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PubMed2001

Rationing and the role of the emergency department as society's safety net.

Emergency medicine has an integral role in the establishment of universal access to health care for all persons living in the United States. Currently, emergency departments provide the only unfunded mandate available to millions of American residents who otherwise have no access to health care coverage. Any effort to establish universal care must accept health care rationing as a basic principle, and establish a minimum standard of benefits to which all human beings are entitled in this country. People and employers should be allowed to purchase additional care based on their willingness and ability to pay, but under no circumstances should anyone be denied a basic package of health care benefits. Emergency care must be part of those basic benefits. Emergency medicine charges should be structured so that they are not unduly onerous to society, and should reflect true expenses, including marginal costs for nonurgent care. Emergency physicians (EPs) and hospital administrations should recognize their critical role in serving society in roles that are not strictly medical, and allocate resources to benefit the general population in the greatest way. This role will be expanded to include preventive care, to provide for basic pharmacologic coverage as needed, and to provide necessary immunizations when traditional primary care has failed. We have a moral obligation to recognize that resources are limited and to allocate them so as to benefit the greatest number of patients in the greatest way. As members of the medical profession best equipped to assume such a task, it is incumbent upon EPs to act as advocates to the public to enable us to fulfill this mission.

Emergency Medical Services↗
PubMedDate not supplied

Should age be a criterion for rationing health care?

The need to decrease healthcare costs is urgent. One method of decreasing costs that has been proposed is age-based rationing. With the burgeoning number of Americans over 65 comes increased spending for health care. It is thought by some that this increase represents disproportionate spending, and that the money should be spent on health care for the young. Another school of thought is that the elderly have a right to health care just as any other group. The author believes that age may have to be one consideration for allocation of resources but not the only one.

Age Factors↗
PubMed1994

Rational-emotive therapy in the management of migraine headache.

Traditional treatments have drawbacks and are not fully effective for all patients suffering from migraine headaches. Rational-emotive therapy (RET) may prove beneficial as a complementary treatment to medication and biofeedback in the management of chronic migraine headache. This article explains RET and provides a rationale for its use in migraine therapy. A case study illustrates RET in action. Research studies of RET with migraine patients are discussed.

Adult↗
PubMed1993

Rationing in practice: the case of in vitro fertilisation.

One of the few examples of explicit rationing in the National Health Service is provided by in vitro fertilisation. Of six purchasing authorities examined three have decided against buying in vitro fertilisation while three have decided in favour. The decisions reflect local factors such as the absence or presence of local providers and the views of the public and health professionals. But in vitro fertilisation also illustrates some of the wider issues involved in all decisions about purchasing: questions about what should be provided by the National Health Service, about what procedures should be compared when weighing up value for money, and whether equity demands national decisions about what to provide.

Decision Making, Organizational↗
PubMed1993

Dimensions of rationing: who should do what?

Priority setting is a complex interaction of multiple decisions at various levels in the organisation and constrained by history. There is no self evident set of ethical principles or analytical tools to determine what decisions we should take at various levels, nor is there an obvious or easy way to resolve the clash of claims on resources. To make priority setting more "rational" we should concentrate on the processes and structure of decision making and the relation of macro and micro decisions. The debate should promote reasoned, informed, and open argument, draw on a variety of perspectives, and involve a plurality of interests. The aim must be to build up, over time, the capacity to engage in continuous, collective argument.

Budgets↗
PubMed1999

Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity.

OBJECTIVES: To determine factors influencing survival and need for hospitalisation in patients needing dialysis, and to define the potential basis for rationing access to renal replacement therapy. DESIGN: Hospital based cohort study of all patients starting dialysis over a 4 year recruitment period (follow up 15-63 months). Groups were defined on the basis of age, comorbidity, functional status, and whether dialysis initiation was planned or unplanned. SETTING: Renal unit in a district general hospital, which acts as the main renal referral centre for four other such hospitals and serves a population of about 1.15 million people. SUBJECTS: 292 patients, mean age 61.3 years (18-92 years, SD 15.8), of whom 193 (66%) were male, and 59 (20%) were patients with diabetes. Dialysis initiation was planned in 163 (56%) patients and unplanned in 129 (44%). MAIN OUTCOME MEASURES: Overall survival, 1 year survival, and hospitalisation rate. RESULTS: Factors affecting survival in the Cox's proportional hazard model were Karnofsky performance score at presentation (hazard ratio 0.979, 95% confidence interval 0.972 to 0. 986), comorbidity severity score (1.240, 1.131 to 1.340), age (1.036, 1.018 to 1.054), and myeloma (2.15, 1.140 to 4.042). The Karnofsky performance score used 3 months before presentation was significant (0.970, 0.956 to 0.981), as was unplanned presentation in this model (1.796, 1.233 to 2.617). Using these factors, a high risk group of 26 patients was defined, with 19.2% 1 year survival. Denying dialysis to this group would save 3.2% of the total cost of the chronic programme but would sacrifice five long term survivors. Less rigorous definition of the high risk group would save more money but lose more long term survivors. CONCLUSIONS: Severity of comorbid conditions and functional capacity are more important than age in predicting survival and morbidity of patients on dialysis. Late referral for dialysis affects survival adversely. Denial of dialysis to patients in an extremely high risk group, defined by a new stratification based on logistic regression, would be of debatable benefit.

