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ESHPM - Jaar 3 > Keuzevak - Rationing Healthcare > Flashcards

Keuzevak - Rationing Healthcare Flashcards

1
Q

Rationing definition of Breyer

A

To limit the beneficial health care an individual desires by any means - price or non price, direct of indirect, explicit or implicit

  • Limit beneficial healthcare
  • price or non price;
  • direct or indirect; direct (have certain criteria for treatment) indirect; limited resources such as doctors and waiting lines
  • Explicit or implicit; explicit different things not included, implicit natural contraints
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2
Q

Other view of rationing definition - Maynard 1999

A

Rationing takes place when an individual is deprived of care which is of benefit (in terms of improving health status, or the length and quality of life) and which is desired by the patient

  • More focus on the deprivation
  • Broad benefit
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3
Q

Why rationing is neccesary

A
  • healthcare spending; Large part of GDP, can not continue
  • Life expectancy; longer living and requiring more resources, but limited, to whom we give them?
  • World wide worries; waiting, copayments, not all treaments covered in collective insurance
  • Culture; differences in priority in healthcare; transparency or solidarity
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4
Q

Scarcity

A

People want always more than the resources allow us to satisfy us all, lead to choice

  • In healthcare; increasing spending

Difficult in how to limit consumption of health care and on what basis; waiting times Individual cases

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5
Q

economics concerned with

A

Efficient allocation of scarce resources over alternative uses (opportunity costs) and equity implications

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6
Q

Opportunity costs

A

The worth of the not chosen alternative
- Inside healthcare; more means something less for other patients
- outside healthcare; less education, less infrastructure etc

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7
Q

Equity

A

Fair distribution of resources to those who need it the most

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8
Q

Efficiency

A

Maximizing wellfare (hapiness) given a budget

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9
Q

Equity and efficiency

A

Go hand in hand and can not be solved independently

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10
Q

Utility is gained when:

A
  • Utility is gained by buying and consuming goods at a price at or below what they are willing to pay from profit-maximizing firms without market power selling at a price they are willing to accept (equal to marginal costs)
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11
Q

Optimality in markets

A
  • Individuals maximize own utility (best judges welfare)
  • Perfect knowledge about price and characteristics
  • Income distribution determines purchasing power
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12
Q

2 ways value of good

A
  • Determined by income (value less because you have less)
  • Determined by preferences
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13
Q

Why healthcare not an optimal market

A
  • Uncertainty and consequences of insurance (moral hazard)
  • Information assymetry; credance good
  • Existance of externalities; Market doenst reflect the true societal costs –> covid, must take into account more external costs

Equity and efficiency balance; allocation and rationing job of the government

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14
Q

Price and non price rationing (breyer 2013)

A
  • Decide if you consume on price or not; price rationing
  • Decide on other things if you consume (waiting times or professional judgement); non price rationing)

Government regulation; not all price mechanisms but also priority, to allocation of healthcare

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15
Q

Ethical argument against health economics

A
  • We must do anaything possible for the patient no matter what the cost, because health is more worth than money

But; resource constraint system cost means sacrifice
In this case the value of benefits foregone by the person who did not get treated
- Consider what we could have done with the spending

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16
Q

First lesson of economics
First lesson of politics

A
  • There is scarcity
  • Disregard the first lesson of economics

Tension between what we can do and what is ideal

  • We ration because of opportunity costs; the same resources can produce more health/wellbeing elsewhere
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17
Q

Inconsistent triad of Weale 1998

A

Basic healthcare principles
- Comprehensive
- High quality
- to all citizens

Given scarcity not all wishes at the same time; must face oppertunity costs when investing in health

  • Inside healthcare
  • Outside healthcare
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18
Q

Breyer need or benefit is related to

A
  • An immediate danger or life
  • The risk of a severe and lasting health impariment
  • Any even only temporary deterioration of health

Not a dichotomous variable, but continuous; context dependent if it is of benefit for society or a person

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19
Q

rationing aspects

A

Societal level decision
Not only cost containment also what is delivered
priority setting

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20
Q

Price vs non price rationing

A
  • Price rationing; allocation of scarces resources through price mechanisms
  • Non price rationing; allocation of limited resources below market price; free of charge

