Health Care Rationing Research Articles

Commentary

How to redesign the incentives structure in the United States to reward effective coordinated care rather than production volume is a staggering public health policy challenge. In the mind of the public, there is a fine distinction between health care rationing and rational health care. Specialists have a vital but underappreciated role in reining in health care costs, but specific incentives to elicit behavior change with positive social outcomes remain ambiguous. It is imperative, therefore, that redesigning the incentives structure is thoughtfully considered, modeled, and tested prior to implementation, lest an inferior-quality model is inadvertently adopted and costs are only marginally contained. Quality metrics need to be universal and reflect real patient outcomes instead of the degree of investment by the institution in the reporting tools. Still, specialists should take immediate action to implement safe and efficient procedures and to assess their long-term impact on patients' quality of life. Scientific evaluations should guide both the assessment of the appropriateness and the safe delivery of care. Investment in high-quality data architecture and the science of health delivery implementation is an imperative if health care reform is to achieve its goals. Coordination and collaboration between specialists and primary care physicians is essential to this enterprise. Specialists can champion these efforts as they pertain to their areas of expertise by considering their care episodes in the context of the patient as a whole, working closely with generalists, and returning to the mindset of the specialist as a family doctor.

External Review Process Options for Self-Funded Health Insurance Plans

Many provisions of the Patient Protection and Affordable Care Act (the “PPACA” or “the Act”), signed into law on March 23, 2010, are highly controversial. Particularly contentious are issues pertaining to the rationing of health care, as illustrated by the recent, highly visible discourse about “death panels.” The issue became so heated that President Obama urged five governors with whom he met to avoid using the word “rationing” in discussing health care reform “for fear of evoking the hostile response that sank the Clintons’ attempt to achieve reform.” Although none of the legislative proposals contained any provisions that would lead to the creation of death panels or any similar body, the Act does have sections that affect decisions about who will receive health care and who will not. One of these sections is the provision of the PPACA governing external review of denial-of-care decisions by insurance companies. This section generally mandates either that insurers comply with external review processes found in state law, or, if they are not subject to state regulation, that they establish an external review process. Insurers in the latter category must implement “effective external review process[es]” that meet “minimum standards established by the Secretary [of Health and Human Services]” and that are “similar” to state-regulated processes. While the framework provided in the Act offers some guidance as to what these processes should look like, it does not dictate a specific review process.

Can Health Care Rationing Ever Be Rational?

Americans' appetite for life-prolonging therapies has led to unsustainable growth in health care costs. It is tempting to target older people for health care rationing based on their disproportionate use of health care resources and lifespan already lived, but aged-based rationing is unacceptable to many. Systems reforms can improve the efficiency of health care and may lessen pressure to ration services, but difficult choices still must be made to limit expensive, marginally beneficial interventions. In the absence of agreement on principles to govern health care resource allocation, a fair, open priority-setting process should be created to allow for reasonable disagreement on principles while being seen as legitimate by all stakeholders. At the patient-care level, careful discussions about the benefits and burdens of medical intervention and support for slow medicine - a gentle, family-centered care approach for frail elders - can do much to avoid harming these patients with aggressive yet unwanted medical care while reducing wasteful spending.

Must We Ration Health Care for the Elderly?

Resistance to rationing health care to the elderly is enormous. This article lays out the need for rationing, based on projections of Medicare expenditure in the near future, and the judgment of policy experts that there will be no technological breakthrough that might lower costs. Various forms of rationing possibilities are discussed as well as cultural and political obstacles to needed reform. Some general principles for thinking about health care for the elderly are presented.

