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PubMed2005

Rationing and competition in the Dutch health-care system.

In this paper we examine the goals and effects of health-care policy in the Netherlands over the period 1980--2000. During this period Dutch health-care policy is marked by a peculiar combination of increasingly stringent cost-containment policies alongside a persistent pursuit of market-oriented reforms. The main goal of cost containment was to keep labour costs down under the restriction of universal equal access to health care. Supply and price control policies were quite successful in achieving cost containment, but in due course prolonged quantity rationing began to jeopardise universal physical access to health services. The main goal of market-oriented health-care reforms is to increase the system's efficiency and its responsiveness to patient's needs, while maintaining equal access. The feasibility of the reforms crucially hinges on the realisation of adequate methods of risk adjustment, product classification and quality measurement, an appropriate consumer information system and an effective competition policy. Realising these preconditions requires a lengthy and cautious implementation process. Although considerable progress has been made in setting the appropriate stage for regulated competition in Dutch health care, the role of the market is still limited.

Cost Control↗
PubMed1993

Clozapine rationing in a state mental hospital: reviewing a HEC's case consultation.

Clozapine (Clozaril) is a new, powerful, costly anti-psychotic medicine, with a possible serious side effect (agranulocytosis) that entails weekly blood monitoring. In a three hundred bed state mental hospital that is allotted thirty clozapine slots (high costs effectively rationing this drug), a woman with schizophrenia responds minimally to this medication. Her attending physician wishes to withdraw the medicine and give it to another patient with schizophrenia on the ward who might have a better response. The woman's family threatens to make a public outcry. Both the attending physician and the family ask the HEC for a consult.

Adult↗
PubMed1999

[Rationing in public health: what criteria, what priorities?].

Rationalization in clinical care has reached its limits. Facing the need of further reducing health care costs it is relevant to reflect which diagnostic and therapeutic procedures are justified considering the public economic interests. A prioritized list of covered medical care requires a consensus of physicians, insurance companies and patients organizations on the basis of evidence-based medicine.

Cost Control↗
PubMed2000

Medical progress and rationing of cardiological services.

Due to the financial restrictions imposed on all national health services, the problem of allocating medical resources has gained new economical and political dimensions. Although each patient expects optimal treatment, the rationing of medical services make it increasingly difficult to provide the most adequate therapy. Health politicians and medical doctors have all advocated that health expenditures can be reduced by effective prevention of coronary heart disease, one of the main cost factors for all health services. Due to the introduction of statins, primary and secondary prevention of coronary heart disease can now be accomplished effectively. However, such treatment does not induce cost reduction, but rather an increase in costs. This applies predominantly to primary prevention. Treatment of all who would benefit from lipid lowering by statins would be prohibitively expensive for all national health care systems.

Anticholesteremic Agents↗
PubMed1992

The efficacy of rational emotive therapy in adults: clinical fact or psychometric artifact?

The efficacy of Rational-Emotive Therapy (RET) in reducing maladjustment, while insistently touted by its advocates, has not been unambiguously demonstrated in outcome research. Previous reviews have generally been quite partisan and subjective, and have not reflected available research. The object of the present review was to determine the extent to which RET significantly improved adjustment of adult subjects on different outcome measures in comparison with wait-list, placebo, and other treatment conditions. In 75 outcome reports, RET was effective in only about 25% of comparisons. Its main effect was to reduce scores of self-reported irrationality and dysphoria. Little change was noted in behavioral measures. The few comparisons favoring RET could be attributed to psychometric artifacts rather than to the reduction of irrational beliefs.

Adaptation, Psychological↗
PubMed1995

The treatment of social phobia: the differential effectiveness of exposure in vivo and an integration of exposure in vivo, rational emotive therapy and social skills training.

Thirty-four social phobic patients were treated with either exposure in vivo or an integrated treatment, consisting of rational emotive therapy, social skills training and exposure in vivo. Comparison with a waiting-list control group showed the effectiveness of both treatments. Contrary to expectations, the integrated approach was not superior over exposure in vivo alone. Also, the long-term effectiveness of both treatments was equally good.