Non price rationing means also you leave it out of the system and not in BBP, up to private market

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21
Q

primary vs secondary rationing

A

primary rationing; how much budget to spent on healthcare (direct and indirect) and how to determine (what contributes more to societal level)

Secondary rationing; budget is there, how to use it (eg. priorization, waiting lists)
- Also natural scaricty resources such as transplantable organs

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22
Q

Narrow rationing

A

Non price rationing; no coverage in BBP leave it up to market resulting in private market and price rationing

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23
Q

implicit vs explicit rationing

A

Implicit; a budget and limits to resources, but no procedures on how to spend it
- Cost budget and allocate it
- choices left to stakeholders in system (bedside rationing;)

Explicit; sets limits to resources in combination with how choices should be allocated
- limiting BBP on criteria
- Breast cancer criteria for treatment
- Explicit who gets what and what not

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24
Q

implicit pro and cons

A

Cons
- Different outcomes at lower level decision makers; other choices (breastcancer)
- doubt if it contributes to outcomes
- Choices left to lower levels

Pro
- Discretionair room for stakeholders to spend (look at every patient)
- Use own expertise on how to make choices- provider autonomy
- Reduces public resistance; as there are no procedures (no rules so no harm)

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25
Q

bedside rationing

A

Choices within implicit rationing are often to lower decision makers targeted; explicit rationing on lower decision level

The process by which healthcare providers, particularly physicians, make real-time decisions about the allocation of limited healthcare resources while treating individual patients.

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26
Q

Explicit rationing pro and cons

A

Cons
- reduced acces to certain treatments because of rules, that maybe have been used in implicit rationing system
- potiental public resistance; why this included and other not
- Difficult so specify general rules
- Can you cover rules for everything?

Pros
- makes allocation transparent; provider and patients know what they qualify for
- distributed to maximize social welfare based on (CEA, outcomes etc)

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27
Q

soft and hard rationing

A

Soft rationing; if you cannot have it publicly, you can have the private market (dental care)

Hard rationing; If you cannot have it publicly you cannot have it elsewhere (organs)

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28
Q

demand side rationing

A

Often associated with explicit rationing; leaving supply unaffected only how to distribute
- consequence; not fund even when there is demand
- limited entitlements / coverage and copayments

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29
Q

supply side rationing

A

Often associated with implicit rationing; leaving demand untouched in a way
- Often waiting times and lists

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30
Q

US explicit, breyer indicates three topics

A
  • Age; if older less priority?
  • Novelty; medical innovation driver of costs of good?
  • Cost effectiveness; maximizing welfare

US is implicit rationing

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31
Q

Healthcare goals and objectives

A
  • Quality of care
  • Access
  • efficiency
  • affordability
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32
Q

Explicit rationing proof

A

You can see if the choices that are made are in line with the goals

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33
Q

Oppertunity costs - Brouwer et al

A

Too expensive can only be anserwed by considering benefits and oppertunity costs

Two perspectives;
- costs within the health care sector; price of health forgone
- outside healthcare sector; other benefits (such as work)

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34
Q

Government and results

A

Market failure government has to steer towards better outcomes
Otherwise
- SID
- Moral hazard

Optimal level is debatable

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35
Q

Hurst typology

A
  • Reimbursement model; you pay premium, declarate and get an reimbursement
  • Contract model; consumer pays premium and insurer pays bills of provider
  • Integrated model; consumer pays premium to insurer which is also the provider (england)

Can be combined with volunary and mandatory insurance

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36
Q

Consequences with voluntary insurance

A

problems with equity problems!
- adverse selection
- Payments; community based or riks related

Solution for equity is mandatory insurance; insuring universal access

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37
Q

Consequences with mandatory insurance

A

Reimbursement model is sensitive towards: efficiency
- SID
- moral hazard (efficiency harmed)

Integrated model;
- efficiency in a way of failures for waiting lines

Contract model; most promising in dealing with efficiency and equity

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38
Q

Convergence of contract model

A
  • Use of government regulation (quality, universal coverage and acces)
  • Own room that permits government arm length; competition mechanisms
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39
Q

