Health Care Rationing Research Articles

Economic evaluation of maintenance treatment with tacrolimus 0·1% ointment in adults with moderate to severe atopic dermatitis

Rational health care decision-making based on outcomes and economic evidence is essential to provide the best possible care for individual patients with atopic dermatitis (AD). To describe treatment outcomes and to evaluate resource utilization and associated cost of maintenance use of tacrolimus ointment (MU) vs. standard use of tacrolimus ointment (SU) in adults with AD. A pan-European, phase III multicentre randomized clinical trial was conducted. Patients with mild to severe AD were randomized to tacrolimus 0.1% ointment (MU) or vehicle (SU) twice per week for 12 months. Disease exacerbations were treated by using open-label tacrolimus 0.1% ointment twice daily. Resource utilization data were collected prospectively alongside the clinical trial. Costs of pooled resource data were determined using German unit cost data. Direct and indirect costs were considered from third party payer, patient and societal perspectives. All patients with moderate and severe AD were included in a subanalysis, 75 patients in the MU arm (57% moderately affected) and 59 patients in the SU arm (59% moderately affected). In patients with moderate AD, the number of disease exacerbations in the MU arm was 2.4 vs. 5.5 in the SU arm (P<0.001); in patients with severe AD corresponding figures were 2.3 vs. 7.4 (P<0.001), respectively. Mean+/-SD total annual cost per patient was euro1525+/-1081 (MU) vs. euro1729+/-1209 (SU) in patients with moderate AD and euro2045+/-2013 (MU) vs. euro2904+/-1510 (SU) in patients with severe AD. Maintenance treatment with 0.1% tacrolimus ointment is more effective and leads to cost savings and improved health-related quality of life in comparison with standard use of 0.1% tacrolimus ointment, especially in patients with severe AD.

The NHS at 60

Your editorial, based largely on benign misunderstandings and wishful thinking in the style of one Rowan Atkinson, urges clinicians [especially those over 40 and fed up] to engage in the debate – presumably with management and politicians (JRSM 2008;101:327). This is dangerous. During the first 20 years of the NHS most clinicians did engage and co-operate with a tiny number of mostly very able administrators and agents of the Ministry of Health, resulting in a very happy NHS indeed becoming the ‘Envy of the World’. The ‘COGWHEEL’ reorganization in 1974 heralded the imposition of an ever increasing management structure, the poor managers more and more burdened by often hasty and reactive schemes, plans, structures, initiatives, targets and the rest, running to millions of words, introduced by a succession of Health ministers, few of whom were long in post and many of whom seemed to have little understanding of health generally or the NHS, and little ability to formulate and think through workable plans. A sensible strengthening of management clearly was needed – first to organize the increasingly complex and expensive technology available; second to try to contain the huge increases in costs by real increases in efficiency; and third to introduce rationing. It all went wrong, for many reasons, most caused by poorly worked out and poorly drafted plans and dictats from the politicians. The abject fear of feeble politicians of association with the idea of rationing of health care in the public mind has led to blundering cuts and devolvement of responsibility to the often powerless managers, rather than to the rational economies and sensible rationing that could have followed an open debate. It is quite wrong, and most regrettable, to suggest that clinicians have so far failed to engage. A large proportion have at times done so, but most of these have found it a bruising and unsatisfactory experience, while many of those who have persisted seem to have adopted management values, making them unfit to represent patients, doctors and other health professionals. Before engaging, therefore, doctors should be well aware of the natural aims and aspirations of those on the other side of the table. Politicians, both local and national, always aware of their need of popularity for re-election, will rarely be concerned beyond the short term. To a Minister, health is a portfolio to be held for just long enough to impress sufficiently for promotion in the next reshuffle. It is much easier to make cuts in services, often deviously disguised, than to achieve economies by real efficiency. A good manager is ambitious and aware that advancement will require loyalty to the organization as his overriding priority. This may be strengthened by bonus payments, sometimes for questionable successes. Altruism is unlikely to appear until the manager or official is very senior, and even then is likely to fail in competition with the Honours system. Whilst recognizing that the managers have a tough and sometimes thankless task running the service as the politicians direct, we must never forget that the patients' ultimate safeguard lies in the independence of the medical profession – and, almost as importantly, that our integrity depends on us fighting against any erosion of that responsibility. We should be involved but we must not be assimilated.

Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26–27, 2007

2008;133;1S-7S Chest Geiling and Lewis Rubinson Asha Devereaux, Michael D. Christian, Jeffrey R. Dichter, James A. * 27, 2007 − January 26 Force for Mass Critical Care Summit, Summary of Suggestions From the Task http://chestjournal.chestpubs.org/content/133/5_suppl/1S.full.html services can be found online on the World Wide Web at: The online version of this article, along with updated information and ISSN:0012-3692 ) http://chestjournal.chestpubs.org/site/misc/reprints.xhtml ( written permission of the copyright holder. this article or PDF may be reproduced or distributed without the prior Dundee Road, Northbrook, IL 60062. All rights reserved. No part of Copyright2008by the American College of Chest Physicians, 3300 Physicians. It has been published monthly since 1935. is the official journal of the American College of Chest Chest

Auswirkungen einer Rationierung auf die medizinische Betreuung während der letzten Lebensphase

Old-age-based rationing of health care takes places both implicitly and explicitly. Its effects show on an emotional level and it affects medical practice. A distinction is made between explicit and implicit health care rationing. For example, performing fewer human organ transplants can be regarded as explicit rationing. Implicit or soft rationing may arise through either an undersupply of medical and nursing staff or through an oversupply of medical care as a consequence of the DRG bonus system. In this way an underlying and misleading incentive for an oversupply of diagnoses and treatments is created while at the same time the pressure is increased to reduce the length of hospital stay. Consequently, patients especially miss out on what they need most at this late stage of life: care and time to care. There are no clear rules for old-age-based health care rationing, which undermines the credibility of the health care system.

The Elderly and Health Care Rationing

This Monograph derives from research undertaken during my appointment as a Visiting Scholar at The Poynter Center for The Study of Ethics and American Institutions, Indiana University, Bloomington in July-August, 2000. The thesis of this Monograph is that before contemporary society can confront the issue of health care rationing for the elderly, it must seek to integrate the disciplines of moral and ethical reasoning with the qualitative formulations of needs and resources. Until such a point is reached, however, the greatest danger to avoid is the perpetuation of non-decisions regarding health care treatment. Such all too frequently result in the non-treatment of elderly patients and institutional residents because of an inability to assess effectively the equitable and efficient allocation of the scarce health care resources which are available. The real moral question raised from this debate is not whether too much treatment or too little is offered. Rather, it is how to optimize the appropriateness of the treatment; and therein lies the moral obligation of health care as well. However difficult or tragic the allocative decisions are to make, taking no action is perhaps the most pernicious conduct of all. Society must realize that aging is not a disease, but an inherent part of human life.

Fórum: racionamento dos cuidados de saúde. Introdução

Explicit rationing of health care is one of the most important issues under debate in the academic and political fields in both developed and developing countries. The articles presented in this Forum provide an approach to some of the questions relating to this issue. The approach is multidisciplinary, covering complex ethical questions and the contribution of economics to the debate. The analyses reveal specificities associated with the shift from implicit approach for rationing of health care, traditionally dominant in health systems, to a systematic and explicit priority-setting method in general and the potential incompatibility between efficiency and equity objectives in health policy in particular. The Forum's reflections link directly to current worldwide discussions on the questions "Why ration health care?" and "How to ration health care?"

Reflexão bioética sobre a priorização e o racionamento de cuidados de saúde: entre a utilidade social e a eqüidade

Since health needs outweigh the available resources, choices are imperative. It is thus necessary to set limits, criteria, and standards in order to prioritize the supply, the recipients, and the services to be provided. Ethical alternatives are discussed for the prioritization and rationing of health care, focusing on the principles of equity and social utility.

Emotional Labor and Health Care

AbstractWe examine the literature on emotional labor and health care to demonstrate the potential for emotional labor research to inform how social and medical scientists think about health care and how examining healthcare contexts has contributed to the scientific understanding of emotional labor processes. In doing so, we first review the key terms and definitions that are used within the emotion management perspective and evaluate the ways in which power differences have remained largely implicit features of research on emotional labor in healthcare settings. Finally, we explore how the increasing economic rationalization of health care may be influencing the emotional experiences of today's healthcare professionals and the implications of this trend for future research on emotional labor and the health and well‐being of care providers and their patients.

