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!!!!. Rationing in health care.
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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!!!!
“The word [rationing] is invoked to make the flesh creep, not to prompt argument about how to deal with the inescapable”
Rudolph Klein, 1992
Price system - objective = efficiency
allocation by WTP/ATP
Non-price - objective efficiency or equity’?
who decides on allocation?
allocation by what criteria?
“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”
(Coast et al, Priority setting: the health care debate, John Wiley, 1996)
“... 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)
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 supportOregon List Version 2
+ 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=???
+ implied neutrality
+ clarity of objectives
inherent value judgements
weaknesses in methods
+ suited to uncertain and complex situations
+ decisions based upon compromise
heavily dependent on which groups are included
slipping back to implicit rationingAdvantages and disadvantages
- patients who are aware that care is being rationed may suffer a sense of grievance if they are not treated
- citizens may suffer disutility from being asked to partake in the process of denying care to other members of societyUtility of implicit rationing
"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)