Supply side rationing

A

restricts supply of care
- eg. budget contstraints, number of beds, limiting doctors (explicit)
- demand is left free
- Mostly integrated systems
- Mismatch between demand and the supply (excess demand)

Consequence; waiting lists

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40
Q

Demand side rationing

A

restricts demand of care
- restricts what is included in BBP
- deductables or copayments
- eg. limiting types of health care inverventions and copayments
- mostly contract and reimbursement models
- mismatch demand and supply (demand less)
- own choices may lead to suboptimal health affects

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41
Q

Dutch model

A
  • Regulated competition

Contract model
- no strict budget but result of demand

rationing through
- Coverage in BBP
- mandatory deductible
- Copayments

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42
Q

Rationing aspectS

A
  • Rationing is making choices between patients and treatments
  • Rationing should be in line with goals of HC
  • monitor effects of rationing
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43
Q

Consequences of rationing in dutch system at different levels

A
  • Patient level; detoriation of health by waiting times
  • society; inequities
  • social environment; family affect - more costs less income
    -health system; though choices, pressure and burden (waiting lists)
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44
Q

Supply side rationing thorough!!

A

Through a restriction of supply; budget, doctos beds
- Associated with implicit rationing!!
- Based on medical need
- Can offer limited servings
- system that is naturally restricted to serve people, leading to waiting
- Providers need to allocate resources bades on their medical need

Demand unthouched; mostly accesable without financial constraints

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45
Q

Two reasons why problem with untouched demand and cons

A
  • Welfare loss; people value less than P* but mandatory to take a insurance; welfare loss
    You need more supply to lower the prices; and minimalize welfare costs
  • If supply goes up, where does the money come from; budget expension and need to be found elsewhere–> inefficiency (oppertunity costs elsewhere more worth)
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46
Q

Waiting times

A
  • waiting times result of more demand than supply
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47
Q

You can value healthcare low because of

A
  • Preferences
  • Low income
  • Low information available; not able to judge own health

WTP < MC may still be socially desiarble; because of own judgements
- Require solidarity and subsidies
- social value =/ private value

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48
Q

Graph of supply side rationing

A
  • fixed supply
  • Demand left untouched

Reflect waiting prices & medical need
- Close to the fixed have a high waiting prices
- left is high medical need

System response is a referral system

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49
Q

Conceptual framework OECD waiting times

A

Private elective treatment; can speed up (not based on medical need)
- Higher waiting time more private sector

Outflow dependent on doctors, capacity private system and productivity

  • How long to stay and influence potential need

-

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50
Q

If there is less waiting times

A
  • Can result in unnecessary treatments
  • Societal value might be lower than MC
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51
Q

Positive aspects of waiting times !!

A
  • Reduced need of other mechanisms
  • Waiting time functions as price (longer waiting induces demand)
  • Principle works good for equity; demand is left untouched (low SES differences)
  • Unnecessary care restricted; need judged by professional
  • waiting times can reduce flow of referrals
  • Waiting list can help to use available capacity optimal
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52
Q

Waiting time functions as price (longer waiting induces demand)

A
  • Individual; not willing to wait long
  • GP; raising the medical treshold; negative side effects of medical waiting is minimized
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53
Q

Waiting times and negative aspects!!

A
  • QALy loss during waiting
  • Recovery time can increase waiting time
  • treatment less succesfull after waiting
  • Higher medical costs to treating worse cases
  • dissatisfaction of society of high waiting times
  • costs of absence waiting for employers
  • Differnences may induces cross-border care
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54
Q

waiting time optimallity

A

Waiting time is long enough to discourage demand and short enough to limit negative aspects from waiting
- But also a smaal financial barrier; otherwise demand to high

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55
Q

Problem optimal waiting times

A
  • differs per disease, per situation, per indivdual, not only based on need somethimes
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56
Q

reduce waiting times mechanisms

A
  • supply side extension; reducing contraints (budget and capacity), rewarding productivity Works! Resources matter
  • Demand side reduction; less refferals, copayments
  • Process and regulations; improving utilitzation facilities, maximum waiting times garantees, choice of provider
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57
Q

Lessons on waiting time mechanisms

A
  • TIme costs; precieved costs of time waiting reduces the need for care
  • Refined system; GP not pushing everyone to the second line but Medical need judgement
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58
Q

Dig harder than the sand is falling

A
  • Reducing waiting times increased demand
  • but also not the waiting times to long

We can dig harder than the sand is falling (not expanding waiting times)
- demand increased with supply but less (Martin and smith)

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59
Q

Siciliani and Hurst 2009

A

Increase in supply (doctors) does not result in more demand but reducing of waiting times

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60
Q

Why waiting times guarantees does not work?