How Physicians Allocate Scarce Resources at the Bedside: A Systematic Review of Qualitative Studies

Although rationing of scarce health-care resources is inevitable in clinical practice, there is still limited and scattered information about how physicians perceive and execute this bedside rationing (BSR) and how it can be performed in an ethically fair way. This review gives a systematic overview on physicians' perspectives on influences, strategies, and consequences of health-care rationing. Relevant references as identified by systematically screening major electronic databases and manuscript references were synthesized by thematic analysis. Retrieved studies focused on themes that fell under three major headings: (i) conditions and influences of BSR, (ii) strategies of BSR, and (iii) consequences of BSR. The range of themes indicates that physicians' rationing behavior is highly variable, strongly influenced by context-related factors, and consists mainly of implicit rationing strategies. Torn between patient advocacy and the obligation to contain costs, physicians experience various role conflicts. The development of explicit rationing strategies seems necessary to avoid arbitrary BSR and allow a fair allocation of health-care resources.

Developing methods that really do value the ‘Q’ in the QALY

Most health economists recommend that improvements in health be valued by asking members of the general public to imagine themselves in different states of health and then to think about how many years of life they would give up or what risk of death they would be willing to accept in order to be in full health. In this paper, I argue that preferences are not a very good guide to future experiences and a more suitable way to value health is to ask people in different states of health how they think and feel about their lives. Valuing health in this way may result in greater priority being given to mental health services. Whatever the precise implications, it is my contention that it is much better to ration health care according to real experiences rather than according to hypothetical preferences.

Lifestyle, responsibility and justice

Unhealthy lifestyle contributes significantly to the burden of disease. Scarce medical resources that could alternatively be spent on interventions to prevent or cure sufferings for which no one is to...

The secret art of managing healthcare expenses: investigating implicit rationing and autonomy in public healthcare systems

Rationing healthcare is a difficult task, which includes preventing patients from accessing potentially beneficial treatments. Proponents of implicit rationing argue that politicians cannot resist pressure from strong patient groups for...

A Gentleman and a Scholar

I remember Dr. Kolb (I could never think of him as ‘‘Larry’’) as one of the last gentlemen, a true representative of the old school, someone with a clear sense of priorities and values. On our first day as residents, he gathered us together to give us a single precept: ‘‘You are all here to learn, and I believe you will learn a lot, but just remember: your first responsibility is to your patients, so be ready, if one of them needs you, to leave off whatever academic work you are engaged in and go to his side.’’ Besides his own example of how to be a clinician, he taught us something our other teachers did not emphasize: to look for the patient’s strengths. ‘‘Yes, yes,’’ he would respond to our litany of the patient’s symptoms, ‘‘but what does he do well? What does he care about?’’—in other words, who is this PERSON, after all? Long after my residency, after he had stepped down from being Commissioner of Mental Health, I met him again, in his last years, when he had returned to his earlier work in post-traumatic stress and was conducting physiological research at the VA in Albany. Still buoyed up by transferential feelings toward him, I asked the ‘‘big question’’: would it ever be possible to resolve the issues around rationing of healthcare, so that at least a modicum of it could be delivered to everyone?’’ ‘‘Certainly,’’ he replied, ‘‘it would be possible; however, too many people are making too much money out of the system as it is. That is the real problem.’’ We all miss his vision and his integrity. We hope his last years, mostly in Georgia, were happy ones for him. There are precious few like him.

The impact of health care rationing in maxillofacial surgery

The impact of health care rationing in maxillofacial surgery

Markets and medical care: the United States, 1993-2005.

Many studies arguing for or against markets to finance medical care investigate "market-oriented" measures such as cost sharing. This article looks at the experience in the American medical marketplace over more than a decade, showing how markets function as institutions in which participants who are self-seeking, but not perfectly rational, exercise power over other participants in the market. Cost experience here was driven more by market power over prices than by management of utilization. Instead of following any logic of efficiency or equity, system transformations were driven by beliefs about investment strategies. At least in the United States' labor and capital markets, competition has shown little ability to rationalize health care systems because its goals do not resemble those of the health care system most people want.

