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PubMed1992

The rationing of health care: should Oregon be transported to Australia?

The Oregon Plan is an ambitious attempt to address the widespread problem in the United States of a growing number of individuals who are without private health insurance and are not eligible for federal assistance programs. Its aim is to provide universal access for all Oregonians, without increasing total health care expenditure, by restricting the cover of some treatments. It has aroused interest in Australia and elsewhere. The appeal of the Oregon Plan lies in its explicit approach to rationing, in community participation in setting priorities, and the use of a cost-effectiveness framework. This paper describes the beginnings and the development of the Oregon Plan, and compares the actual development of the Plan with the rhetoric. There is a gap between the rhetoric of the Plan and its reality. The Oregon plan should be considered in the context of the United States health care system. We compare the American problems with those facing the Australian health care system and conclude that the answer to the question of whether Oregon should be transported to Australia is no. Nevertheless there are elements of the rhetoric of the Plan which could be applied in rationing health care in Australia.

Health Care Rationing↗

PubMedDate not supplied

Rationing decisions and individual responsibility for illness: are all lives equal?

OBJECTIVES: This survey measured individuals' rationing allocation choices for situations in which patients are deemed to hold personal responsibility for their diseases and the influence of different arguments on such choices. METHODS: The association between allocation decisions for liver disease and asthma and the belief that a patient was responsible for his or her illness was modeled using multivariable regression analysis, controlling for the effect of arguments on choices. RESULTS: In data from 310 returned surveys (43% response rate), respondents were 10 to 17 times more likely to allocate liver transplants or asthma treatment to patients they deemed not responsible for their illnesses than to patients they deemed responsible for their conditions (liver transplants: odds ratio [OR] = 10.3, 95% confidence interval ([CI] = 2.5-42.1; asthma: OR = 16.8, 95% CI = 2.1-136.6). CONCLUSIONS: Personal responsibility for illness was an important consideration in respondents' rationing allocation decisions. These choices appeared to be stable although possibly influenced by respondents' interpretations of the survey scenarios and decision tasks.

Adult↗

PubMed2003

Opening the black box of rationing care in later life: the case of 'community care' in Britain.

Research on the rationing of care to older patients in Britain and America typically focuses on acute care here I consider 'chronic care' as illustrated by 'community care' in Britain. Adopting a critical sociological approach to dependency and to the construction of 'later life,' I argue that chronic care users constitute a class, and that clinical need has played a pivotal role in its development. As this reflects the allocative rationing of care I call into question, the claim made by the current British government that need can provide a benchmark of age justice.

Aged↗

PubMed1997

Breast cancer patients' attitudes about rationing postlumpectomy radiation therapy: applicability of trade-off methods to policy-making.

PURPOSE: Along with evidence, clinical policies must take patients' values into account. Particularly where evidence is limited and where assumptions of utility-maximizing behavior may not be valid, new methods such as trade-off techniques (TOTs), which allow elicitation of patients' treatment alternatives, might be useful in policy formulation. We used TOTs to assess breast cancer patients' attitudes toward two clinical policies designed to ration adjuvant postlumpectomy breast radiation therapy. METHODS: Cross-sectional interviews were performed in a tertiary cancer center. A total of 102 patients were presented with information about the side effects and benefits associated with two hypothetical decisions: (1) willingness to receive treatment elsewhere to shorten the wait for radiation therapy, and (2) foregoing radiation therapy in the face of small marginal benefits. For each scenario, a TOT was used to identify the maximal acceptable wait time (MAWT) for therapy and the benefit threshold at which the patient would forego therapy. Associations of clinical and demographic factors with these decisions were determined by regression analysis. RESULTS: Patients would be willing to wait, on average, 7 weeks before wanting to leave their city for radiation therapy, less than the 13-week delay our patients actually faced. Older patients were less willing to wait (P = .013); 46% of patients would not give up radiation therapy, even in the face of no stated benefit. Willingness to give up radiation therapy was predicted by willingness to accept delay (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.05 to 3.37) and being employed (OR, 2.61; 95% CI, 1.08 to 6.54). Patients with larger tumors were less willing to give up radiation therapy (OR, 0.57; 95% CI, 0.31 to 0.97). CONCLUSION: Even in difficult decisions such as rationing postlumpectomy breast cancer radiation therapy, TOTs can inform policy formulation by indicating the distributions of patients' preferences.

Adult↗

PubMed1989

Psychometric properties of the Survey of Personal Beliefs: a rational-emotive measure of irrational thinking.