A
  • supply doens’t change
  • After a year added to the medical need group
  • Waiting time of high medical needs go up
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61
Q

Go elsewhere when having less waiting times

A
  • Dont like traveling
  • Shadows maybe quality
  • Dont know doctor
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62
Q

Adverse incentives to reduce waiting lists

A
  • Give hospitals with large waiting lists money for supply increase
  • Profitable to have long waiting lists
  • Somethimes waiting lists reduced but also demand increases again (Laeven et al. 2000)
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63
Q
A

g

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64
Q

Alternative of effective waiting time management

A

Induce some competition through transparancy of waiting times

Raising clinical treshold of GP

GP dont refert to second line they do not know

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65
Q

Koopmanschap et al; effect of waiting times

A
  • Figure 1; stable health, reversable effect
  • Figure 2; deteriorating health, but reverasble effect ( back to normal)
  • Figure 3; deteriorating health; reversable effect prolonged rehabilitation
  • Figure 4; Deteriorating health, partly reversable
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66
Q

What should determine priority

A
  • Age
  • Forecast of health; how bad when not treated
  • Cost effectiveness
  • Work
  • Culpability; fault eg smoking
  • Reciprocity
  • WTP
  • Having dependents
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67
Q

Still SES differences in Supply side rationing

A
  • higher SES know the system more and pressure when long delays
  • Better social network
  • May beter articulate need and wishes
  • higher oppertunity costs and less room to take of work; more missed appointments
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68
Q

Full insurance

A

Under full insurance consumers do not experience the costs of care
- Incentivizing overconsumption
- Welfare losses

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69
Q

Moral hazard ex ante

A

Knowing being insured; behave differently
- less prevention
- More risk

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70
Q

Moral hazard ex post

A

Payed already an amount; use more care
- Demand more and more expensive care

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71
Q

Problems with moral hazard, consequences of overconsumption of care

A

More own payments
- Problems with equity, targets more among the poorer

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72
Q

Cost sharing

A

P* and Pcs
- own payments decrease wellfare loss

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73
Q

Not consuming care because of three things

A
  • No medical need (assymetric information)
  • No income
  • Low valuation of healthcare (benefits lower than costs believed)
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74
Q

Assymetric information

A

People are not well informed about options and self diagnose of Healthcare but dependent
- Also problem for cost sharing; not choosing to pay when needed
-

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75
Q

Worry with demand side rationing

A

Adverse health effects
- Copayments reduce demand living longer with disease,

Equity
- Copayments react stronger to the poorer; restricting healthcare use

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76
Q

RAND experiment

A
  • Really poor react strong to copayments; exempting them from coypayment
  • But Little difference in use when a copayment is used
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77
Q

Copayments can lead to

A
  • Less demand
  • SID (higher cost for society)
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78
Q

goal of copayments

A

Use not to much healthcare; Make a decision if its worthwhile to visit

Primary line; be a gatekeeper for use of healthcare

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79
Q

objections of copayments

A
  • only a shift in costs from society to individual
  • Assymetric information can lead to health consequences
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80
Q

Limiting entitlement; limiting BBP

A

Explicit form of rationing
- limiting demand for treatments (others left to private market)
- hard vs soft rationing for escapes
- Through looking at opportunity costs

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81
Q

Demand side rationing mechanisms

A
  • Limiting BBP
  • Copayments
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82
Q

health technology demand side

A

Drive the costs up
- when to include and when to exclude?
- only fund the most cost effective

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83
Q

Funnel (in Dutch: trechter) of Dunning

A
  1. Necessity (of insurance and of care)
  2. Effectiveness
  3. Cost-effectiveness
  4. Feasibility
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84
Q

