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Rationing in health care

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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 rationing Methods and examples of explicit rationing

3 Rationing: what’s in a name?
Economics concerned with choice between competing alternatives Based on axiom of scarcity - resources limited relative to wants Fundamental ‘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 rationing Market system - price mechanism establishes equilibrium (efficient allocation) Non-market system - absence of price as allocative tool leads to other, non-price, techniques Issue is one of: (i) philosophical basis for rationing; and (ii) applied technique for rationing

6 ‘Philosophical’ basis of rationing
Price system - objective = efficiency consumer sovereignty allocation by WTP/ATP Non-price - objective efficiency or equity’? who decides on allocation? allocation by what criteria?

7 Objective: efficiency or equity?
maximisation of ‘benefit’ utilitarian ethic distribution is irrelevant Equity just distribution based on need? age? lottery?

8 Objective: efficiency or equity?
Philosophical basis price system/efficiency is utilitarianism Other philosophical bases are generally pursued in non-price allocation Which 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 others Rawlsian - ‘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 level Utilitarian and Rawlsian generally ‘population’ level, Deontological generally individual May adopt different ethical principle at each level of rationing (decision-making)

11 Who pays? Health Authority? Government? Taxpayer?

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 choice Who 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 rationing 1989/91 reforms Health Committee Report 1996 Rationing Agenda Group NICE?

16 Methods of explicit rationing
(Coast et al, Priority setting: the health care debate, John Wiley, 1996)

17 Explicit rationing: technical methods
Single principle Little distinction between setting priorities at different levels Examples maximising health gain need-based rationing lotteries age-based rationing

18 Technical method 1: ‘league tables’
Economic evaluation produces information on cost-effectiveness If using comparable outcomes (eg QALY) can ‘rank’ according to c/e Can use resultant ‘league table’ to allocate resource to most c/e first

19 League tables: handle with care!
Studies show differences in methodology choice of discount rate method of estimating utility values range of costs included choice of comparator Requires consistent methodology, ‘admission criteria’ for inclusion, applicability in local decision context

20 The Oregon Plan decision to stop funding for organ transplantation Oregon Health Services Commission begins work List 1 List 2 plan begins

21 Oregon List Version 1 Efficiency principle
1600 condition/treatment pairs Cost/QALY gained social values outcome cost

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 pairs Method: Development & ranking of categories Ranking C/T pairs within categories Public preferences Outcome Professional judgement

24 Oregon List Version 2 Top Five C/T pairs Bottom Five C/T pairs
1 Pneumonia - medical 2 Tuberculosis - medical 3 Peritonitis - medical/surgical 4 Foreign body - removal 5 Appendicitis - surgical Bottom Five C/T pairs 705 Aplastic anaemia - medical 706 Prolapsed urethral mucosa - surgical 707 Central retinal artery occlusion - paracentesis of aqueous 708 Extremely low birth weight, < 23 weeks - life support 709 Anencephaly - life support

25 Technical method 2: PBMA
Split health care service into ‘programs’ and subprograms - homogenous output Estimate current spending and outputs (benefits?) achieved by each programme Identify ‘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 structures Debate and bargaining “multiplicity of objectives” Micro versus macro level

29 Medical discussion and debate
Yes Current form of decision making Variable: therapies funded in some localities but not all Different weight to different principles? Yes No No Yes

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 Document National Advisory Committee on Core Health and Disability Support Services Public meetings about broad priority areas Consultation over broad ethical framework Panel discussions to formulate guidelines incorporating social factors

32 Success of Core Services
Incrementalism but how much has actually changed? Public consultation emphasis on hearing many voices have public ACTUALLY influenced priorities? how have methodological problems been dealt with? concern with “overconsultation”

33 Advantages and disadvantages
Technical + implied neutrality + clarity of objectives data hungry inherent value judgements weaknesses in methods rigidity implementation problems Bargaining + suited to uncertain and complex situations + decisions based upon compromise heavily dependent on which groups are included slipping back to implicit rationing

34 Challenges to explicit rationing
Potential impact upon the stability of the health care system Potential for disutility arising from explicit rationing

35 Potential instability (Mechanic)
Individual strength of preference not considered Lack of acceptance of explicit rationing Challenges to health authority Weakening resolve of health authority Return 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 treated Denial 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)

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