Presentation on theme: "Rationing in health care"— Presentation transcript:
1 Rationing in health care With indebtedness and gratitude to Joanna Coast, Department of Social Medicine, University of Bristol, for writing a book, PhD thesis and presentation on priority-setting……and for allowing me to plagiarise it all!!!!
2 Rationing in health care What does ‘rationing’ mean?Rationing with respect to efficiency or equity?Implicit versus explicit rationingMethods and examples of explicit rationing
3 Rationing: what’s in a name? Economics concerned with choice between competing alternativesBased on axiom of scarcity - resources limited relative to wantsFundamental ‘economic problem’ is therefore allocation of these scarce resources‘Rationing’ (and priority-setting) just another term for resource allocation
4 Rationing: what’s in a name? “The word [rationing] is invoked to make the flesh creep, not to prompt argument about how to deal with the inescapable”Rudolph Klein, 1992
5 Means of rationingMarket system - price mechanism establishes equilibrium (efficient allocation)Non-market system - absence of price as allocative tool leads to other, non-price, techniquesIssue is one of: (i) philosophical basis for rationing; and (ii) applied technique for rationing
6 ‘Philosophical’ basis of rationing Price system - objective = efficiencyconsumer sovereigntyallocation by WTP/ATPNon-price - objective efficiency or equity’?who decides on allocation?allocation by what criteria?
7 Objective: efficiency or equity? maximisation of ‘benefit’utilitarian ethicdistribution is irrelevantEquityjust distributionbased on need? age? lottery?
8 Objective: efficiency or equity? Philosophical basis price system/efficiency is utilitarianismOther philosophical bases are generally pursued in non-price allocationWhich do we adopt?
9 Three important ethical theories Utilitarian - greatest good for greatest number (maximise ‘utility’ or ‘happiness’)Deontological - cannot ignore duty to one individual for sake of good of othersRawlsian - ‘maxi-min’ criteria for seeking to secure good of the least fortunate in society
10 Ethics and ‘levels’ of rationing Theories have varying degrees of applicability at population and individual levelUtilitarian and Rawlsian generally ‘population’ level, Deontological generally individualMay adopt different ethical principle at each level of rationing (decision-making)
12 Who really pays?Opportunity cost - if we choose to do one thing, the cost of doing that is the value which would have been obtained from the best alternative choiceWho pays - the person who does not receive treatment
13 Implicit or explicit rationing? Implicit rationing: care is limited, but neither the decisions, nor the bases for those decisions are clearly expressed.Explicit rationing: care is limited and the decisions are clear, as is the reasoning behind those decisions.
14 Rationing in the UK“Rationing in Great Britain has been implicit…It is a silent conspiracy between a dense, obscurating bureaucracy, intentionally avoiding written policy for macroallocation (rationing), and a publicly unaccountable medical profession privately managing microallocation so as to conceal life and death decisions from patients”(Crawshaw, 1990)
15 Rationing in the NHS Predominately implicit rationing BUT increasing advocation of explicit rationing1989/91 reformsHealth Committee Report1996 Rationing Agenda GroupNICE?
16 Methods of explicit rationing (Coast et al, Priority setting: the health care debate, John Wiley, 1996)
17 Explicit rationing: technical methods Single principleLittle distinction between setting priorities at different levelsExamplesmaximising health gainneed-based rationinglotteriesage-based rationing
18 Technical method 1: ‘league tables’ Economic evaluation produces information on cost-effectivenessIf using comparable outcomes (eg QALY) can ‘rank’ according to c/eCan use resultant ‘league table’ to allocate resource to most c/e first
19 League tables: handle with care! Studies show differences in methodologychoice of discount ratemethod of estimating utility valuesrange of costs includedchoice of comparatorRequires consistent methodology, ‘admission criteria’ for inclusion, applicability in local decision context
20 The Oregon Plandecision to stop funding for organ transplantationOregon Health Services Commission begins workList 1List 2plan begins
21 Oregon List Version 1 Efficiency principle 1600 condition/treatment pairsCost/QALY gainedsocial valuesoutcomecost
22 Oregon List Version 1“... looked at the first two pages of that list and threw it in the trash can”“... the presence of numerous flaws, aberrations and errors”(Harvey Klevit, member, Oregon Health Services Commission)
23 Oregon List Version 2 Equal treatment for equal need 709 condition/treatment pairsMethod:Development & ranking of categoriesRanking C/T pairs within categoriesPublic preferencesOutcomeProfessional judgement
24 Oregon List Version 2 Top Five C/T pairs Bottom Five C/T pairs 1 Pneumonia - medical2 Tuberculosis - medical3 Peritonitis - medical/surgical4 Foreign body - removal5 Appendicitis - surgicalBottom Five C/T pairs705 Aplastic anaemia - medical706 Prolapsed urethral mucosa - surgical707 Central retinal artery occlusion - paracentesis of aqueous708 Extremely low birth weight, < 23 weeks - life support709 Anencephaly - life support
25 Technical method 2: PBMA Split health care service into ‘programs’ and subprograms - homogenous outputEstimate current spending and outputs (benefits?) achieved by each programmeIdentify ‘marginal programs’ which would be the first to be cut or expanded as budget changes
26 Technical method 2: PBMA Identify change in output as result of adding/subtracting budget (eg £100,000)Decision based on (re)allocation which yields greatest overall benefit
27 PBMA: panacea or poison? + combines pluralistic bargaining & technical exercise+ applies ‘correct’ concept within data limitations- problems with data - quality, absence, robustness- subjectivity (bargaining) - who decides?- what is the maximand - output=???
28 Explicit rationing: political processes Processes and structuresDebate and bargaining“multiplicity of objectives”Micro versus macro level
29 Medical discussion and debate YesCurrent form of decision makingVariable: therapies funded in some localities but not allDifferent weight to different principles?YesNoNoYes
30 Public participation? Who should be involved? What methods should be used to obtain representative views? silent voices?How should information be presented?How should public views be used?What weight should public views be given?
31 New Zealand’s Core Services Consultation DocumentNational Advisory Committee on Core Health and Disability Support ServicesPublic meetings about broad priority areasConsultation over broad ethical frameworkPanel discussions to formulate guidelines incorporating social factors
32 Success of Core Services Incrementalismbut how much has actually changed?Public consultationemphasis on hearing many voiceshave public ACTUALLY influenced priorities?how have methodological problems been dealt with?concern with “overconsultation”
33 Advantages and disadvantages Technical+ implied neutrality+ clarity of objectivesdata hungryinherent value judgementsweaknesses in methodsrigidityimplementation problemsBargaining+ suited to uncertain and complex situations+ decisions based upon compromiseheavily dependent on which groups are includedslipping back to implicit rationing
34 Challenges to explicit rationing Potential impact upon the stability of the health care systemPotential for disutility arising from explicit rationing
35 Potential instability (Mechanic) Individual strength of preference not consideredLack of acceptance of explicit rationingChallenges to health authorityWeakening resolve of health authorityReturn to implicit rationing
36 Utility of implicit rationing Deprivation disutility- patients who are aware that care is being rationed may suffer a sense of grievance if they are not treatedDenial disutility- citizens may suffer disutility from being asked to partake in the process of denying care to other members of society
37 (Evans & Wolfson, in Mooney, 1994) "it is easier to bear inevitable disease or death than to learn that remedy is possible but one's personal resources, private insurance coverage or public programme will not support it"(Evans & Wolfson, in Mooney, 1994)
38 “for physicians to have to face these trade-offs explicitly is to assign to them an unreasonable and undesirable burden”(Fuchs, 1984)