The Graying of America: Challenges and Controversies

journal of law, medicine & ethics Growth of the world’s population is accelerating. It reached one billion people in 1800, and added the next billion by 1930 — 130 years later. The population reached three billion by 1960 — in only 30 years — and ever since then, a billion more people have been added every 12-13 years. The world’s population now stands at nearly seven billion, and epidemiologists project that it will rise to 9.3 billion by 2050. The majority of that population, 61%, lives in Asia, mostly China and India, and only 4.5% live in the United States — those proportions will change little by 2050 (see Figure 1). In developing countries, the population’s frequency distribution by age is heavily weighted toward youth, while in developed countries such as the U.S., the bulk of the population is in the 30-60 year age group.1 In the U.S., the expanding population is reaching old age more rapidly than in most of the rest of the world, largely because the baby boom of 1946-1964 produced a large bump in population, and the first of the baby boomers reached age 65 in 2010. Between 1900 and 2010, the proportion of the population age 65 and older increased at an average rate of 0.74% per decade, but over the next two decades, the rate of increase in the elderly population will be over 3% per year (see Figure 2). By 2030, the rate of population growth related to the baby boom will level off, and by then, about 20% of the U.S. population, 72 million people, will be over the age of 65 years (see Figure 3). This aging of the U.S. population has brought to the fore a number of ethical issues that will grow in importance as the elderly population expands. The 16th Annual Thomas A. Pitts Memorial Lectureship in Medical Ethics addressed several of these issues, including the idea of rationing health care based on age; disparities in health care of the elderly; caring for the growing number of persons with advanced dementia; and physician-assisted death for terminally ill individuals with unremitting suffering. Some of the nation’s leading authorities in these areas were brought together for this conference. Daniel Callahan has been one of the foremost proponents of rationing health care for the elderly since the publication of his 1987 book, Setting Limits: Medical introduction

Toward a Methodology and Public Discourse of Christological Concreteness: Lessons from a Discussion of Health Care Rationing in the United States

Abstract A recent passage of the Affordable Care Act (ACA) has once again sparked fierce public debates within the United States over the permissibility of health care rationing. Unfortunately only a handful of public theologians have addressed this issue, and those who have often fail to draw upon Jesus’ ethical praxis. This article corrects this lacuna by offering a clarifying theological analysis and defence of one form of rationing, known as Comparative Effectiveness Research (CER), through a proposed method of Christological concreteness. The article begins by outlining which CER provisions are included in the ACA, and then discusses how they will re-shape US public health expenditures in the future. An examination of Richard Land’s and Jim Wallis’s theological evaluations of rationing is used to demonstrate that, while each is helpful in some respects, both omit the moral saliency of Jesus. To correct these shortcomings, the article draws upon some recent methodological trends within Christian ethics and devises a Christological method based upon a synthesis of integrative, canonical, reiterative, embodied and incarnational variables. Finally, a critical analysis of Allen Verhey’s discussion of health care rationing explains why his approach not only provides a compelling justification for using CER but also a preferable approach for public theology.

Critical Care Rationing: International Comparisons

Every country has finite resources that are expended to provide citizens with social "goods," including education, protection, infrastructure, and health care. Rationing-of any resource-refers to distribution of an allotted amount and may involve withholding some goods that would benefit some citizens. Health-care rationing is controversial because good health complements so many human endeavors. We explored (perceptions regarding) critical care rationing in seven industrialized countries. Academic physicians from England, Spain, Italy, France, Argentina, Canada, and the United States wrote essays that addressed specific questions including: (1) What historical, cultural, and medical institutional features inform my country's approach to rationing of health care? (2) What is known about formal rationing, especially in critical care, in my country? (3) How does rationing occur in my ICU? Responses suggest that critical care is rationed, by varying mechanisms, in all seven countries. We speculate that while no single "best" method of rationing is likely to be acceptable or optimal for all countries, professional societies could serve international health by developing evidence-based guidelines for just and effective rationing of critical care.

