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PubMed1993

Double agency and the ethics of rationing health care: a response to Marcia Angell.

The arguments against doctors as "double agents" that are presented by Marcia Angell in the preceding article do not defeat the core justification for rationing some relatively high-expense, low-benefit care, and they do not enable us to conclude that clinicians should be barred from any active, substantive role in decisions to limit that care. They do, however, reveal several important conditions that need to govern cost-conscious medial practice in order to preserve an ethic of fidelity to patients: insurers' profits and providers' incomes must be fair, providers must inform patients of any economic reasons that lead to the foregoing of care, and "direct incentive" arrangements must not be used to contain costs.

Cost-Benefit Analysis↗

PubMed1996

Measured fairness, situated justice: feminist reflections on health care rationing.

Bioethical discussion of justice in health care has been much enlivened in recent years by new developments in the theory of rationing and by the emergence of a strong communitarian voice. Unfortunately, these developments have not enjoyed much in the way of close engagement with feminist-inspired reflections on power, privilege, and justice. I hope here to promote interchange between "mainstream" treatments of justice in health care and feminist thought.

Community Health Services↗

PubMedDate not supplied

Viagra: a success story for rationing?

The 1998 launch of Viagra prompted widespread fears about the budgetary consequences for insurers and governments, all the more so since Viagra was only the first of a new wave of so-called lifestyle drugs. The fears have turned out to be greatly exaggerated. This paper analyzes the rationing strategies adopted in four countries (United States, Britain, Germany, and Sweden), relates them to the characteristics of different types of health care systems, and identifies the conditions necessary for successful cost containment. The case of Viagra, it concludes, holds out two general lessons: first, allow exceptions to total bans on reimbursement; second, involve the medical profession in the decision-making process.

Cost Control↗

PubMedDate not supplied

[Suicide and its psychopathological relations: a qualitative analysis of 6 cases of rational suicide].

UNLABELLED: We studied the meaning given to the terms "death" and "suicide" among psychiatric inpatients. Forty-four patients who had been admitted in a psychiatric inpatient unit following a suicide attempt underwent a qualitative interview, using a "general guide interview" approach. The results were analyzed systematically to investigate the relationship between attempted suicide and mental disorder. In 6 cases there was no correlation between the attempted suicide and psychopathological symptoms. One of these patients had a psychiatric diagnosis, but this did not seem to be related to the suicide attempt. All of them made a rational a deliberate suicidal act. CONCLUSION: even in a psychiatric inpatient setting, suicide attempts are not always a behavioural expression of underlying psychopathological disturbances - individual and social factors also play a decisive role.

Adolescent↗

PubMed1995

Resource allocation, health policy, and rationing craniofacial care.

The United States allocates health care without an overt system of rationing. This article analyzes the forces that guide resource allocation to craniofacial care. Various possible allocation systems are reviewed for how decision makers might evaluate proposed programs for legislative funding. Using a case-based exercise, readers are asked to weigh the potential costs and benefits of six health and social programs. These programs are also systematically examined for factors that are likely to affect resource allocation decisions. Eleven factors that affect decision-making are utilized in the analysis, ranging from the cost per client to emotional or human interest content of the proposed programs. Decisions about preventive programs are compared with those involving therapeutic programs. The allocation of resources to craniofacial programs, including those for children with rare major craniofacial conditions, is considered in the context of social justice and broad contemporary ethical and health care delivery issues.

Acquired Immunodeficiency Syndrome↗

PubMed1979

Biofeedback and rational-emotive therapy in the management of migraine headache.

Twenty-four migraine patients were randomly assigned to one of four conditions: (a) self-monitoring of headache activity (waiting list), (b) frontalis EMG biofeedback, (c) digit temperature biofeedback, and (d) digit temperature biofeedback plus Rational-Emotive Therapy (RET). Bidirectional control over the target physiological response was assessed through a reversal design in each session. Following at least a four-week baseline, the three biofeedback groups received 8 to 10, 30-minute sessions of bidirectional biofeedback training, scheduled twice a week. Subjects in the combined digit temperature biofeedback plus RET group received three 40-minute sessions of RET as an addition to the third, fifth, and seventh biofeedback sessions. Records of daily home practice were kept throughout treatment and three-month followup. Subjects on the waiting list monitored headaches for at least five months, corresponding to "baseline", "treatment", and three-month followup. Digit temperature biofeedback alone and in conjunction with RET did not prove to be more effective than the control conditions. All the EMG subjects reduced headache activity to two-thirds or less of the baseline level by the third month of followup. Bidirectional digit temperature performance did not improve with training, was demonstrated in only 33% of the biofeedback sessions, was not maintained over time, and was unrelated to improvement in headache activity. EMG subjects reported biofeedback performance to be an easier task and met the performance criterion on 85% of the sessions. The frequency of home practice contributed over 55% of the variance in retrospective estimates of headache improvement but was not related to changes in daily records of headache activity.