Activities of Daily Living↗
PubMed1993

A critique of using age to ration health care.

Daniel Callahan has argued that economic and social benefits would result from a policy of withholding medical treatments which prolong life in persons over a certain age. He claims 'the real goal of medicine' is to conquer death and prolong life with the use of technology, regardless of the age and quality of life of the patient, and this has been responsible for the escalation of health care expenditure. Callahan's proposal is based on economic rationalism but there is little evidence to suggest that substantial economic savings could be achieved. Moreover, his argument raises serious moral objections. A policy of withholding treatments from members of a social group involves elements of compulsion and discrimination, both of which would intrude on the doctor-patient relationship, undermine the autonomy of elderly patients, and invoke the slippery slope towards involuntary forms of euthanasia. Life-death decisions should be based on more than the one criterion of age, and take account of more relevant factors such as the patient's usual state of well-being, her/his expressed wishes, informed consent and the type of illness. Any move to the implementation and enforcement of the policy Callahan recommends would be rejected by health professionals and the public.

Ethical Analysis↗
PubMed2004

Evidence based medicine guidelines: a solution to rationing or politics disguised as science?

"Evidence based medicine" (EBM) is often seen as a scientific tool for quality improvement, even though its application requires the combination of scientific facts with value judgments and the costing of different treatments. How this is done depends on whether we approach the problem from the perspective of individual patients, doctors, or public health administrators. Evidence based medicine exerts a fundamental influence on certain key aspects of medical professionalism. Since, when clinical practice guidelines are created, costs affect the content of EBM, EBM inevitably becomes a form of rationing and adopts a public health point of view. This challenges traditional professionalism in much the same way as managed care has done in the US. Here we chart some of these major philosophical issues and show why simple solutions cannot be found. The profession needs to pay more attention to different uses of EBM in order to preserve the good aspects of professionalism.

Costs and Cost Analysis↗
PubMed1995

Why bioethicists have nothing useful to say about health care rationing.

Bioethicists are increasingly commenting on health care resource allocation, and sometimes suggest ways to solve various rationing dilemmas ethically. I argue that both because of the assumptions bioethicists make about social reality, and because of the methods of argument they use, they cannot possibly make a useful contribution to the debate. Bioethicists who want to make a practical difference should either approach health care resource allocation as if the matter hinged upon tribal competition (which is essentially what it does), or they should do political philosophy in the traditional sense, and examine the health system from the outside.

Attitude of Health Personnel↗
PubMed1997

Resource allocation in neonatal and medical ICUs. Epidemiology and rationing at the extremes of life.

This study compared resource allocation to patients who eventually die in neonatal ICUs (NICUs) and adult medical ICUs (MICUs). It was performed via retrospective, chart review study at ICUs at the University of Chicago-an inner city, tertiary care, academic medical center. All patients were admitted to the neonatal, general medical, or coronary ICU during 1 calendar yr. Overall mortality in the NICU (66/827; 7.9%) was significantly lower than in the adult ICUs (219/1320; 16.5%) (p < 0.001). However, mortality for the smallest newborns (< 751 g; 51% mortality) was higher than for the oldest adults (> 54 yr; 30% mortality) (p = 0.05). Fifty-six percent (37/66) of all neonates who died in the NICU did so within the first 48 hr of life. In contrast, nearly two-thirds (134/219) of adult ICU deaths occurred after 48 hours in the ICU (p < 0.02). The percentage of ICU bed-days devoted to nonsurviving adults (28.8%) was significantly larger than the percentage of NICU bed-days devoted to nonsurviving babies (7.8%). Even among babies at greatest risk to die (birth weight < 751 g), the percentage of NICU bed-days allocated to nonsurviving infants was less than 20%. In contrast, for the oldest ICU patients (> 84 yr) this value exceeded 50%, for ICU patients > 84 yr old who required mechanical ventilation, the percentage of ICU bed-days allocated to nonsurvivors approached 90%. Care for the elderly in MICUs involves a far greater proportional expenditure of money toward those who will not survive than does care for newborns in NICUs. To the extent that allocation decisions are driven by concerns about distributive justice and the efficient use of scarce resources, it would be more justifiable to ration intensive care for the very old than the very young.