Qaly

A

1 = good health

0= dead

Derived from the general public

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85
Q

Decision rule CEA

A

B-C > 0

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86
Q

Vi

A

valuation of society

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87
Q

delta ct

A

costs of treatment compared

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88
Q

delta Qi

A

difference in effects QALY

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89
Q

ICER

A

Delta ct / delta Qi

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90
Q

goal with CEA in healthcare

A

Assisting decision maker to maximize health from the given budget

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91
Q

Society costs perspective on CEA

A
  • Direct medical costs
  • Direct non medical costs
  • Productivity costs
  • Benefits or improved well-being
  • Indirect costs in gained lifeyears
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92
Q

ICER comparison to value of health society

A
  • ICER< Vi –> cost effective
  • ICER > Vi –> not cost effective (to expensive)
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93
Q

Oppertunity costs views

A
  • What we are currently spending on
  • Move away from somewhere else (sacrifice outside healthcare)
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94
Q

How opportunity costs included in CEA

A

alternative should reflect the oppertunity costs

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95
Q

2 ways of CEA!!!!!

A
  • Cost per QALY below treshold or not
  • All gained QALYs (2000 patients * 0,6) * total cost per QALY (80.000) = 96 million

96< 160 million vi; 96 health benefits and 160 million of costs!!!!

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96
Q

Losing of QALY calc

A
  • 160 million
  • ICER now is 40.000 per QALY

160.000/ 40.000 = 4000 QALY lost

4000 - 1200 (0,6 *2000 patients) = 2800 QALY lost opportunity costs

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97
Q

Alternative of yes or no in appraisal stage

A

Now we negotiate to bring the price down; and will result in better CEA ratio

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98
Q

some criteria for explicit rationing in BBP

A
  • More health gains per euro; higher priority
  • Adjusted for equity considerations
  • More health loss if not treated
  • More solidarity with more severe ill; higher treshold
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99
Q

Kidney transplants benefits

A
  • Live longer
  • QOL improves
  • Cheaper than dialysis
  • productivity in society possible
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100
Q

Kidney transplants and rationing

A
  • Demand is increased and left untouched
  • Supply decreased; natural scarcity
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101
Q

Kidney transplantion live more advantages

A

More on supply side
- solution for shortage
- recipient in better condition
- shorter waiting time
- longer transplant life expenditure

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102
Q

How to do something about supply of kidneys

A
  • Promote live donation
  • Promote exchange programs (cross change)
  • break down barriers
  • resolve misconceptions
  • education professionals and public
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103
Q

Costs of kidney transplants

A

longterm survival is nog changing so fast as the demand is increasing (renewal)
- anti rejection therapy
- rejections and insecurities
- risk of infection

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104
Q
  1. Why the rationing of organs is inevitable from an economic perspective
A

Demand is higher than the supply so people have to rationing;
- Supply is scarce through natural scarcity, have to decide who going to treat and who not

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105
Q

relative scarcity of resources

A

insufficient goods to satisfy all wants and needs, trade-off is necessary

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106
Q

Natural scarcity of resources;

A

supply of good is naturally limited

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107
Q
  1. How organ transplantations can lead to opportunity costs within the healthcare system.
A

The costs of what you sacrifice to do something; resources such as organs. Bed, time, equipment, physicians, nurses.

They can not be used in other settings to treat patients
Organ transplantation is really expensive (time, , money) could have been spend on other goods in healthcare.

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108
Q

Implicit rationing: assignment

A

Implicit rationing: society determines the health care budget, but leaves it to physicians to allocate resources t to individual patients (fixed budget; bedside rationing)
Limit the resources; for instance doctors, beds, kidney transplants
o Government sets budget
o Can be differences between hospitals and doctors

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109
Q

Explicit rationing: assignment

A

society determines the rules that determine under which circumstances patients can claim medical services (flexible budget)
o How to decide on basic benefit package
o Government sets the rules
o Exceed budget that is allowed to some extent

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110
Q
  1. Explain whether you would describe not prioritizing the 34-yo woman as soft or hard rationing
A

