rationing health care - a general scheme for prioritizing health services

There are probably several legitimate methodologies that could be used for devising a “health services priorities list” for open rationing. The scheme I am about to outline is based on the methodology used in Oregon, with the general exception that the guiding ethical principle here is the FCEO standard instead of the “maximization of beneficence” standard. There are also innumerable specific problems with the Oregon methodology, and we will note a few of them. This outline is not meant to be a fully developed system for rationing, however, but instead is intended merely to illustrate that it is at least possible to conceive of a rationing strategy that optimizes both fairness and beneficence.

1. Establish a Health Standards Commission.

Such a Commission should be publicly accountable, and should consist of medical practitioners, nurses, and patients. We agree with the Oregonians that the medical practitioners on this Commission should be generalists rather than specialists, as generalists are more likely to have a global view of medicine, whereas specialists are more likely to be conflicted.

2. Establish an exhaustive list of condition-treatment pairs.

Part of the problem with the cost-effectiveness analysis in Oregon is that the condition-treatment pairs they examined were not specific enough. It is not enough to say, “coronary artery bypass grafting for coronary artery disease,” as bypass surgery can be performed electively (to relieve angina), or emergently (to save a life threatened by acute or impending occlusion of a major blood vessel), and can be performed in otherwise healthy patients or in patients whose underlying disease produces relatively high risk and relatively poor outcomes. Condition-treatment pairs should be developed, and subsequently ranked, for all of these possible contingencies. It should be noted that this task of defining an adequate breadth of condition-treatment pairs is in itself a major undertaking.

3. Establish an exhaustive, accurate Quality of Well-Being instrument.

The problems associated with Oregons’ QWB survey are severe. It is doubtful, for instance, that the people answering the survey realized just how their answers would be used – otherwise, it is unlikely that preventing death would have turned out to be only three times better than curing nausea.

Yet, while making death only three times worse than nausea seems absurd on the surface, there may in fact be patients with chronic, unrelenting nausea, retching, and inability to eat, whose lives really are not much better than being dead. Perhaps curing three of these people would produce enough “increase in quality” that it should be given the same weight as saving a life.

The point is, of course, that the QWB survey employed in Oregon did not give respondants the opportunity to differentiate between the transient nausea one might have after a hard night’s celebrating and the sort of horrible, unremitting nausea we have just mentioned.

A new quality survey should be devised that (similar to redoing the list of condition-treatment pairs) would be broad enough to provide a full range of highly specific quality measures. It should be administered to enough people (to at least tens of thousands) to allow a good statistical differentiation among various quality states. This, too, is a huge undertaking in its own right – but nonetheless is doable.

4. Use rigorous standards for computing cost-effectiveness.

Evaluating the cost-effectiveness of each condition-treatment pair should be based on the most rigorous scientific standards possible. For each pair, pains should be taken to estimate as accurately as possible the benefits of therapy, the harms of therapy, and the costs. Before any therapy receives a high ranking, there must be convincing evidence that it works (i.e., a therapy should not be seriously considered because it “might” work.) The potential benefits of a therapy being considered should clearly outweigh the potential harms, and compared to the “next best” therapy, it should clearly represent an advance in benefit, a reduction in risks, or a reduction in costs. Finally, the burden of proof should rest with the ones who want to institute a new health care service (i.e., the company marketing the service, the health care workers providing the service, and patients who want to receive the service). Since these individuals are proposing that “their” service displace other services on the priority list, they should be obligated to provide the data necessary for assessing its cost-effectiveness.

Since quality measures are an integral part of cost-effectiveness analysis, care should be taken to assure that the quality measures used in the analysis adhere to the three rules defined above.

Appendix C offers a more rigorous discussion of cost-effectiveness calculations, with emphasis on how ethical choices are expressed in the mathematics of those calculations.

5. Public input should be sought for integrating social values into the priority list.

The Oregon model might serve as a good starting point, since it appears that, while not everybody in Oregon agreed with the end result, the process undertaken there for achieving community involvement resulted in a general consensus supporting the state’s open rationing efforts.

It is likely that prioritizing condition-treatment pairs by category, similar to what was done in Oregon, will result in a priorities list that is more acceptable to the public than a straight cost-effectiveness listing would be. However, these categories do not have to be absolute. For instance, wanting life-saving treatments to have priority over preventative treatments does not necessarily mean that every life-prolonging treatment has to be ranked ahead of every preventative treatment. There are many ways of preventing apparent inconsistencies. For instance, we could allow a higher funding cut-off in the higher priority category than in a lower priority category. (For instance, we might be willing to spend $75,000/QALY for life-saving therapies, whereas preventive therapies would be funded to a rating of only $50,000/QALY).

Whichever methods are used to garner the general support of the public, the public must “sign-off” on any system devised. It is their money, and their lives.

6. A rigorous system for collecting data on the benefits, harms, and costs of therapies needs to be developed.

In operational terms, the weakest link in any rationing system will be our relative lack of the information needed to perform rigorous cost-effectiveness analysis. As an integral part of any rationing program, therefore, an extensive data gathering system will be required for tracking, on an ongoing basis, the data needed for cost-effectiveness analysis. Such a system will also facilitate the continuous revision of the priority list of health care services, as new therapies and new information about older therapies become available.

We owe a great debt of gratitude to the citizens of Oregon. They have taught us much, and the general scheme we have just outlined relies heavily on their efforts. Following this sort of general scheme, which admittedly will be anything but a trivial effort, it ought to be possible to devise a system for prioritizing health care services that is fair, equitable, and acceptable to the great majority of Americans.

Next: Appendix C: Implications of cost-effectiveness calculations

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