Adult↗
PubMed1997

The applicability of selected rational-emotive therapy principles for pastoral counseling.

Examines the compatibility and possibility of communication between pastoral counseling and Rational-Emotive Therapy (RET). Uses a Delphi technique to determine whether a randomly selected group of pastoral counselors (N = 15) believe that the basic principles of RET can be used without surrendering theological tenets foundational to pastoral counseling. Concludes that some RET principles may be applicable for pastoral counseling.

Data Collection↗
PubMed1995

Attitudes toward age-based health care rationing. A qualitative assessment.

This study is designed to contribute to recent efforts to assess public views on age-based rationing of health care by reporting findings from a qualitative research project using focus group interviews. Group interviews find that respondents are concerned about the high costs of health care, but few attribute these costs to overuse by older people. Respondents reject the notion of specific policies limiting health care based on the age of the patient. Respondents of all ages tend to reject the idea of paying for treatment to extend the life of the hopelessly ill when all beneficial treatment efforts have been attempted. Although expressing strong feelings about equality of opportunity for health care, respondents are ambivalent about the role that government should play to accomplish this goal. Differences in attitudes toward allocation of health care appear to be associated more with differences in socioeconomic status and political orientation than with differences in age of respondents.

Age Factors↗
PubMed1997

Reluctant rationers: public input to health care priorities.

Members of the public can adopt any one of at least three roles when providing input to public decision-making: taxpayer, collective community decision-maker, or patient. Each of these potential roles can be mapped onto three areas of public policy decision-making in health care: funding levels and organization for the system, the services we choose to offer under public funding, and the characteristics of those who should receive the offered services. The increasing desire to involve the public across the spectrum of health care decision-making has yet to result in a clear delineation of either which of the areas are most appropriate for public input or which of the roles we wish individual participants to adopt. The average citizen (as opposed to the self-interested patient, the provider or the manager) has so far shown little interest in contributing and rarely has the requisite skills for most of the tasks asked of him or her. The widespread motivation of governments and others for seeking public input appears to be to get the public to take or share ownership in the tough rationing choices consequent on fiscal retrenchment in health care. Evaluation of existing literature leads to the conclusion that there are only limited areas where we might wish to obtain significant public input if we adopt this widespread policy motivation. Specifically, the general public should be asked to give input to, but not determine, priorities across the broad service categories that could potentially be publicly funded. Members of the public have neither the interest nor the skills to do this at the level of specific services. The role expected of such members of the public should be made explicit and should focus on collective views of the community good rather than self-interested views of individual benefit. Groups of patients, however, should be the source of input when socio-demographic characteristics are being used to decide who should receive offered services. The role expected of these consumers is not, however, to take a self-interested perspective; rather, it is to adopt Rawls' 'veil of ignorance' to reflect compassionate views of priorities across socio-demographic characteristics. Finally, there appears to be no best method for obtaining public input that overcomes the common problems of poor information upon which to base priorities, difficulty in arriving at consensus, poor representativeness of participants, and lack of opportunity for informed discussion prior to declaring priorities. There is some suggestion, however, that panels of citizens or patients, convened on an ongoing basis and provided with the opportunity to acquire relevant information and discuss its implications prior to making consensus recommendations, offer the most promising way forward.

Canada↗
PubMed1999

Oregon's bold experiment: whatever happened to rationing?

In 1994 Oregon began rationing health care for its Medicaid population, offering health policy makers and analysts around the country a view of one alternative future for health care delivery. The question now, four years after the experiment began, is what does that future look like? The short answer is that it does not look all that different from the present, but it looks different enough to offer important lessons to other states and the federal government. The Oregon experiment, including the prioritization of services and the aggressive use of managed care, has facilitated the expansion of health care coverage to over 100,000 additional Oregonians, helped decrease the percentage of the uninsured as well as reduce uncompensated care in hospitals, reduced the use of hospital emergency rooms, and reduced cost shifting. By most measures, the Oregon experiment appears to be a success.

