Disinvestment policy and the public funding of assisted reproductive technologies: outcomes of deliberative engagements with three key stakeholder groups.

Katherine Hodgetts,Annette J Braunack-Mayer,Janet E Hiller,The Astute Health Study Group ,Jackie M Street,John R Moss,Amber M Watt,Adam G Elshaug,Drew Carter

doi:10.1186/1472-6963-14-204

Abstract

BackgroundMeasures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain.MethodsDeliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis.ResultsEach forum demonstrated stakeholders’ capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around ‘equity’ and ‘patient responsibility’, culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access).ConclusionsDeliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder ‘self-interest’ proved unfounded as each group sought to prioritise universal values (in particular, ‘equity’ and ‘responsibility’) over specific, within-group concerns. Our results - from an emotive case study in ART - highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.

Highlights

Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern
Increasing agreement that stakeholder input is required for disinvestment processes to be representative and accountable has complicated the establishment of pragmatic mechanisms for disinvestment [8,9]
Consumers Values underpinning arguments for and against subsidy restrictions It might have been expected that consumers of assisted reproductive technologies (ART) – those whose treatments resulted in successful live births – would be ‘protective’ of funding in this area, and reluctant to see restrictions applied in a domain with such personal resonance [31]

Summary

Introduction

Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. As costs and service demands increase against a background of limited resources, priority setting has become a complex and increasingly central component of healthcare policymaking. Within this context, decisions must inevitably be made as to the public reimbursement of new treatments and technologies and the restriction of funding for established services [2]. Decisions must inevitably be made as to the public reimbursement of new treatments and technologies and the restriction of funding for established services [2] An approach to the latter concern, ‘disinvestment’ has emerged as a means of improving healthcare outcomes by evaluating existing services that do not provide sufficiently safe, effective or cost-effective care, and re-directing funding to services deemed superior against these criteria [3]. Increasing agreement that stakeholder input is required for disinvestment processes to be representative and accountable has complicated the establishment of pragmatic mechanisms for disinvestment [8,9]

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