Soft rationing; Markets for goods/services that are not offered by the public healthcare system are allowed
Hard rationing; Such markets (in this case for organs) are prohibited

There is no market for organs; China there is market for death penalties organ donations, but also a black market network – Organ trade

  • Hard rationing in this case
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111
Q
  1. Explain how different rationing rules at the hospital level can lead to inequalities between patients waiting for a transplant
A

Implicit rationing; fixed amount or organs to be transplanted and no rules set to distribute these organs

Decisions to transplant individual patients made at hospital level may lead to different assessments and decisions – general rules (e.g., by profession on European level) help to avoid this (explicit rationing)
- Bedside rationing; physician decide at the bedside to who’s the kidney goes

  • low ses; not good at articulating wishes and needs
  • not good at finding way in the system
  • Low SES can not take time and not pay traveling costs
112
Q

Koopmanschap et al. (2005)
1. Which of the five scenarios do you think is most likely in the case of the 34-yo woman;

  1. How waiting 2.5 years for a kidney may affect the costs and effects of treatment.
A

Most likely situation 4 or 5, as they are not compliant with current treatment. Health will deteriorate and be not at the same level before treatment

Additional costs with waiting possibly additional costs associated with more intensive follow-up care

Effects treatments; higher chance of kidney rejection, as the QOL after the transplant may be lower

113
Q

Belgium healthcare system aspects 5

A
  • Financed through taxes and membership
  • NIHDI; distribute money between insurers (differentiated between populations
  • fee for service
  • no gatekeeping
  • open budget financing
  • inpatient; reimbursed
  • outpatient coverd directly
114
Q

outpatient care

A

Medical or support services provided without requiring hospital or facility admission (e.g., doctor visits, therapy, or day treatments).

115
Q

Inpatient care

A

Care provided in a facility where individuals stay overnight or longer, including hospitals or residential settings like nursing homes, with ongoing medical or nursing support.

116
Q

unconvictioned

A

Cannot charge tarifs above the maximum by the health insitute

117
Q

oppertunity costs inside and outside

A

The same resources can produce more health/ wellbeing elsewhere
- Outside healthcare; less educatiom safety, infrastructure
- Inside healthcare; price of health is forgone, more for this means less for others

118
Q

Supply side belgium

A

Implicit rationing; closed end budget set
- global budget with partial budgets; overrun adjust fee schedule or increase copayments
- different budgets per region population that is served

Quota
- Numerus fixus
- Quota on hospital and inpatient services
- Quota on hospitals that can provide certain times of care (cancer quality)

cost effectiveness & budget impact analysis
- If we reimburse, what will be the impact on the closed end budget

119
Q

Closed end budget

A

Budget is fixed
- hospitals less incentive to growth unless behind of competition
- not more than budget

120
Q

GP in belgium

A

Fee for service
- Now incentive for prevention
- Capitation payment

121
Q

Overrun of closed end budget

A

Clawback clausule
- Own responsibility of company
- risk own
- there is a maximum you can resitute between projections and actual spending

122
Q

What are the intended actions with closed end budget for pharmaceutical companies?

A
  1. international review about pharma prices each year, not to much is asked
  2. Incentive correct use of drugs; efficient use of budget
123
Q

Locoregional networks

A

Services need to be offered within a hospital network and not in each hospital
- Better quality
- more concentration
- reducing of overprovision

124
Q

supra regional networks

A

Only for rare diseases treatment offerd in a supra regional network with the right
- equipment

  • investments
125
Q

Disadvantages of supply side rationing belgium

A
  • Reduced capacity; labour shortages
  • Waiting times
  • no rationing mechanisms for nurses (personell shortage); higher mortality with few nurses
126
Q

Demand side rationing Belgium

A

Copayments; spot price and little copayment per visit
- Paying everything upfront; reimbursement
- Maximum treshold
- differences between SES

127
Q

Barrier low SES demand side rationing belgium

A

Low income can ask for a status which they dont have to pay the spot price
- IR; increased reimbursement as solution

128
Q

IR and problems

A

Increased reimbursement
- status
- lower copayments
- Third party system GP

Problems; stigma, arbitrary treshold

129
Q

IR and healthcare spending

A

Those with the IR status used more healthcare
- System problem

130
Q

LMIC rationing different why?