Cost Allocation↗
PubMed2003

A technocratic fix to the "legitimacy problem"? The Blair government and health care rationing in the United Kingdom.

The work of the National Institute for Clinical Excellence, an agency which has recently been created by Tony Blair's Labour government to provide guidance on best clinical practice to the National Health Service, has generated considerable controversy in the United Kingdom. It has been argued that the role which the institute plays in appraising cost effectiveness, especially of expensive new health technologies, constitutes explicit, national rationing. Although the employment of scientific and evidence-based criteria as the basis of decisions might have been expected to secure legitimacy for the institute--even when its recommendations have the effect of denying access to a particular treatment--the reaction to much of its work so far indicates that this goal has not been fully achieved. While alterations to structure and procedure may be considered as possible means of addressing the agency's difficulties, such proposals are not without problems. Consequently, in the final analysis, the British example may serve as a demonstration that the inherently political nature of priority-setting in health care precludes any easy technocratic solution.

Academies and Institutes↗
PubMed2002

Rationing hospital services in Hong Kong: priority setting by clinicians using the Delphi method.

This article presents the results of a demonstration project of priority setting by clinicians in Hong Kong's public hospitals. Thirty-five chiefs-of-service of public hospitals in Hong Kong participated in a three-round Delphi exercise on identifying interventions that should be charged in public hospitals on the basis of questionable effectiveness and other reasons. A total of 246 interventions were identified in the first round, 126 of which received a positive score (indicating a high degree of consensus amongst the participants) at the end of the final round. The interventions that received higher scores tend to be preventive services, treatment of an elective nature, and procedures for sex-related conditions. As the number of interventions with positive scores in the final round are relatively small, the amount of money to be recovered from charging these interventions is not likely to be substantial. Such results suggest that rationing by itself cannot be a solution to the problems of healthcare financing in Hong Kong.

Cost-Benefit Analysis↗
PubMed2003

Patients' views of explicit rationing: what are the implications for health service decision-making?

Patient groups in England and Wales have expressed concerns about the decision-making processes of the National Institute for Clinical Excellence (NICE), the body responsible for explicit rationing. Five key issues were identified by the Multiple Sclerosis Society regarding NICE appraisals and guidance: they focus too narrowly on costs to the National Health Service; quality-adjusted life-years are an inadequate measure of health gain, particularly for long-term conditions; NICE takes too conservative a view of long-term benefits; NICE's cost-effectiveness threshold is inappropriate; and NICE evaluations fail to capture patients' personal experiences of their condition and treatments. We question the veracity of some of these arguments and, where appropriate, suggest ways in which NICE's processes might be strengthened.

Academies and Institutes↗
PubMed2002

The doctor is out: physician participation in the Rationed Access Day work stoppage in British Columbia, 1998/99.

BACKGROUND: In 1998/99, the British Columbia Medical Association (BCMA) asked physicians to withdraw elective services on a series of 20 Rationed Access Days (RADs). This work stoppage was called to protest continued free proration triggered by total physician billings exceeding a fixed budget cap. This paper examines how physicians' practice activity changed on RADs, the rates of participation in this job action and characteristics of those physicians who participated. DESIGN: Population-based cohort study of physicians based on administrative data. POPULATION: All full-time physicians billing the provincial healthcare plan. METHODS: Participation in the RAD initiative was inferred by comparing physicians' average daily billings on RADs, Sundays, holidays and regular weekdays. Using thresholds established from these distributions, the number of RADs observed by each physician in 1998/99 was calculated and examined in relation to their demographics, location and prior years of practice activity. RESULTS: For the 4,131 physicians studied, average daily payments on RADs were similar to those on Sundays and holidays but much lower than those on non-holiday, non-RAD weekdays. Using billing thresholds of $200 (for GPs) and $400 (for specialists), we found a high degree of participation with the study population observing a median of 15 of the 20 scheduled RADs. While there were some differences in participation among age groups, geography and the prior years of practice activity, the differences were small. INTERPRETATION: This study found high solidarity in the BCMA's 1998/99 RAD initiative. Most full-time fee-for-service FS physicians appeared to participate in at least three-quarters of the 20 scheduled RADs.

British Columbia↗