The Allocation and Rationing of High-Cost Services-Reply

In Reply.—  I appreciate Dr Ashley's support of my editorial. I urge him, however, to reread it, going beyond my deliberately provocative statement suggesting that rationing of ICU services, if it consisted only of refusing occasional patients who were too healthy to require intensive care, could be viewed as painless.In the remainder of the editorial, I explain why such "painless" rationing decisions are ineffective in saving costs. They simply do not lead to a reduction in a total allocation of hospital resources allocated to intensive care. I then emphasize how the more difficult and painful decisions, those that truly reduce expenditures, are not yet being made. Both points are illustrated well by the letter from Franklin and colleagues. They describe how, in response to an increased demand for ICU services at Cook County Hospital, they responded by almost doubling the size of the ICU!Such investments may temporarily avoid