Just Caring: Defining a Basic Benefit Package

What should be the content of a package of health care services that we would want to guarantee to all Americans? This question cannot be answered adequately apart from also addressing the issue of fair health care rationing. Consequently, as I argue in this essay, appeal to the language of "basic," "essential," "adequate," "minimally decent," or "medically necessary" for purposes of answering our question is unhelpful. All these notions are too vague to be useful. Cost matters. Effectiveness matters. The clinical circumstances of a patient matters. But what we must ultimately determine is what we mutually agree are the just claims to needed health care of each American in a relatively complex range of clinical circumstances. Answering this question will require a public moral conversation, a fair process of rational democratic deliberation aimed at defining both just claims to needed health care and just limits.

Rationing and Health Care Reform: Not a Question of If, but When

Evidence-based medicine and rationing have been increasingly discussed in the context of health care reform recently. Both concepts are frequently the source of heated debate, leading to polarization of different health care practitioners and public parties. In some public arenas, rationing has become a dirty word. The term evidence-based medicine is perceived as being used as a "cover" for rationing. However, rationing is widespread, whether explicit or implicit, and exists within health care. Evidence-based medicine (or imaging) and rationing overlap considerably, and it looks like both are here to stay, given the current state of developed-world health care systems and the proposed reforms. The authors review these entities and argue that evidence-based medicine (or imaging) is one form of health care rationing. Rationing already occurs, and it is important that it be done in a way that provides the greater good for the majority. This article reviews the history of rationing and evidence-based medicine, the reasons evidence-based medicine and rationing are necessary, examples of rationing that already exist (economic), proposed forms of rationing (age based), the need for physicians (radiologists) to be at the forefront of any rationing efforts, and the basis (cost and comparative effectiveness research and evidence-based medicine) and principles of physician decision rationing (optimum outcome-based rationing) in the context of proposed health care reforms.

Do health care professionals find the use of age‐based rationing to reduce health care costs ethical?

PurposeAs a result of the aging of American society, health care costs have been and will continue to rise, to the extent that they are not sustainable. Obviously, this trend will continue in spite of the 2010 health care reform. As a result of this uncontrollable problem, writers such as Daniel Callahan have proposed age‐based rationing of health care while utilizing the utilitarian notions of ethics and justice. However, other writers, utilizing more egalitarian notions of justice, have opposed this. This suggests an ethical dilemma, which has to be debated in the future. The author believes professors teaching health care related courses will be instrumental in this debate, explaining why she decided to seek the opinion of a sample of 18 professors regarding this issue. The purpose of this paper is to report on the results of this research.Design/methodology/approachQualitative methodology, specially grounded theory, was used in this study that sought to explore the views of 18 full‐time professors who teach health care policy and administration in Northeast Pennsylvania about age‐based rationing of health care. Qualitative research is very useful uncovering the views of individuals as they relate to their experiences. In the study, professors were asked 14 questions by the author, four of these being demographic. The remaining ten questions, open ended ones, sought the opinions of these professors about their support or opposition to age‐based rationing.FindingsThe author's interviews of those 18 professors and the analysis of the responses, which revealed the complexity and multidimensional nature of the issue, led to the emergence of eight different themes.Originality/valueThe author used a qualitative method of research, interviewing 18 professors, to uncover personal views not previously published.

PHP9 Temporary Use Authorizations: The Economic and Clinical Future of Drugs Used in the French Compassionate Program

ISPOR 14th Annual European congress : Rational Health Care Decision Making in Challenging Economic Times, 11-2011, Madrid, Espagne

Delegation and Institutional Design in Health‐Care Rationing

The delegation of decision‐making powers to nonmajoritarian, independent agencies has become a significant phenomenon in more and more policy areas. One of these is the health‐care sector, where decisions on the range of services covered within public systems have, in most developed countries, been delegated to specialized bodies. This article offers an analytical framework that seeks to grasp the empirical variety and complexity of delegative processes and appointed institutions. The framework is used to describe decision‐making processes and institutions in six countries: Austria, Germany, Norway, Sweden, New Zealand, and the United Kingdom. We find that, although constrained by preexisting institutional structures and traditions, delegators enjoy a considerable degree of discretion in their institutional design choices and engage in strategic design and redesign of appointed bodies.

