not by any government program - my husband and I have been blessed to have parents who saved for the “worst case” scenarios in their old age - they were all children of the Great Depression). What the heck is going to happen when the next generation (mine and my husband’s) meets old age and death - well it won’t be a pretty sight IMO? Robyn
As an aside Red Baron - I assume from what you said about triage that you are an ER doc. Have to tell you - the most amazing medical thing I ever saw in my whole life was when my FIL came into the ER with what was thought to be another episode of his CHF - but which turned out to be a double pneumothorax. The ER doc - knowing there was a cardiac surgeon in house (this was at Mayo JAX - and the cardiac surgeon was waiting for an organ to arrive for a transplant - and I think the ER doc was a little scared) called the cardiac surgeon down stat - and he did the standard procedure for this condition. My husband and I watched it. And it was like a miracle - someone who looked on the edge of death being almost normal in 10 minutes. Note that even if I were a doctor - I’d be really scared sticking those tubes into a patient.
Great story.
And you get used to it, honest. We were all just as scared once upon a time.
As for whether the double extra low foam latte or the AICD will be the eventual cause of our nation..?
I like the analogy of spending as a four sided box. Take away any side of the box and it is no longer a box.
So I guess my response would be (and I mean this with no disrespect): “will you be first?”
All I hear all day long is how someone else needs to cut back their consumption so the rest will do great things. And I (perhaps incorrectly) read that you do see how your parents spent a awful lot of money before they died and you wonder if this really added all that much quality time on the planet and whether these resources could be spent in better ways? And I tip my stethoscope to your noble observations as I too have experienced this same issue with parents and wondered the same thing.
But in a world where all spending is connected to all other spending, are you absolutely sure that if your parents are were kind enough to give up a few extra months of life on this planet in order that the rest of us in the collective could do great things with their gift, the collective will spend this gift wisely? That the collective will use it in ways to assure their grandchild will be better off tomorrow?
Look at some of the way we spend our money and how we would continue to spend it if the debt-o-holics were allowed to continue with your parents life’s credit card.
Many of us see your point (if this is it), and would even agree with it, but not if the money is used just any old way.
Throwing good life after bad spending seems just as silly to me.
If this is what is making America bankrupt, then she was already bankrupt long ago.
Sorry typo
I meant to say:
As for whether the double extra low foam latte or the AICD will be the eventual cause of our nation’s demise..?
I like the analogy of spending as a four sided box. Take away any one side of the box and it is no longer a box.
All wasteful spending is just that, wasteful.
How about this:
Is a month of your parents life worth an additional 500 square feet of home construction? Maybe we can keep the size but just lower the quality of the construction to (say) “builder grade” materials.
Or perhpas this time is worth moving to 150 count sheets vs. 250 count sheets? Or perhaps driving a $22,000 cars vs. a $45,000 car? Or our kids fooling around less in college and completing their major in 4 years as opposed to 6 years?
In the end, when it comes to an economy, spending is just spending. And even with our nation’s elderly consuming away the hopes and dreams of their children, still health care is only 16% GDP.
Don’t get fooled by the random ways people try to split the atom. We can split it any way we want.
What we do not agree on as a society is how to spit that atom and so it gets split in some very bizarre ways. At least that is the way I tend to see things but that is only my reality.
Red Baron - I get what you’re saying. How about this for another interesting story. My FIL never made more than $25k a year - but died with an estate worth about $1 million (after spending almost 3 years in an SNF). And it’s not like he made a killing in the stock market. CDs all the way. And I’m sure he never knew doodle about thread counts in sheets. Bought them at Walmart. He probably wouldn’t have done as well had I not managed his money for the last 3 years of his life. But he gave me a big chunk of money to start with. Now he was miserly. My MIL inherited $100k - which I managed - and he never let her spend a penny of it (although I encouraged her to do so for things like Christmas presents for grandchildren). First and only check written off that account was for her funeral expenses.
OTOH - last week I found an expensive cell phone in my side yard. Long story short - it belonged to the 8 year old son of my next door neighbor (two adults in the house - 4 cars). Apparently - they had been complaining to him since it was the 3rd such phone he had lost in the last year.
I do agree with you that - theoretically - there is a middle ground between these 2 extremes in terms of how people live their lives. But I haven’t seen much evidence of it in my day-to-day life (although my husband and I try to walk down the road “in the middle”).
As for the last month or so of our our late parents’ lives - they could have done without them. And it wasn’t a question of money - just pain and suffering in different ways/shapes/forms. Going from bad but I can go to the mall - albeit in a wheelchair - to pretty awful. I am grateful to the person who invented the morphine drip (worked for 2 parents in horrible shape - 3rd refused dialysis and died peacefully from ESRD). Don’t think the ICD helped my FIL a bit - but it didn’t hurt him either. Perhaps there should be a national database on death - to teach baby boomers like me what to expect and to do. My husband and I were just learning with our parents - but luckily had the help of good health care profesionals in a SNF and hospice situations. My only regret with the 3 deaths was that my mother was diagnosed with colon cancer when she had early Alzheimers’ - she refused reasonable medical treatment - my father (still alive - he’s 92 - and I’m in charge of him now) was too concerned about his own stuff to do anything reasonable for her - and she died very miserably. I’m glad my brother the doctor was there when she died - because I don’t think any child except one who was a doctor could have handled a total bleedout from a “perforating” (?)colon cancer in a home situation.