Handbook for health care ethics committees

Preface Acknowledgments I. Curriculum for Ethics Committees 1. Ethical Foundations of Clinical Practice The Role of Ethics in Clinical Medicine Ethics Committees in the Health Care Setting Fundamental Ethical Principles Principlism and Alternative Approaches The Role of Culture, Race, and Ethnicity in Health Care Conflicting Obligations and Ethical Dilemmas 2. Decision Making and Decisional Capacity in Adults Health Care Decisions and Decision Making Decision-Making Capacity Assessment and Determination of Capacity Deciding for Patients without Capacity 3. Informed Consent and Refusal Evolution of the Doctrine of Informed Consent Elements of Informed Consent and Refusal The Nature of Informed Consent Exceptions to the Consent Requirement 4. Truth Telling Justifications Disclosure Disclosure of Adverse Outcomes and Medical Error Privacy and Confidentiality Genomic Testing and Control of Information 5. Special Decision-Making Concerns of Minors Decisional Capacity and Minors Consent for and by Minors Confidentiality and Disclosure Special Problems of Functionally Alone Adolescents 6. Ethical Issues in Reproduction The Ethics and Politics of Reproductive Choice Assisted Reproductive Technologies Surrogacy and Gestational Carriers Termination of Pregnancy Maternal-Fetal Issues Prenatal/Newborn Genetic Testing and Genomic Newborn Screening Special Decision-Making Concerns of the Elderly The Other Side of the Mountain Diminishing Autonomy and Decisional Capacity Promise that you won't ever put me in a nursing home Independence, Dependence, and Role Reversals Prior Wishes and Current Needs Intimacy and Security Transition from Hospital to Home or Nursing Home 8. Ethical Issues in the Care of Disabled Persons Disability and Its Place in Bioethics Defining Disability The Medical and Social Models of Disability The Disability Rights Critique of Prenatal Genetic Testing Special Challenges in the Care of Persons with Severe Cognitive Impairment Medical Decision Making and the Disabled 9. End-of-Life Issues Decision Making at the End of Life Defining Death Organ Donation Advance Health Care Planning Honoring Patients' End-of-Life Decisions Goals of Care at the End of Life Forgoing Life-Sustaining Treatment Protecting Patients from Treatment Rejection of Recommended Treatment and Requests to Do Everything Medical Futility 10. Palliation From Caring to Curing and Back Again The Experience of and Response to Pain The Moral Imperative to Relieve Pain Assisted and Permitted Dying Pediatric Palliative Care Palliative Care and Hospice Palliative Care 11. Justice, Health, and Access to Health Care Access to Health Care in the United States Justice and Health Disparities Health Care as a Requirement of Justice Health Care and Health Theories of Justice Rationing Health Care Reform 12. Organizational Ethics From Bioethics to Health Care Organizational Ethics Moral Responsibilities of Health Care Organizations Organizational Ethics and Compliance Ethics and the Allocation of Resources Ethics Committees and Organizational Issues Developing an Organizational Ethics Service II. The Creation, Nature, and Functioning of Ethics Committees 13. Profile of Ethics Committees Origins Committee Functions Membership Expertise in Ethics Leadership Securing a Foothold Clinical Ethics Consultation Overview of Ethics Consultation Three Models of Clinical Ethics Consultation Services Building an Ethics Consultation Service Credentialing and Privileging Clinical Ethics Consultants Analytic Approaches to Clinical Ethics Consultation Selecting the Best Clinical Ethics Consultation Service Model for Your Institution Access to Clinical Ethics Consultation Policies 15. Ethics Education Brown Bag Lunches Journal Clubs Case Conferences Ethics Grand Rounds Ethics Modules in Residency Training and Medical School Programs Ethics Symposia White Papers, Memoranda, Guidelines, and Protocols Additional Education Opportunities 16. Sample Clinical Cases Adolescent Decision Making Advance Directives Autonomy in Tension with Best Interest Confidentiality Decisional Capacity Disclosure and Truth Telling End-of-Life Care Forgoing Life-Sustaining Treatment Goals of Care Informed Consent and Refusal Medical Futility Parental Decision Making Surrogate Decision Making 17. Sample Policies and Procedures III. Organizational Codes of Ethics Regional Medical Center Code of Conduct Metropolitan Medical Center Code of Ethics University Health Network Code of Ethics IV. Key Legal Cases Informed Consent Privacy Confidentiality Health Care Decision Making Medical Decision Making for Minors Reproductive Rights State Action to Protect Public Health State Action to Control What Practitioners Must or Must Not Discuss with Their Patients Health Care Reimbursement V. An Ethics Committee Meeting Index

Can We Say No? The Challenge of Rationing Health Care

Book Review| June 01 2007 Can We Say No? The Challenge of Rationing Health Care Henry J. Aaron and William B. Schwartz, with Melissa Cox. Can We Say No? The Challenge of Rationing Health Care. Washington, DC: Brookings Institution, 2005. 212 pp. $44.95 cloth; $18.95 paper. Rudolf Klein Rudolf Klein Search for other works by this author on: This Site Google J Health Polit Policy Law (2007) 32 (3): 539–543. https://doi.org/10.1215/03616878-2007-014 Cite Icon Cite Share Icon Share Facebook Twitter LinkedIn MailTo Permissions Search Site Citation Rudolf Klein; Can We Say No? The Challenge of Rationing Health Care. J Health Polit Policy Law 1 June 2007; 32 (3): 539–543. doi: https://doi.org/10.1215/03616878-2007-014 Download citation file: Zotero Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search Books & JournalsAll JournalsJournal of Health Politics, Policy and Law Search Advanced Search The text of this article is only available as a PDF. Duke University Press2007 Article PDF first page preview Close Modal You do not currently have access to this content.