Adult↗

PubMed1995

When drug treatment in the elderly is not cost effective. An ethical dilemma in an environment of healthcare rationing.

In light of moves towards the view that rationing of healthcare resources is inevitable, the question arises as to whether age is a relevant consideration. To hold age as relevant in this context attracts the charge of agism; however, age may be related to some other characteristic(s) that are pertinent. In the context of drug treatment of the elderly, there is evidence to suggest that there are important differences between older and younger patients in terms of adverse responses to drugs because of factors such as physiological changes and multiple health problems, which occur with aging. On the other hand, some studies show beneficial effects of drug therapy. There is a need for more empirical data on cost effectiveness. Ethics arguably have to take into account factors other than cost effectiveness, such as equity. A central question is whether what is required is a set of criteria in addition to cost effectiveness, or an interpretation of cost effectiveness sensitive to broader considerations, such as quality of life (QOL). In relation to the latter, the issue of age-specific measurements of QOL remains problematic.

Aged↗

PubMed1996

Age as a basis for healthcare rationing. Arguments against agism.

Age alone is a poor marker of disability. Decision making in medicine should be based on potential benefit to the individual. Most healthcare expenditure on the elderly is for routine care, which few could argue should be denied because of age. Healthcare reforms that encourage functional independence and community based care of the elderly are more likely to lead to cost savings than simple rationing according to age. Treatment options previously thought futile in the elderly, particularly surgical interventions and drug therapy for cardiovascular disease, have been shown to be effective in terms of improved health and cost benefit. Thus, discrimination on the basis of age (agism) is not only ethically unacceptable in a society embracing principles of justice and equity, but also unsupportable on scientific and/or economic analysis.

Aged↗

PubMed1994

Change in the British National Health Service: policy paradox and the rationing issue.

The National Health Service of the United Kingdom is trapped in a policy paradox. On the one hand, the 1990 reforms encourage the devolution of power to local purchaser and provider units through the operation of the "internal market." On the other, mechanisms of control and accountability are being revamped to produce a centrally managed system bound together by corporate contracts. The political frictions generated by this paradox are exacerbated by the problem of rationing health care in the face of apparently unlimited demand. This article examines the political problems faced by a single Health Authority as it sought to implement the changes required of it by the conflicting policies.

Consumer Behavior↗

PubMed1996

Effects of a group rational-emotive behavior therapy program on the Type A behavior pattern.

A sample of 44 male Type A insurance representatives, selected by means of the Videotaped Structured Interview, were randomly assigned to a treatment (n = 22) and a delayed treatment control group (n = 22). The treatment group participated in 9 weekly sessions of group Rational-Emotive Behavior Therapy and were followed up after 10 weeks. After the control period, the delayed treatment control group received the same treatment program. Repeated measurements were obtained by means of the Videotaped Structured Interview, Jenkins Activity Survey, Cook-Medley Hostility Scale, and Type A Cognitive Questionnaire. Self and spouse/friend ratings of Type A behavior were obtained by means of the Bortner Rating Scale. Analysis indicated that, compared to the control condition, the therapy significantly reduced the intensity of Type A behavior and its time urgency component. These improvements were maintained at follow-up and were accompanied by self-reports of significant positive changes in Type A behavior and irrational beliefs.

Adaptation, Psychological↗

PubMed2000

Rationing healthcare in New Zealand: the use of clinical guidelines.

A 1991 "Green and White Paper", Your health and the public health. A statement of government health policy, advised that healthcare services in New Zealand could be rationed by a simple list. The Health and Disability Services Act 1993 provided a framework for resource allocation. The Core Services Committee rejected the "Oregon approach" of using a simple list to determine what condition/treatment pairs should be funded, preferring the development of clinical guidelines as a basis for assessment. Clinical priority assessment criteria derived from guidelines are used to define the degree of clinical benefit for public funding. Criteria have been developed for entry into end-stage renal failure programs, access to coronary artery surgery, and entry into booking systems for other elective services. The development of clinical criteria to define access to services has had a difficult road, but is a start in defining public expectations of New Zealand's healthcare system.

