HaDSoc Session 8 Flashcards
What is explicit rationing based on?
Defined rules of entitlement/institutional procedures for systematic allocation
What is implicit rationing based on?
Individual clinical decisions without explicit criteria
Why is healthcare expenditure rising worldwide?
Changing demography, technology, consumerism, increasing demand
What are the problems associated with implicit rationing?
Inequities, discrimination, can be abused, social deservingness
What are the benefits associated with implicit rationing?
More sensitive to complexity of medical decisions, needs and preferences of individual pts
What are the advantages of explicit rationing?
Transparent, accountable, opportunity for debate, more clearly evidence-based, mor opportunities for equity
What are the disadvantages of explicit rationing?
Very complex, heterogeneity of pts and illnesses no accounted for, pt and professional hostility, impact on clinical freedom, some evidence of pt distress when denied Tx
What are the 5 levels of allocation?
Allocation to NHS vs other sectors; across specialities; specific interventions; interventions between pts of same group; investment for each initiated intervention
What is the purpose of NICE?
Evidence of clinical cost effectiveness integrated to inform a national judgement on the value of a Tx relative to alternative use of resources
Why does NICE guidance replace local recommendations?
Provide equal access across the country so effective and cost-effective interventions are made available quickly
What happens if an intervention receives NICE approval?
Local NHS organisations must fund if clinically appropriate, thus removing funding from elsewhere
What happens if NICE does not approve an intervention?
Pts are effectively denied access except for individual requests
What is the purpose of health economics?
Provide info to assist allocation of scarce resources to maximise social benefits
What is the need for economic assessment?
Bring reality of fixed NHS resources to public attention, expose opportunity costs, enable consistency in investment, direct innovation, help make principles of allocation explicit, help Dr’s to understand/contribute to evidence
What are the basic concepts in health economics?
Scarcity, efficiency, equity, effectiveness, utility, opportunity cost
What are the 5 levels of allocation?
Allocation to NHS vs other sectors; across specialities; specific interventions; interventions between pts of same group; investment for each initiated intervention
What is the purpose of NICE?
Evidence of clinical cost effectiveness integrated to inform a national judgement on the value of a Tx relative to alternative use of resources
Why does NICE guidance replace local recommendations?
Provide equal access across the country so effective and cost-effective interventions are made available quickly
What happens if an intervention receives NICE approval?
Local NHS organisations must fund if clinically appropriate, thus removing funding from elsewhere
What happens if NICE does not approve an intervention?
Pts are effectively denied access except for individual requests
What is the purpose of health economics?
Provide info to assist allocation of scarce resources to maximise social benefits
What is the need for economic assessment?
Bring reality of fixed NHS resources to public attention, expose opportunity costs, enable consistency in investment, direct innovation, help make principles of allocation explicit, help Dr’s to understand/contribute to evidence
What are the basic concepts in health economics?
Scarcity, efficiency, equity, effectiveness, utility, opportunity cost
Describe the concept of scarcity in healthcare economics.
Need outstrips resources therefore prioritisation is inevitable
What is technical efficiency?
Most efficient way of meeting a need
What is allocative efficiency?
Choosing between many needs to be met for the population
What is utility in healthcare economics?
Value an individual places on their health state
What is opportunity cost?
Value of next best use of resources measured in benefits foregone
What is the aim of investigating opportunity cost?
From a limited budget want to find the most efficient mix of services generating the greatest aggregate benefit
What are the implications of trying to find the greates aggregate benefit from a limited budget?
Ethical due to different conceptions of welfare
What is economic evaluation of healthcare underpinned by?
Scarcity, efficiency, opportunity cost and utility
What costs are considered in healthcare economics?
Healthcare services, pt’s time, care-giving, ilness, economic costs borne by employers and society
What benefits are measured when using economic evaluation in healthcare?
Impact on health status, savings in other healthcare resources, increased productivity with sooner return to work
What are the problems with economic evaluation of healthcare?
Assumptions built into approach may influence conclusion, some health benefits are not felt for some years
How can problems associated with economic evaluation of healthcare be resolved?
Use of sensitivity analysis to check effects of assumptions. Discounting to take calculate present values of inputs and outcomes that accrue in the future
What are the 4 types of economic evaluation of healthcare?
Cost minimisation analysis, cost effectiveness analysis, cost benefit analysis, cost utility analysis
What is cost minimisation analysis?
Outcomes are equivalent (benefits all the same) so focus is on cost
Why is cost minimisation analysis not often relevant?
Outcomes are rarely equivalent
Give an example of cost minimisation analysis.
Improvements to mobility for different hip prostheses are equal so chose the cheapest
What is cost effectiveness analysis?
Comparison of interventions that have a common health outcome in terms of cost per unit outcome
What question does cost effectiveness analysis ask?
Is extra benefit worth extra cost?
What is cost benefit analysis?
All opin outs and outputs are valued in monetary terms to allow comparison outside of healthcare
What difficulties are seen in cost benefit analysis?
Methodological: putting monetary value on non-monetary benefits e.g. Willingness to pay
What is cost utility analysis?
Focuses on quality of health outcomes produced or foregone most frequently by QALY
What do QALYs combine to evaluate healthcare?
Quality and quantity of life
What does 1 QALY equal?
1 year of perfect health/10 years of 0.1 QoL/2 years at 0.5 QoL/6 months at 1 QoL for 2 people
What are the problems associated with the evidence used for QALYs to evaluate healthcare?
RCTs not perfect evidence, comparison Tx differ, length of follow-up implications, atypical pts and care, limited generalisability, sample size implications
Name some alternatives to QALYs.
Health Year Equivalents (HYEs), Saved-Young-Life-Equivalents (SAVEs), Disability Adjusted Life Years (DALYs)
What are the problems associated with NICE use of QALYs?
Resented by pts and pharma, CCGs prioritise NICE-approved interventions with unintended consequences to opportunity costs, political interference
How do NICE use QALYs?
Technology appraisals of clinical and cost effectiveness with consultation involving identification of topics, scoping, assessment and appraisal
How does the cost per QALY influence NICE approval?
£30k needs a strong case
Who is involved in the NICE use of QALYs?
DoH, professionals, pts, carers, public, health technology assessment groups, committees
What are the disadvantages associated with using QALYs to evaluate healthcare?
Values embodied, distribution of resources is not by need, may disadvantage common conditions, technical problems, data unrepresentative, impact on carers
How is cost effectiveness calculated using QALYs?
Calculate QALYs with and without intervention. Subtract to find QALYs gained. Divide total cost (cost per annum times life expectancy) by QALYs gained