Adult↗
PubMed1987

The dilemma of osteopathic physicians and the rationalization of medical practice.

Years ago, Peter New observed that osteopathic medical students faced a dilemma concerning their identity. On the one hand, they wished to be considered complete medical practitioners. On the other hand, they wished to be seen as different from MDs. There is evidence that osteopathic physicians continue to face that dilemma. I hypothesize that in part this stems from a conflict between classical 'lifestyle commitments' of the osteopathic community (e.g. toward general practice, osteopathic manipulative therapy, holism) and the rationalized model of medicine practiced by MDs (characterized by specialization and scientific elitism). Results of a survey of a local population of osteopathic physicians generally confirm this. Specific findings are that (1) classical elements of osteopathic commitment are not tied to commitment to the profession in general, (2) there appears to be a waning of commitment to general practice, (3) an increasing number of osteopathic physicians used the DO degree as a 'back door' into medicine and are less likely to identify with classical osteopathic norms, and (4) DOs from socially conservative backgrounds are more likely than others to maintain commitment to the classical elements of osteopathic practice.

Attitude of Health Personnel↗
PubMed2005

A clinician's guide to the appropriate and accurate use of antibiotics: the Council for Appropriate and Rational Antibiotic Therapy (CARAT) criteria.

In response to the overuse and misuse of antibiotics, leading to increasing bacterial resistance and decreasing development of new antibiotics, the Council for Appropriate and Rational Antibiotic Therapy (CARAT) has developed criteria to guide appropriate and accurate antibiotic selection. The criteria, which are aimed at optimizing antibiotic therapy, include evidence-based results, therapeutic benefits, safety, optimal drug for the optimal duration, and cost-effectiveness.

Anti-Bacterial Agents↗
PubMed2005

Responsibility, fairness and rationing in health care.

OBJECTIVE: People make different choices about how to live their life and these choices have a significant effect on their health, the risks they face and their need for treatment in the future. The objective of this article is, drawing on normative political theory, to sketch an argument that assigns a limited but significant role to individual responsibility in the design of the health-care system. METHOD: In developing our argument, we proceed in five steps. First, we review the literature on criteria for priority setting. Second, we explore the most prominent contemporary tradition in normative theory, liberal egalitarian ethics, with the aim to clarify the role of responsibility for choice. In particular, we discuss where liberal egalitarian theories would draw the 'cut' between the responsibility of the state (which is extensive) and the responsibility of the individuals (which is limited but significant). In the third step, we identify a priority setting dilemma where the commonly advocated criteria would assign equal priority. Finally, we develop a simple model in order to examine the implications of introducing a well-defined notion of responsibility for choice in a priority-setting dilemma of this kind. RESULTS: Liberal egalitarianism holds individuals responsible for choices that affect their health, given that (i) the illness is completely or partly a result of individual behaviour and choice; (ii) the illness is not life-threatening; (iii) the illness does not limit the use of political rights or the exercise of fundamental capabilities; and (iv) the cost of treatment is low relative to the income of the patients. The paper shows how this type of considerations can be used to determine an optimal level of co-payments for diseases even when individual choices cannot be observed directly. CONCLUSIONS: It is possible to assign a limited but significant role to individual responsibility in the rationing of health-care resources. The liberal egalitarian argument captures a concern that is not captured by traditional criteria for priorities in health care. It can thus help policy makers in situations where the cost-effectiveness of different alternatives and the severity of the illnesses are approximately the same, or if the society wants to assign some weight to responsibility for choice. It can easily be linked to a system of graduated co-payments, but need not be.

Health Care Rationing↗
PubMed2005

Healthcare rationing: a guide to policy directions in Sri Lanka.