Appointments and Schedules↗

PubMedDate not supplied

Health care rationing.

The following two-part article sets the scene for an ongoing dialogue in future Updates on rationing and its impact on our health care delivery system and on society at large. Part one establishes the framework for future discussions, while Part two zeros in on the efforts of one state to confront the issue head-on.

Catastrophic Illness↗

PubMed1992

Decision time for rationing.

As Oregon state officials await a decision from HCFA on whether it will issue a waiver of Medicaid rules needed to implement a healthcare rationing proposal, the debate rages on. The state hopes for a decision by early February so the program can be up and running by July, but there are still many issues to be addressed before the plan's start-up.

Health Care Rationing↗

PubMed1994

Medical resource allocation: rationing and ethical considerations, Part II.

The proliferation of medical technology during the past decade has doubtless surpassed that of any other recent period. We have witnessed and are continuing to witness rapid advances in human genetic engineering, reproductive technology, and biomedical intervention in the life process. Our population has benefitted from this technology as a result of its ability to extend the life of individuals, particularly the elderly sector of our society. This technological proliferation has caused philosophers, physicians, engineers, and policy strategists to focus upon questions of ethics and mortality relating to their application. In approaching the ethics of rationing, consideration must be given to both the deontological concepts of the individual and the utilitarian principles of societal preservation. This article continues a discussion of the issues of resource allocation that was begun in the February 1994 issue of Physician Executive.

Advance Directives↗

PubMed1993

Rationing health care in Canada.

Canada has been able to develop a fairly successful system of healthcare rationing by balancing the conflicting concerns of equal access and cost efficiency, federal funding and provincial control, and public sector management and private sector provision. Financial constraints limit the kinds of services included within the notion of equal access, however, forcing healthcare providers to make difficult choices about who will receive a particular healthcare service.

Attitude to Health↗

PubMed1994

How will care be rationed?

No bill before Congress fully answers the explosive question of who gets how much care--and who ultimately makes the hard choices. But experts say health care rationing of some kind is inevitable. Here's how to decipher the debate, and what it means for your practice.

Forecasting↗

PubMed1992

Rationing and regionalisation of health care services: a critical care physician's opinion.

It is becoming apparent that we have created a demand for medical goods and services that threatens to overwhelm our health care system. Present fiscal policies for financing health care such as excluding a large portion of the population are clearly unacceptable to the public. Current reimbursement policies for health care providers are so murky and, in some cases, so conflicting that they could have been designed only as a method of rationing by inconvenience. Some improvements in the cost effectiveness of health care delivery are needed without increasing the administrative and regulatory bureaucracy currently feeding on itself. Regionalisation of medical services has proven to be cost-effective in the specialties of trauma and neonatology. There is accumulating evidence that this same concept, using severity of illness scoring as an objective marker of potential benefit, may maximise cost/benefit for medical and surgical critical care patients. However, multifaceted deterrents to the concept of regionalisation must be addressed, including reimbursement problems, logistics of bed occupancy and physician incentives to participate.

Canada↗

PubMed1999

Compliance with post-hospitalization follow-up visits: rationing by inconvenience?

OBJECTIVES: Appointment-keeping after hospitalization is a poorly understood link between inpatient and outpatient care. We investigated how health care system and patient characteristics influence appointment-keeping after discharge from an acute care hospitalization. DESIGN: Prospective cohort study. SETTING: Urban public teaching hospital. SUBJECTS: All 372 consecutive eligible patients admitted over a 15 week period to medicine wards. METHODS AND MEASURES: We interviewed patients during hospitalization and after discharge, searched the hospital's electronic databases, and reviewed charts. We measured medication compliance, health care access and use, health status (SF-36), previous appointment compliance, and physician recommended follow-up appointments. Main outcome was appointment adherence after discharge. RESULTS: Patients were primarily African American (71%), uninsured (64%), female (53%), and had a mean age of 48 years; 64% of first appointments after discharge were kept. Adjusted odds ratios (95% confidence intervals) for appointment-keeping were 3.3 (1.7, 6.5) for receiving a written appointment at discharge, and 0.50 (0.27, 0.90) for previous difficulty with obtaining health care. Readmission rates were not associated with appointment adherence. CONCLUSION: Modifiable system, as well as patient, characteristics are associated with follow-up appointment-keeping. The practice of not giving patients written appointments at the time of discharge may constitute an implicit form of "rationing by inconvenience." Further studies should also evaluate potential associations between appointment-keeping and re-hospitalization.

Aftercare↗