Health Care Resource Prioritization and Rationing: Why Is It So Difficult?

Dan W. Brock Health Care Resource Prioritization and Rationing: Why Is It So Difficult? T h e p r i o r i t i z a t i o n o f h e a l t h c a r e r e s o u r c e s a n d r a t i o n i n g i s a paradigm example of difficult choices, and yet one m ight well wonder why. Individuals are continually forced every day to prioritize their own resources, deciding w hat to use them for and w hat to forego. The process could not be m ore familiar. Since our wants typically outrun our resources, and although we may regret w hat m ust be foregone, we learn to make the choices and move on to the next ones. So why is the very idea of prioritizing and rationing health care resources so trou­ bling and controversial? Americans are deeply ambivalent and inconsistent about health care rationing. On the one hand many like to pretend that it does not take place, but they fear being denied beneficial care, in particular paym ent by their health insurance plans for care they need. If rationing does not take place, of course, there is little to fear. On the one hand, m any say that we are a rich country and have no need to ration health care, but they resist the rising costs of health care, particularly w hen they result in greater out-of-pocket costs to them . On the one hand, m any say that life is precious and money should not enter into deci­ sions about medical treatm ent, but on the other hand they resist the ever increasing proportion of both our national w ealth and their own social research Vol 74 : No 1 : Spring 2007 125 w ealth that goes to health care. And on the one hand many recognize the need to lim it the use of some health care, but resist those limits w hen they are applied to them or others about whom they care. Now these inconsistencies m ight sim ply reflect a perfectly common and understandable desire to have more of a valued good like health care, but not to pay m ore for it. For goods that we m ust purchase in a m arketplace, we soon learn th at this is not a desire th at can be satisfied—if we w ant more, we m ust be prepared to pay more, and so we m ust decide how m uch that m ore is w orth to us in comparison with other uses for our resources. Most Americans, however, do not pay out of pocket the full costs of the health care they receive, but instead have m ost or all of the costs of their health care paid through health insur­ ance. So unlike goods fully purchased and paid for in the marketplace, we do not bear the full, often most, or sometimes even any, of the real costs of the health care we consume. In the extreme, if we can get it for free, it is hardly surprising that we do not support rationing w hich will have the effect of denying some health care to us. Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who w ant and could be benefited by th at good will not receive it. This allocation or rationing can take place by m any means. The use of a m arket to distribute a good is one common way to ration it, since attaching a price to a good or service is one way of allocating it in conditions of scarcity and results in some who would w ant it and could be benefited by it not getting it. One reflection of our ambivalence toward health care rationing is seen in our resis­ tance to having it distributed in a m arket like m ost other goods: m ost Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another...

It ain’t what you do, it's the way that you do it: Characteristics of procedural justice and their importance in social decision-making

Standard welfare economic analysis evaluates all actions by their consequences. However, evidence from other disciplines suggests that the procedures by which decisions are made also affects the welfare of individuals. This paper outlines six characteristics on which judgements about procedural justice may be based. Using the example of health care rationing, we examine the importance of each characteristic using qualitative and quantitative methods. We further consider the importance of each of these characteristics relative to one another and examine whether they are important for consequential or non-consequential reasons.

Rationing and critical care medicine

As healthcare expenditures have continued to grow in the United States and elsewhere, the demand for cost-cutting measures has increased. This has led many to wonder if we are, in fact, rationing health care. Critical care is characterized by very high expenditures on a relatively few number of patients, many of whom do not survive, and it is therefore a likely place where rationing could occur. Although much has been written about the concept of rationing, there are few data about the practice, with the exception of studies that examined triaging in the intensive care unit. Research in this area is greatly hampered by the fact that identifying rationing can be very subjective given the relatively inconsistent methods by which critical care is actually practiced and the lack of a clear definition of rationing. This article reviews the concept of healthcare rationing by exploring the many different definitions and methods by which it could occur and the ethical principles underlying these methods. In addition, we review the pertinent literature on resource allocation and rationing in intensive care units.