Sri Lanka's tax-financed public health system has played a significant role in achieving high levels of health status for its people. The 21st century brings new challenges in terms of rapidly aging population and increasing prevalence of NCDs. These challenges are expected to place a heavier burden on the government health financing and provision. However, the government expenditure as a proportion of GDP has declined to 1.1-1.2%, the lowest level, since the country's independence in 1948. Available funding is channeled out of the preventive services and primary healthcare to the complex hospitals, contributed by inadequacy of prioritization in resource allocation. Already, there are evidences of high level of under-funding and implicit rationing with higher impacts on the rural poor and the estate poor. Analysis of the government subsidization of healthcare shows shifting of benefits to the urban better-off from the poor. In light of the findings, the paper focuses attention on policy directions the government health sector in Sri Lanka should follow.

Health Care Rationing↗
PubMedDate not supplied

Rationing psychosocial treatments in the United States.

This paper briefly reviews the recent history of psychosocial treatment for adults with severe mental illnesses in the United States. It examines the current sources and financing of such care, revealing the planned and unplanned reclassification of entitled beneficiaries and eligible patients, appropriate treatment, acceptable outcomes, and levels and sources of payment. One illustration of this phenomenon is seen in current efforts to identify and deliver only those public services that are covered by Medicaid, so as to allocate state resources only when they can be matched by federal monies. Another is the reliance on private health insurance, tied in the U.S. almost exclusively to employment, for medical care delivered under an acute, rather than a chronic care model. These analyses conclude with a discussion of the implicit and explicit mechanisms used to ration access to psychosocial treatment in the United States. The implications for individuals with serious mental illnesses, their families, and the general public are placed in historical and current policy contexts, recognizing the economic, social, and clinical variables that can moderate outcomes.

Adult↗
PubMed2005

The nature of procedural preferences for health-care rationing decisions.

Substantial debate on the appropriate foundations of economic evaluation in health-care has been conducted between welfarists and non-welfarists in the health economics literature. This has focussed on defining and measuring appropriate outcomes. However, there has been little discussion of the importance of procedures. This paper examines six dimensions of procedure in relation to health-care rationing which are drawn from existing literature and previous empirical investigation. A survey of the general public was used to test for preferences for each dimension of procedure. Results show that for each dimension the importance differed according to the level of decision-making (we tested decision-making at the level of the individual doctor, health authority and government). We identified three distinct clusters of respondents who can be broadly described as "proceduralists" (47%), "pluralists" (15%) and "anti-consequentialists" (38%). The paper concludes that consequentialism is insufficient to provide the conceptual framework that public decision-making in health requires, although this does not mean that consequences are unimportant.

Adult↗
PubMed2001

Making choices in cardiology: difficulties of rationing and equality of access.

Ethics, clinical performance, resource constraints and research all interact regularly in informing and driving the debate about the direction of health care in modern societies. Medicine has become the practice of what should be done rather than the art merely of what is possible. A public report criticising one of Europe's leading heart centres of being less willing to perform complex heart surgery in children with Down's syndrome generated a thoughtful discussion on whether equality of access is compatible with resource decisions in the rationing of limited health care resources. This and the developments in new high-technology solutions to end-stage heart failure make decision making on the cardiovascular medicine of the 21(st) century ever more important. This article discusses these issues in the light of realisation that performance issues, greater public oversight of medical decision making and the expansion of expensive medical options set policy makers, the public and the medical profession on a collision course which only prolonged and thoughtful debate can avoid.

Down Syndrome↗
PubMed2001

Value focused rationality in AIDS policy.

A health policy analysis to contain the effects of the HIV epidemic in Norway has been carried out. It was performed as a Multi Criteria Decision Analysis where participants in a decision panel used personal values to weight benefits and costs of alternative policies. The analysis is of particular interest since Norway afterwards adopted a controversial HIV policy: the authorities warned the general population against sexual relations with immigrants from countries south of Sahara. The policy might reap benefits, but a certain cost was to stigmatise that group. This paper describes the analysis and defends the underlying consequentialistic ethics against other approaches involving rule-based ethics and benefit-cost analysis. The main argument is based on Hume's insight that reason alone does not prompt action; values will always be involved and should therefore be more explicitly focused on. The paper concludes that we need an extended notion of rationality that includes well-foundedness of values. Decision-makers should try to reach an emotional equilibrium where their values concerning the issue at hand become stable. The paradigm of decision analysis provides useful methods to approach this situation, although it must be considered only an input to policy rather than something producing a final answer.