Optimal public rationing and price response

Abstract We study optimal public health care rationing and private sector price responses. Consumers differ in their wealth and illness severity (defined as treatment cost). Due to a limited budget, some consumers must be rationed. Rationed consumers may purchase from a monopolistic private market. We consider two information regimes. In the first, the public supplier rations consumers according to their wealth information (means testing). In equilibrium, the public supplier must ration both rich and poor consumers. Rationing some poor consumers implements price reduction in the private market. In the second information regime, the public supplier rations consumers according to consumers’ wealth and cost information. In equilibrium, consumers are allocated the good if and only if their costs are below a threshold (cost effectiveness). Rationing based on cost results in higher equilibrium consumer surplus than rationing based on wealth.

Resource scarcity and priority-setting: from management to leadership in the rationing of health care?

While continued interest in the application of priority-setting technologies is perhaps unsurprising in a time of austerity, they require sensitive implementation for their full potential benefits to be realized. This article looks at the role and value of leadership in addressing problems of a lack of perceived legitimacy and governance that have been raised in connection with the rationing enterprise. The potential and limitations of key leadership concepts such as ‘sense-making’ and ‘framing’ are explored, and notions of relational leadership and the importance of leading with political astuteness are discussed.

Conflicts and ambivalences: a case study of clinical pathways in Norway

Without any introduction, I asked one of the doctors: ‘What do you think when you hear the word “clinical pathways”?’ Still working at his computer and not looking at me, he said with contempt: ‘I shiver!’ This article examines a significant contemporary feature of the increasing economic rationality in healthcare, and exemplifies this in the activity model: clinical pathways; further it argues that the role of emotions in developmental processes is often underestimated. Clinical pathways (CP) in Norway can be translated into something like ‘a treatment line’, although quite a few professionals associate this with ‘assembly lines’. The CP model facilitates a focus on patient welcoming in healthcare services, but is also associated by professionals with lower ranked values such as administration, documentation, logistics, standardization, measurements and ‘good enough’ service at minimum cost. This stands in contrast to traditional values such as autonomy, high professional practice, relational care and empathic attitudes, thus sharpening the contradictions between being a care versus a service worker. The article examines a multidisciplinary CP project and points to hidden and ambivalent emotions and opinions about CP that the informants never discuss in their project meetings. The hidden emotions never came to the surface, thereby functioning as an energy leak instead of a valuable dimension of developmental processes.

