1. Developing a Principled Framework for Decision-Making Gopal Sreenivasan Arthur Ripstein University of Toronto

2. Medicare Basket  what medical services should be covered by Canada’s medicare system?  what should be in?  what should be out?  how should this be decided?

3. ‘values’ sub-project  what medical services should be covered by medicare?  how should this be decided?  on basis of what principles?  on basis of what values?  ‘Canadian’ values

5. Romanow report  values served by medicare  equity, fairness [i.e., justice]  solidarity  responsiveness  responsibility  efficiency  accountability

6. focus for today  focus here on justice  connect to other Romanow values in larger paper  what are the requirements of justice in relation to our health care system?

7. justice  what does justice require of a health care system? 1. universal access to health care  everyone is entitled to health care on the basis of need, without regard to ability to pay

8. ‘universality’  in Canada, ‘universality’ of health care has two meanings 1. everyone is entitled to access 2. ban on tiering (no 2 tier system)  no parallel private sector  certainly not in financing  also not in delivery?

9. justice  what does justice require of a health care system? 1. universal access to health care 2. no tiering (parallel private provision) in health care financing

10. justice 1. universal access 2. no tiering (in financing)  this tells us that everyone is entitled to the same health care  but not how much care everyone is entitled to  two questions to ask here

11. two questions  how much health care should be covered? 1. what should the national health budget be? 2. what services should be covered by this budget?

12. medical ‘necessity’  how much health care should be covered? 2. whatever services are ‘medically necessary’ 1. budget should be sum of cost of services actually required

13. mistake  justice actually rejects this answer, for any strictly medical definition of ‘necessity’  health is not the only good  balance of goods implies some independent limit on health spending

14. the ordering matters  how much health care should be covered? 1. what should the national health budget be? 2. what services should be covered by this budget?

15. simplification  how much health care should be covered? 1. what should the national health budget be? what % of GDP?  assume 10% (= current %)  or OECD average (9%)

16. fixed budget  how much health care should be covered? 1. what should the national health budget be? 2. what services should be covered by this budget?

17. priority setting  hence, justice itself requires some form of rationing from a fixed budget  that is, priority setting  medical necessity is not a complete criterion  for inclusion in medicare basket

18. justice includes efficiency  for inclusion in medicare basket, justice requires 1. medical necessity 2. cost-effectiveness  within limits, does not compete with justice  cf. ‘efficiency’ as separate value

19. what else?  for inclusion in medicare basket, justice requires 1. medical necessity 2. cost-effectiveness 3. what else?  leave as open question

20. already implies reform  inclusion in basket requires 1. ‘medical necessity’

21. already implies reform  inclusion in basket requires 1. ‘medical necessity’  scientific determination  not post hoc label for sectors the system already covers

22. already implies reform  inclusion in basket requires 1. ‘medical necessity’ 2. cost-effectiveness  how to define?  moral assessment of existing methodologies  December workshop

23. reform 1. ‘medical necessity’ 2. cost-effectiveness  criteria apply equally to decisions  to add a service to basket  to continue covering a service already in the basket  same question in justice

24. example  consider (non-hospital administered) pharmacare  presently outside of medicare basket, which is  restricted to ‘hospital and physician services’

25. example  pharmacare (outside hospital)  is it ‘medically necessary’?  in scientific sense: yes  in CHA sense: no  but this reflects wrong logic  historical accident vs. principled

26. rough truth  what follows?  pharmacare should be on a par with other medically necessary services  i.e., within the medicare basket

27. objections  pharmacare should be within the medicare basket 1. how is this different from Romanow and Kirby? 2. isn’t this simply too expensive?

28. different from R & K?  they only propose to include (some form of) catastrophic coverage for pharmacare  an inferior version of ‘without regard to ability to pay’  to first dollar coverage by public single payer insurance

29. objection 2  pharmacare should be within the medicare basket 2. isn’t this simply too expensive?  e.g., won’t this push us over our assumed budget cap of 10% of GDP?

30. too expensive? i. even if so, there is no principled basis for applying the point only to pharmacare  and not to rest of hospital and physician services

31. too expensive? i. even if so, there is no principled basis for applying the point only to pharmacare  and not to rest of hospital and physician services  revisit meaning of ‘without regard to ability to pay’?

32. too expensive? ii. the 10% of GDP figure is total spending on health  (a) public and (b) private  7% + 3%  some (most?) pharmacare $ will just be shifted from (b) to (a)  painless tax increase!

33. less rough truth iii. being on a par with other medically necessary services  actually means being subject to a cost-effectiveness criterion  not all pharmacare may qualify  but same applies to rest of (i.e., existing) medicare basket