A test consistency and confirmatory factor analyses were performed on the Survey of Personal Beliefs, a new measure of irrational thinking based on rational-emotive personality theory. The survey, which was logically derived, includes a general rationality factor and subscales measuring five hypothesized core categories of irrational beliefs. Subjects included a nonclinical sample of 130 men and 150 women, with a mean age of 46. Results indicated that the Survey of Personal Beliefs had satisfactory total and scale reliability. The confirmatory analyses supported a higher order factor model including 5 first-order factors ( awfulizing, self-directed shoulds, other-directed shoulds, low frustration tolerance, and self-worth) and 1 second-order or general factor.

Adult↗

PubMed1999

The Oregon Health Plan and the political paradox of rationing: what advocates and critics have claimed and what Oregon did.

The article proceeds in three sections. First, we very briefly review the original proposals and ensuing (and misleading) debate over rationing in Oregon. Next, we explore how the politics of rationing unfolded in Oregon from the enactment of OHP to its implementation. Finally, we consider the character of Oregon's innovation and the broader lessons that it holds for reform efforts elsewhere.

Diffusion of Innovation↗

PubMed2001

The need is to prioritize, not ration.

The Canadian model of medicare is based on shared values among governments, providers of care and the consumers of care. Rationing implies that a consensus exists as to what constitutes the most beneficial medical services and that an active decision be made by providers to choose inferior services to save societal resources. Such rationing can be arbitrary and non-scientific. A better option to prioritize healthcare spending is the development of best-practice guidelines that are agreeable to all concerned. Another approach is to reform the system in order to optimize the use of facilities, personnel and other resources. Many of these reforms will be expedited by the creation of information technology linkages between care providers.

Canada↗

PubMed2001

Advocacy and rationing are compatible.

In his paper, Peter Ubel attempts to make the case for "bedside rationing" by clinicians in order to help control healthcare costs. This commentary addresses a number of conceptual, logical and linguistic problems with Dr. Ubel's paper, challenges his apparently "heretical" view of advocacy, but provides additional support for his central claim that physicians should do bedside rationing.

Cost Control↗

PubMedDate not supplied

Analysis of health rationing policies in the NHS.

Explicit rationing policies are beginning to appear in the NHS in response to the increasing demand for health care and rising treatment costs. Such policies challenge the traditional values upon which nursing in the UK is founded. This article examines the case for rationing and its implications for nursing.

Attitude to Health↗

PubMed2003

Rationing home care resources: how discharged seniors cope.

Rationing home care services has become a common strategy used by state/provincial governments to control escalating health care costs, particularly at a time when very little new funding has been re-directed to the home care sector. Across British Columbia, Regional Health Authorities had implemented service reforms that call for the discharge of higher functioning clients from home support service. This paper describes the coping strategies of 137 senior clients who were discharged from home support services and from the Continuing Care Program in the Simon Fraser Health Region located in British Columbia, Canada. Personal interviews were conducted by experienced case managers to gain an understanding of how seniors were coping 19 to 21 months after their discharge. Of the 137 clients, 34.3% are characterized as being "home alone and suffering in silence," 29.2% reported receiving assistance from informal sources or reported paying out-of-pocket for private care, and 28.4% reported that they can do the work better themselves. The remaining 8.0% of participants reported mixed feelings about the impact of their discharge from home support service. The effectiveness of discharge targeted to a senior population is discussed and it is suggested that functional status together with age are important criteria when rationing home care services.

Activities of Daily Living↗

PubMed1994

Health care cost containment: rationing medical technology.

Effective and efficient delivery of health care is one of the critical issues facing the nation today. Currently, nearly 13% of the nation's GDP in spent on Health Care. Perhaps one-half of the increase in health care costs have been linked to the acquisition of new medical technology. This paper examines some of the issues relating to the acquisition and dissemination of the use of medical technology by acute care and outpatient facilities and discusses the rationing of medical technology. The paper concludes by identifying some of the approaches to controlling health care costs through the rationing of technology that have been presented in the literature and outlines the evolving new paradigm that is being advanced to address the issues of cost containment and access to health care.

Canada↗

PubMed1991

Should basic care get priority? Doubts about rationing the Oregon way.

Recognition of the need to ration care has focused attention on the concept of "basic care." It is often thought that care that is "basic" is also morally prior. This article questions that premise in light of the usual definitions of "basic." Specifically, it argues that Oregon's rationing scheme, which defines "basic" in terms of cost-effective care, fails to pay sufficient attention to important ethical principles such as justice.