A
  • Higher own payments
  • Differences in healthcare acces
  • Fewer resources
  • Weaker institutional frameworks
131
Q

Which rationing type LMIC

A

Supply side
- Left demand untouched
- Free care JSY

But
- Waiting lines
- Own payments;
- High opportunity costs; travelling free time

132
Q

Problems LMIC

A
  • Discrimination of ethnic groups
  • Care costs catastrophic to
  • Bribes as copayment
  • Lot of diseases you can prevent with communication
133
Q

why bribes as payment

A

To bridge the gap between
- actual supply
- Needed supply for the equilibrium

134
Q

OOP signals catastrophic spending

A

After health shock
- push them beyond the poverty line

Demand side rationing

135
Q

Filmer et al 2002 Dimensions of when governments should intervene and how

A

Horizontal axis; high responsiveness to policy

Vertical axis; low degree of distortion of high degree of distortion in consumption of care

High responsiveness to policy and high degree of distortion
- vaccinations
- research
- information provision

low responsiveness to policy and high degree of distortion
- emergency care
- information from noncredible governments

high responsiveness to policy and low degree of distortion
- routine care when percieved risk is low

low responsiveness to policy and low degree of distortion
- routine care when percieved risk is low

136
Q

distortion LMIC

A

Market failures
- externalities
- asymmetric information
- uncertainty

Government should intervene

137
Q

UHC and SDG index

A

UHC: Ensures everyone gets quality healthcare without financial hardship.

SDGs: Global goals addressing health, poverty, environment, and inequality.

138
Q

preston curve and difficulties

A

Correlation between life expectancy and GDP

Why difficult for causality
- Life expectancy driven by infant deaths
- Health institutions quality lower; monitoring
- If you have bad health, lower productivity

139
Q

Primary care in LMIC

A

Should be tax funded; tax capacity low
- OOP too high

Gatekeepers

140
Q

Lancet commission on primary care suggestions in LMIC

A
  • Public resources for financing PHC
  • Free PHC via pooled funds
  • Equitable resource allocation; needs based per capita allocation
  • Blended provider payment (capitation)
141
Q

Rationing application LMIC for pregnant women in hospitals

A

Beta * s - C + beh. component

B> C
- in costs included also bribes and traveling costs with makes the cost pretty high

142
Q

Policy tools to reduce corruption in healthcare

A
  • Punishment
  • Fee
  • Enough resources and personnel
  • Awareness of rights for women
  • Culture changes; guideliness
  • detection and checks; list experiment; ask 4 and then 5 questions -> difference if paid a bribe
143
Q

Discrimination in rationing in LMIC

A

When faced waiting times, Based on:
- taste of provider
- statistical; some people higher chance of getting better
- Class system
- Gender; more productivity

144
Q

Bribes effect and paradox - Landrian

A

If they pay they recieved less healthcare checks; where higher eductated

  • Initial thoughts; higher educated recieved more care, not the case!
145
Q

wedges - Dupas

A

are problems or barriers that cause differences in healthcare utilization
- Economic returns; men more productive, societal norms
- Biased preferences; male health over female health
- Female specific costs; barriers as limited mobility, travel costs

146
Q

Implications for wedges

A
  • gender targeted policies; Lower costs of mobility for women; gender targeted policies
  • societal adressing
  • l
147
Q

Beveridge style

A

Healthcare provided by the government
- Owns hospitals
- Healthcare providers are employees of government
- Almost free at point of use

UK

148
Q

Copayments in UK

A

Out of pocket expenses; free time, travel and parking charges (biggest costs, costs of own time)

Prescription charges

Long term care

149
Q

Biggest costs in the UK for people

A

The costs of their own time in seeking and receiving healthcare

150
Q

Rationing mechanisms used

A
  • Rationing by waiting time (supply side)
  • Rationing by science (rationing by demand)
  • rationing by location (supply side)
  • Rationing by how rich people are (demand side)
151
Q

Rationing by waiting time UK + disadventage

A

Fixed budget
- Limit of resources; beds, nurses and physicians
- Demand results in waiting times
- Depends on type of services and time of year

