Date post: | 08-Apr-2018 |
Category: |
Documents |
Upload: | muhammad-aslam-channa |
View: | 227 times |
Download: | 0 times |
of 38
8/6/2019 Rationing in Health Care
1/38
M207: Health Economics
Rationing in health care
With indebtedness and gratitude to
Joanna Coast, Department of Social
Medicine, University of Bristol, forwriting a book, PhD thesis and
presentation on priority-setting
and for allowing me to plagiarise it
all!!!!
8/6/2019 Rationing in Health Care
2/38
M207: Health Economics
Rationing in health care
What does rationing mean?
Rationing with respect to efficiency orequity?
Implicit versus explicit rationing
Methods and examples of explicitrationing
8/6/2019 Rationing in Health Care
3/38
M207: Health Economics
Rationing: whats in a name? Economics concerned with choice
between competing alternatives
Based on axiom ofscarcity- resourceslimited relative to wants
Fundamental economic problem is
therefore allocation of these scarce
resources Rationing (and priority-setting) just
another term forresource allocation
8/6/2019 Rationing in Health Care
4/38
M207: Health Economics
Rationing: whats in a name?
The word [rationing] is invoked to
make the flesh creep, not to promptargument about how to deal with the
inescapable
Rudolph Klein, 1992
8/6/2019 Rationing in Health Care
5/38
M207: Health Economics
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 forrationing; and (ii) applied technique for
rationing
8/6/2019 Rationing in Health Care
6/38
M207: Health Economics
Philosophical basis of rationing
Price system - objective = efficiency
consumer sovereigntyallocation by WTP/ATP
Non-price - objective efficiency or equity?
who decides on allocation?
allocation by what criteria?
8/6/2019 Rationing in Health Care
7/38
M207: Health Economics
Objective: efficiency or equity?
Efficiency
maximisation of benefit
utilitarian ethic
distribution is irrelevant
Equity
just distribution based on need? age? lottery?
8/6/2019 Rationing in Health Care
8/38
M207: Health Economics
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?
8/6/2019 Rationing in Health Care
9/38
M207: Health Economics
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 insociety
8/6/2019 Rationing in Health Care
10/38
M207: Health Economics
Ethics and levels of rationing
Theories have varying degrees of
applicability atpopulation and individual
level
Utilitarian and Rawlsian generally
population level, Deontological generally
individual May adopt different ethical principle at
each level of rationing (decision-making)
8/6/2019 Rationing in Health Care
11/38
M207: Health Economics
Who pays?
Health Authority?
Government?
Taxpayer?
8/6/2019 Rationing in Health Care
12/38
M207: Health Economics
Who reallypays? 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
8/6/2019 Rationing in Health Care
13/38
M207: Health Economics
Implicit or explicit rationing?
Implicit rationing: care is limited, but
neither the decisions, nor the basesfor those decisions are clearly
expressed.
Explicit rationing: care is limited andthe decisions are clear, as is the
reasoning behind those decisions.
8/6/2019 Rationing in Health Care
14/38
M207: Health Economics
Rationing in the UKRationing in Great Britain has been
implicitIt is a silent conspiracy between a
dense, obscurating bureaucracy, intentionallyavoiding written policy for macroallocation
(rationing), and a publicly unaccountable
medical profession privately managing
microallocationso a
sto conceal life anddeath decisions from patients
(Crawshaw, 1990)
8/6/2019 Rationing in Health Care
15/38
M207: Health Economics
Rationing in the NHS
Predominately implicit rationing
BUT increasing advocation of explicitrationing
1989/91 reforms
1994-5 Health Committee Report
1996 Rationing Agenda Group
NICE?
8/6/2019 Rationing in Health Care
16/38
M207: Health Economics
Methods of explicit rationing
Lay
participation
Medical
paternalism
Politicalprocesses
Equity Efficiency
Technicalmethods
Explicit
rationing
(Coast et al, Priority setting: the health care debate, John Wiley, 1996)
8/6/2019 Rationing in Health Care
17/38
M207: Health Economics
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
8/6/2019 Rationing in Health Care
18/38
M207: Health Economics
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
8/6/2019 Rationing in Health Care
19/38
M207: Health Economics
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
8/6/2019 Rationing in Health Care
20/38
M207: Health Economics
The Oregon Plan
1987 - decision to stop
funding for organ
transplantation 1989 - Oregon Health
Services Commission
begins work
1990 - List 1 1991 - List 2
1994 - plan begins
8/6/2019 Rationing in Health Care
21/38
M207: Health Economics
Oregon List Version 1
Efficiency principle
1600 condition/treatment pairs
Cost/QALY gained
social values
outcome
cost
8/6/2019 Rationing in Health Care
22/38
M207: Health Economics
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)
8/6/2019 Rationing in Health Care
23/38
M207: Health Economics
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
8/6/2019 Rationing in Health Care
24/38
M207: Health Economics
Oregon List Version 2
Top Five C/Tpairs
1 Pneumonia - medical
2 Tuberculosis - medical
3 Peritonitis -
medical/surgical
4 Foreign body - removal
5 Appendicitis - surgical
Bottom Five C/Tpairs
705 Aplastic anaemia - medical
706 Prolapsed urethral mucosa -
surgical
707 Central retinal artery occlusion
- paracentesis of aqueous
708 Extremely low birth weight,