Cost-Benefit Analysis↗

PubMed2001

Jewish and Roman Catholic approaches to access to health care and rationing.

In addressing issues of access to health care and rationing, Jewish and Roman Catholic writers identify similar guiding values and specific concerns. Moral thinkers in each tradition tend to support the guarantee of universal access to at least a basic level of health care for all members of society, based on such values as human dignity, justice, and healing. Catholic writers are more likely to frame their arguments in terms of the common good and to be more accepting of rationing that denies beneficial and needed health care to some persons. Jewish writers are more likely to consider individual responsibility for illness in allocation decisions and to accept differences in health care that different members of society receive. The article considers the relevance of both shared and complementary perspectives for deliberations in nations such as the United States.

Catholicism↗

PubMed2002

Medicine, public health, and the ethics of rationing.

Physicians, like all citizens, have communal and private identities, each attending various associated roles and fulfilling diverse obligations. In light of these dual personae, we seek a moral philosophy which encompasses the responsibility for providing care to the patient and at the same time acknowledges the physician's role of arbiter of distributed care. In the traditional doctor/patient relationship, rationing, the admission that health resources are limited and must be distributed equitably by universally accepted criteria, is essentially ignored. When the physician assumes a population-based system of ethics to optimize care for all patients within a group, rationing is embraced as the realistic admission that any social action resides within boundaries--in this case health care resources--and that such restraints have economic consequences that present ethical choices. A common ground to accommodate these dual allegiances is offered by communitarian philosophy, whose outline and applicability is presented here as an alternative to the apparent moral opposition of optimized individual care and the requirement of community-wide distribution of limited health resources.

Bioethics↗

PubMed1996

Age as a basis for healthcare rationing. Support for agist policies.

It is inevitable that publicly funded, technically sophisticated medical treatments will be increasingly rationed. Other things being equal, there is a greater duty to use them to prolong the lives of younger than older people. Age is therefore an ethical rationing criterion. Denial of this may actually harm older people.

Aged↗

PubMed2006

Silenced complaints, suppressed expectations: the cumulative effects of home care rationing.

In many Western welfare jurisdictions, publicly provided home care is being eroded and its provision increasingly individualized. These shifts are of a particular significance for older women, a group for whom supportive home care has been an important buttress against the social and physical jeopardies of old age. A longitudinal, qualitative study of such women in Ontario, Canada, spanned the implementation of managed competition in home care and a period of rapid privatization and service rationing. Study participants experienced cuts and, stemming from increasingly precarious employment conditions in the home care workforce, inconsistent care providers. These changes generated distress, insecurity, and isolation in participants' lives. This article explores how their complaints about insufficient care were silenced: by fear, hopelessness, and the cultural injunction to put a stoic and selfless face on the limitations of old age. Their accounts reveal how large material and discursive shifts and state restructuring come to penetrate identity, feeling, and speech. This examination of the silencing of complaint at home care's front lines reveals the cumulative effects of rationing; it also illuminates how, if heard, service users' voices can inform collective struggles to resist the degradation of home care and reposition older people in relation to the state.

Adult↗

PubMed1980

Rational-emotive therapy and depression: a clinical case study.

Rational-emotive group and bibliotherapy were used to treat a depressed patient in a clinical setting. Psychological test data document a dramatic improvement. It is suggested that rational-emotive therapy may prove efficacious for the treatment of some depressed patients in clinical settings.

Adult↗

PubMed1989

Beliefs and inferences: a test of a rational-emotive hypothesis: 2. On the prospect of seeing a spider.

96 subjects were asked to imagine that they were about to enter a room in which there may have been one or more spiders. They were also asked to imagine that (a) they either held a rational or an irrational belief about spiders, (b) they were about to enter the room either alone or with someone, and (c) that the room was either dark or light. Having absorbed their assigned role, the subjects were then asked to make inferences about various elements of their situation. The results supported the hypothesis that holding an irrational belief leads to more negative inferences. It was also found that the lighting conditions in the room and whether the subject was alone or with someone affected the negativity of the inferences made. In addition, there were several two-way and three-way interactions between the independent variables which indicated that entering a light room or being with someone else tended to moderate the negativity of inferences made by those holding a rational belief rather than the opposite, amplifying the negativity of inferences made by those holding an irrational belief. The results supported Ellis's (1985) recent formulation concerning the complex relationship between events and inferences (A), beliefs (B), and emotional and behavioral consequences of beliefs (C).

Adolescent↗