Realigning Incentives for Developing and Pricing New Anticancer Treatments

THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) proposed in late March that Medicare cover sipuleucel-T, a new therapy for patients with terminal prostate cancer. Three independently conducted randomized controlled trials found that sipuleucel-T extends survival by 3 to 5 months. But the price is $93 000 for a course of therapy. It is probably pure coincidence that the announcement occurred as Congress was locked in intense negotiations over the budget, but few recent developments better symbolize the challenges facing lawmakers who want to rein in Medicare spending. Sipuleucel-T is only one of an increasing number of costly and controversial cancer treatments. Previously, bevacizumab and other genetically engineered chemotherapeutics attracted attention from insurers. These drugs, like sipuleucel-T, extend life by months, not years, and are costly. Between 1995 and 2005, lifetime medical costs for Medicare patients who received a diagnosis of metastatic colorectal cancer and who received chemotherapy increased from $63 000 to $100 000 (2006 dollars). More drugs are forthcoming; in late March, the Food and Drug Administration (FDA) approved a new treatment for late-stage melanoma, ipilimumab, that extends survival by 4 to 5 months. The cost is $120 000. Manufacturers of new chemotherapeutics face few constraints on their pricing power. Oncologists make money from office-administered chemotherapeutics, and most insurers, such as Medicare, cover FDA-approved drugs. Patient cost-sharing provides little incentive to economize on care for privately insured patients who have exceeded their deductibles and for Medicare patients with supplemental coverage. Standard economic models do not adequately explain pricing patterns for new chemotherapeutics. Why should the price of sipuleucel-T be so much greater than the price of bevacizumab (a chemotherapeutic originally approved for metastatic colorectal cancer) when the benefits are similar? It seems as if social norms, rather than market forces, dictate pricing decisions. For instance, if one company introduces a drug that costs $30 000, insurers complain but still cover the drug. The next company to introduce a drug, seeing that the first was able to charge $30 000, sets its price at $40 000, and the cycle continues. Although the introduction of sipuleucel-T will have only a small effect on total health care costs, the cumulative effect of the continuous introduction of expensive treatments is that Medicare spending is increasing at an unsustainable rate. Any credible approach to reducing the rate of growth in spending must curb some combination of the introduction, use, and prices of new technologies. The Patient Protection and Affordable Care Act (PPACA) seeks to reduce costs by enrolling Medicare beneficiaries in accountable care organizations (ACOs). Although cancer patients would benefit from care coordination, ACOs do not seem particularly well suited for restraining spending on medical technologies. The final rule for ACOs states, “Nothing in the Shared Savings Program shall be construed to affect the payment, coverage, program integrity, and other requirements that apply to providers and suppliers under [feefor-service] Medicare,” and that ACOs will not achieve savings by “withholding any needed care that helps beneficiaries.” President Obama recently proposed that the Independent Payment Advisory Board, a presidentially appointed committee authorized under the PPACA, be given more power to “reduce unnecessary spending.” “Unnecessary” is a vague term, but, according to common usage in health care settings, it does not apply to costly but effective treatments. In any event, the act explicitly restricts the ability of the board to limit access to new technology, stating that the board’s proposals “shall not include any recommendation to ration health care.” Congress could go one step farther and grant CMS the authority to set coverage policies and reimbursement rates based on drugs’ cost-effectiveness, as is the practice in many European countries. Advocates hope this approach will rationalize medical care. However, organized interest groups may make it difficult to reach “rational” decisions. It is telling that of the 657 public comments received (as of May 7,

보건의료자원의 거시적 배분과 민주주의적 정당성

Almost all countries in the world experience a scarcity of health care resources and the need to ration health care services. Each medical system is faced with difficult decisions concerning treatment coverage and priorities. Current methods of allocation are based on (1) substantial principles of justice, (2) cost-effectiveness analysis, (3) cost-value analysis, and (4) market mechanisms. Given these methods of allocating health care services, the question of legitimacy is rightfully raised. The question of legitimacy needs to be approached in an orderly manner. In the first place, the concept of democratic legitimacy needs to be articulated. Secondly, current methods of allocation must be evaluated. Thirdly, a legitimate method of allocation is needed. This article concentrates on the first and the second step. I argue that current methods of allocation fail to satisfy a democratic conception of legitimacy. However, this conclusion does not mean that these methods of allocating should be totally rejected. Each of these methods has an important element that at least contributes to democratic legitimacy. Based upon the evaluation provided in this article, I introduce a very promising method of allocating health care services, one developed by N. Daniels and J. Sabin.

Long-term survival rates of older breast cancer patients: Population-based estimates over three decades.