Many doctors probably see end of life stuff close up all the time. But for most of us - it’s our parents - and our spouse - one or the other goes first (and the occasional child). And based on my limited experience along those lines - I think the patients’ best friend at the end of life is the morphine drip - great skilled and loving nursing care (keeping you warm and clean and hydrated and as well fed as you care to be fed) - and not things like ICDs.
P.S. All of our parents who died died between very late December and mid-February (2 within 6 weeks of one another). This is my time of year to burn Yahrzeit candles and remember them (even though 2 aren’t Jewish). Sorry if get too much into thinking about them.
Gosh you guys are really getting off message.
All Dr Rich is saying is that the physician should put the patient’s interest first. By allowing a third party to get between the patient and physician, physicians have prospered financially and suffered ethically. Now that the resource limit has been reached, physicians have a choice of which master they serve.
The midwife at the birth of our profession was the Hippocratic recognition that the physician has a selfless relationship to his/her patient.
What DrRich fails to address is that a supermajority of practitioners recognize this responsibility but can’t wean themselves off the guaranteed cash the third parties provide and thereby submit to the demands third parties make.
Perhaps it is the guilt resulting from this basic conflict as well as the existential threat paygo medicine poses to third party control and profits that is responsible for the backlash he sites. As third party payment becomes less lucrative and more onerous, expect more opting out and more push back.
An interesting question for DrRich
When I go overseas to practice, the locals care for all my needs, I get far more food and shelter than I could consume in ten lifetimes, A standard of living differential many times what I have back in the states and no plaintiff attorneys in sight, that’s not why I go, but it does make it hard to leave…..We have seen a hardline tightening of capital controls as it attempts to leave our insolvent nation. How long before we see the same tightening on intellectual capital?
Anon, agreed and amen
Rich sorry
Anon - Sorry to get OT.
Where do you go overseas and what area if any do you specialize in? I have a couple of cousins who go outside the US to do some (charitable) work in second and third world countries - but they usually wind up in tents with occasional guerilla attacks. Can’t really comment intelligently without at least some specifics. I travel a lot - and might have something to say depending on the areas on which you’re basing your statements.
An underlying assumption of this discussion is that patients are dumb and dumber - and cannot make decisions for themselves (so that when their doctors are hamstrung by rules emanating from “on high” - they cannot take matters into their own hands - whether their decisions are reasonable or unreasonable from the POV of a medical professional).
Like I have said before - the internet is ubiquitous these days - and there is a lot of interesting info out there in the ethernet (a lot of junk too). Doctors cannot underestimate how much their patients will try to learn on their own when faced with serious medical decisions (even though their attempts may be kind of feeble - depends on the patient). I never thought that doctors were gods 30 years ago - and I still don’t think that (although the House of God is a great book). To me - what a doctor suggests - regardless of motivation - or where that motivation comes from - is simply a suggestion. And my willingness to accept the suggestion depends on my own personal cost/benefit analysis. Take a low dose statin - sure - no questions asked. Get medium deal surgery with possibly bad complication for something benign - I need to get a lot of questions answered first. Etc.
Another premise here is that patients have to rely 100% on third party payers. If one takes charge of one’s medical care - and treats things that insurances might not pay for as part of one’s normal expenses - there can be no rationing (unless it becomes illegal for all providers to accept patients who pay cash - and I think we are a long ways off from that). Have never heard of the possibility of rationing cosmetic surgery - which is almost 100% self-pay.
Does this mean the average person might have to give up some optional stuff in his/her life to pay for medical care - sure. And I also don’t believe in the “lowest common denominator” when it comes to health care. If I can afford to pay 10 times as much for something as an alcoholic street person - I think I’m entitled to better health care - at least in terms of style. Kind of luck of the draw (and some research) in terms of the competence of doctors - and I wouldn’t want street people dropping dead on the street - or being treated in unsanitary facilities - but I’ll tell you - I won’t go near a provider or facility that accepts Medicaid these days. Moreover - if I get cancer and want to go to a great cancer facility 1000 miles away - and will pay whatever extra it costs - I should be allowed to do so. As a taxpayer - I don’t want to pay to send my local street people there.
Finally - my cousins who do health care abroad also say - ain’t it great - don’t have to worry about malpractice. I think this is an overblown concern for most doctors - except perhaps for those in certain underpaid/high risk specialties - like OB. I’ve done a lot of medical/legal work - and think I understand the area pretty well. Apart from the questions asked above (like your area of practice) - have you ever been sued? Robyn