Communicable Disease Control↗
PubMed2002

Rationalising rationing: economic and other considerations in the debate about funding of Viagra.

Although the cost-effectiveness of Viagra for the treatment of patients with erectile dysfunction is favourable, both public and political opinions seem to be inclined not to fund, or merely to partially fund (i.e. by reimbursing only specific patient groups) this medicine. This shows that in funding discussions, cost-effectiveness information is not solely decisive. In a theoretical framework for choices in health care that was developed in The Netherlands (the Dunning report, 1991), two other criteria besides cost-effectiveness were put forward as being important for rationing decisions: "necessary care" and "individual responsibility". Overlooking the Viagra discussion, many of the arguments put forward seemed to be related to these two criteria. However, a clear operationalisation of the criteria necessary care and individual responsibility is lacking, which makes it difficult to use the arguments in funding decisions. In this paper, we try to demonstrate how these criteria were presented in the Viagra discussion and we will indicate how these criteria can be operationalised in relation to the outcomes of a cost-effectiveness analysis.

Cost-Benefit Analysis↗
PubMed1997

Costs of dying: alternatives to rationing.

In western industrialised countries, about 30% of health-care expenditure of retired people is incurred by individuals in their last year of life. The corresponding high costs of dying have led medical philosophers to ask for a rationing of health-care services according to age. By contrast, this paper pursues an individualistic approach. High costs of dying are identified as a consequence of moral hazard on both the demand and supply side of the health-care sector. Health insurance prevents demand for health-care services from decreasing when an individual's residual life expectancy shrinks. Age-related moral hazard can be limited by a coinsurance scheme with a deductible that increases with the age of the insured. Given the high costs of dying, the optimal insurance policy links the coinsurance rate to the age-specific mortality risk.

Actuarial Analysis↗
PubMed1999

Involving the public in rationing decisions. The experience of citizens juries.

There is growing interest in involving the public in decisions about rationing health care. But who are the public, why should they be involved and how might this be achieved? This paper reviews an innovative new technique for involving the public in healthcare decisions, called citizens' juries. Despite some limitations, the experience of a number of pilots suggest that given enough time and information, the public is willing and able to engage in debates about the allocation of finite resources for health care. As there are no right or wrong answers in health care choices, it is vital that the decision making process has legitimacy, and that the public has an opportunity to be involved.

Choice Behavior↗
PubMed1999

Rationing health care in France.

Since the Plan Juppé (1995), many facets of the French health care system have been the target of new legislative measures. This paper discusses the main features of the financing and provision of health care services, and focuses on issues related to priority setting and rationing. For more than 20 years, successive but systematic changes have been implemented. Most changes and measures affected the demand and supply of health care services, as well as their prices. Attempts to control demand focused mainly on the increase of user charges (ambulatory care as well as the hospital sector). Control over the volume of supply consisted, for the most part, in limiting the number of health professionals and restricting hospital beds. As far as payment is concerned, the French public authorities had set a general system of administrative prices (negotiated fees for private practice physicians, pharmaceuticals and other medical goods) and implemented global budgets for public hospitals. Among the new features designed in 1996, which target both cost-containment and quality of care, we emphasise the Parliament's involvement in setting national expenditure targets for sickness funds, the experimentation with a gatekeeper-like system (médecin référent), the development of practice guidelines and quality controls through the accreditation of hospitals. As the 1998 Eurobarometer Survey clearly shows, none of these reforms is easy to implement; they will take time to be accepted and will need physicians' support to succeed.

Cost Control↗