9051 Background: Significant progress has been made in the treatment of breast cancer. However, the impact of these treatments on survival in older patients with breast cancer is not clear. Methods: We used data from the Surveillance, Epidemiology, and End Results database to determine relative survival of older patients with breast cancer. We compared trends in survival between 1977-86, 1987-96 and 1997-2006 in patients 65-74, 75-84 and 85+ years of age. Survival rates were calculated for up to 9 years after diagnosis. Results: Between 1977-86 and 1997-2006, 1 year survival increased from 94.9% to 97.9%, 93.6% to 96.7% and 88.5% to 93.5% in the 65-74, 75-84, and 85+ age groups, respectively. Survival gains increased with each year in all three age groups with the greatest improvement observed at 9 years of follow up. Smaller differences were seen between 1987-96 and 1997-2006. Although the ‘oldest old’ (85+ years) had the lowest survival rates, improvement in overall survival was greatest in this age group. Conclusions: Relative survival for older patients has increased considerably in the interval between 1977 and 2006, with the largest improvement seen in those 85 years and older. These results likely indicate that the benefit from advances in therapy and supportive care also extends to older patients with breast cancer including the ‘oldest old’. This may have significant relevance in terms of defining management strategies for the treatment of older breast cancer patients particularly at a time when rationing of health care is under consideration. Relative survival rates for breast cancer. Calendar period Time since diagnosis (Years) Age group (years) 1977 to 1986 Survival % (SE) 1987 to 1996 Survival % (SE) 1997 to 2006 Survival % (SE) 1 5-74 94.9 (0.4) 97.1 (0.2) 97.9 (0.2) 75-84 93.6 (0.6) 96.3 (0.4) 96.7 (0.4) 85+ 88.5 (1.4) 92.8 (1.0) 93.5 (1.0) 5 65-74 78.8 (0.6) 87.7 (0.6) 91.4 (0.6) 75-84 77.0 (1.2) 86.9 (0.8) 91.8 (1.0) 85+ 67.7 (2.9) 80.3 (2.6) 85.0 (3.0) 9 65-74 68.4 (0.8) 81.9 (0.7) 87.3 (1.2) 75-84 67.6 (1.6)* 81.5 (1.4)* 89.7 (2.2)* 85+ 54.4 (4.6)* 68.2 (4.4) 78.4 (8.6) * Relative survival increased from a prior interval and has been adjusted. Abbreviation: SE, standard error to estimate 95% confidence interval.

The American Cancer Society and the American Health Care System

The U.S. health care system is in critical condition. Costs are rising to the point that the high price of health care is a threat to the U.S. economy. In 2010, health care was more than 17% of the gross domestic product, and if it continues to rise at current rates, health care will become more than 25% of the overall U.S. economy. This growth rate is not sustainable. While U.S. per capita costs are the highest of any country worldwide, quality is varied. Indeed, American health care outcomes for cancer and other diseases are inferior to several European countries with far lower per capita costs. The truth is many Americans cannot afford adequate health care, and health care is rationed in the U.S. While many do not get the health care they need, some are actually harmed by overconsumption of unnecessary health care. These Americans are treated outside of established guidelines and get unnecessary procedures and take unnecessary medications. A substantial number of Americans are supportive of health care reform with the goal of getting needed, high-quality health care to those Americans who currently do not get it. The American Cancer Society is committed to using the established scientific methods of epidemiology to define the problems and identify possible solutions. We are committed proponents of the rational, evidence-based use of health care to avoid the wasteful and inefficient rationing of health care.

Diagnostic Value and Cost-Effectiveness of Good Quality Digital Images Accompanying Electronic Referrals for Suspected Skin Malignancies

The aim of this study was to investigate the outcome and cost-effectiveness of good and poor quality photographs accompanying the electronic referrals for suspected skin malignancies. A retrospective study of 100 patients, divided into 2 groups, 50 with good quality photographs and 50 with poor quality photographs. Patients with no digital images, or who failed to attend, or patients with incomplete notes were excluded from the study. The treatment pathway, waiting times, and estimated cost between the 2 groups were compared. Good photographs were more likely to be treated at the 1-Stop Clinic (P = 0.05). Good images had a better positive predictive value than poor quality images (62.55% vs. 42.86%). Good quality images are more accurate than poor quality images in triaging of patients, and thus more effective in facilitating the treatment of malignant lesions timely. Good quality photographs allow a delayed appropriate treatment of benign lesions. This increases the safety for patients in a queue in a rationed health care system, and improves patient flow.