Download Rationing - msccreepmodule

Rationing
Priority setting
Ann Winter
Definition
• A fixed quantum of health care per person
(New Shorter Oxford Dictionary)
• Raising the price of a commodity so as to
restrict the number of people who can
afford to buy it. Rationing by price (Oxford
English Dictionary)
Accountability for Reasonableness
• Publicity – decisions must be publicly accessible
• Relevance – rationales for decisions must rest
on evidence that for minded parties agree are
relevant
• Appeals – there is a mechanism for challenge
and dispute resolution
• Enforcement – there is regulation of the process
to ensure the first three conditions are met
Daniels N & Sabin J (1998) The ethics of accountability in
managed care reform, Health Affairs, 17: 303 - 50
Explicit rationing
Why not?
Confused criteria – cannot deny it just
because its messy
Deprivation utility – scarce resources to fund
treatment incur distress (perceived
deprivation)
Effectiveness, visibility & clinical decisions
Implicit rationing
• Happens at the bedside or consultation
between patient and doctor
• Clinical decision making
• Benefits knowledgeable patients
Macro
• Resources allocated to local popn. on
basis of needs assessments
• Divided proportionally between different
types of disabling and treatable illnesses
within pop
• Specific illnesses should not be
discriminated against due to
popularity/social worth
• Rationing within not between eg triage
waiting lists
• Informed /influential public
Utilisation management
managed care
•
•
•
•
Precertification for admission
Concurrent review of length of stay
Case management of high cost cases
Second surgical opinions
• Decisions often made by administrators
UK
•
•
•
•
•
•
Quasi explicit rationing
Medical discretion
Block purchasing
Waiting lists
Getting on waiting lists
Undersupply of doctors, staff, machines,
facilities etc
Rationing Agenda Group
• Real ethics of rationing is to minimise the need
to ration by eliminating ways that entrenched
institutional, political and professional interests
lock in waste.
Eg
•
•
•
•
•
Over testing
Inappropriate prescribing
Follow up organisation
Utilising doctors when nursing skills
Budgets and contracts that protect hospitals, consultants and GPs
from integrated and more effective contracts
• If all this waste is eliminated waiting lists would disappear and never
return
Hancock C Rationing – not the spice of life, Health Service Journal 1997 June
26:26
• Muir Gray J (1997) Evidence Based Health Care – How
to make health policy and management decisions
• The NHS must shift from maximising the
number of episodes to maximising the
number of effective interventions and
beneficial outcomes
• Critical to reducing such waste and the
need for rationing is the strong
implementation of EBM
• Probability of particular outcomes
• Valuation of the outcomes
• Degree of risk
• Outcomes can only be expressed as probabilities
applying to populations eg Glue ear surgery is often
unnecessary and is less effective if the hearing loss is
<25 dB, but some children with lower levels of hearing
loss do benefit
• Probability can be applied to populations not individuals
New Zealand
1992 – National Advisory Committee on Core
Health and Disability Support Service now
national Health Committee
Higher priority patients attract higher points
severity of illness, treatment effectiveness, ability
to work, ability to care for dependents
Level of funding dictates the points at which
patient can expect treatment
Sweden
• Priorities Commission report – ethical principles
• Human dignity – all people have equal dignity and the
same rights regardless of their personal characteristics
and function in the community
• Needs and solidarity- direct resources to those whose
needs are greatest but also pay special attention to
those less able to voice needs/exercise rights
• Cost efficiency – there should be a reasonable relation
between cost and effect
Forms of rationing
• Denial – threshold of eligibility
is raised/lowered to exclude
• Selection – of
beneficiaries/deserving cases
• Dilution – reduction in scale
and depth of services –
everyone gets less – order
fewer tests, less time with
patients – quality reduced
• Delay – long exchange of
letters/discouragingly long
waits for appointments/waiting
lists
• Deflection – beneficiaries are
steered towards another
programme – education
problems are redefined as
housing problem which in turn
is re defined as a social
security problem – dumping
the problem in someone else's
lap
• Deterrence - barriers/costs of
entry into system receptionists/
incomprehensible forms/long
queues in dismal surroundings
• Termination – discharging
patients, closing lists
CLOAK OF INVISIBILITY
Decision analysis
1.
2.
3.
4.
Structure tree
Assess probability
Attach utilities /values to tree
Identify option that maximises expected utility
Lanza & Bantley (1991) Decision analysis makes explicit
those often implicit considerations in making the best
possible choice in difficult or complex situations
Lanza M & Bantley A (1991) Decision analysis. A method
to improve quality of care for nursing practice. J of
Nursing Care Quality 6.1. 60-72