Disadvantage;
- Gatekeeper mechanism ist working, harm yourself health

152
Q

Shorten waiting time by

A
  • Waiting list targets; with or without penalties
  • Offering patients more choice and competition
  • Prioritizing waiting lists on medical need
153
Q

Rationing by location

A

Look per location at the scares resources
- based on the medical need in a area resources are provided
- in England much greater area; litte copayment, because of larger need

154
Q

rationing by postcode

A

Postcode rationing is when access to services, resources, or benefits is determined by where a person lives, based on their postcode (or zip code). often determined by specific policies of local healthcare organizations.
- Difference per city on how you are reffered to do with policies
- Differences per city in population and funding because of taxes for example

155
Q

Rationing by how rich people are

A

Scarces resources are distributed to how wealthy people are
- Knowlegde, better navigate in healthcare system
- Private insurance
- Soms forms of care limited public provision

156
Q

Rationing by science

A

Allocate resources based on science, effectiveness and cost effectiveness

157
Q

Need maynard 2013

A

Need is a health condition for which there is a clinically and cost effective treatment

158
Q

Absolute QALY shortfall

A

QALY a person loses due to a disease, compared to what they would have experience with perfect health
- 10 QALY los, shortfall is 10

159
Q

Proportional QALY shortfall

A

Percentage of the expected qaly lost relative to a persons total expected QALY without the illness.
- loss in proportion to the life expectancy and health potential

Example: If a person was expected to have 20 QALYs but loses 10 due to an illness, the proportional shortfall is 50%.

160
Q

Distinction bewteen absolute and proportional QALY shortfall

A

Absolute QALY Shortfall: Younger people lose more QALYs because they have more potential healthy years left. Older people lose fewer QALYs as they have less time remaining.

Proportional QALY Shortfall: Focuses on the percentage of life quality lost. Conditions often take a smaller proportion of QALYs from older people compared to younger people.

Ensure fair decisions on which to reimburse balancing the impact of conditions across ages

161
Q

Downsides of waiting time rationing

A
  • delays can lead to worse outcomes
  • discriminates agianst individuals that might lose income of taking time off or difficulties making appointments because of inflexibility
  • Much out of the pocket costs; free time and parking costs
  • Outdated and repeated test; because of the waiting time
162
Q

rationing by location cons

A
  • Induces inequalities between postcodes, location (postcodes with low literacy are worse off); less resources and no allocation system
  • variation in practice; when being corrected for medical need and population in location –> less Resources per location, fixed budgets in public financed system
163
Q

Rationing by how rich people are cons

A

Jumping ques because of private insurance (short waiting times)
- Differences in contracts (MSZ)
- separating public and private facilities
- Monitoring of waiting time

164
Q

Rationing by science cons

A
  • Explicitly denying –> political resistance
  • might be effective, but not cost effective
  • discrimination because of science most value

Maximizing overall health for population given the scarces recouces

165
Q

HTA and why rejected

A

health technology assesment
- mostly cancer drugs
- recommendations

Cons;
- Effectiveness is insufficiënt
- Methodological inconsistencies

166
Q

ICER; incremental cost per QALY why handy?

A
  • Provides an standard approach for sequence of decisions
  • recognizes the budget constraint
  • relative transparent in comparison with qualitive effectiveness studies
  • recognizes severity and young and old; modifiers
167
Q

Treshold of QALY should reflect the 3

A
  • oppertunity costs; of the alternative
  • WTP for health
  • Aspiration about levels to spend healthcare
168
Q

shortcomings of assumptions on QALY

A

Assumptions

  • Interval scale; all changes worth the same value, different per disease
  • constant proportional trade off; the length of an health state does not impact valuation; maybe the case
  • The order of health states does not affect the value of a state (maybe the case)

Qalys do not reflect al the societal value gained from the health interventions, spillovers, scientific advances

Methodological variances sometimes, but less than than other methods

169
Q

QALY pros

A
  • standardized metric for sequence of decisions
  • QALY can also be overruled by deliberate decision making processes, just an added value
  • other alternatives (added clinical value, DCE) are not standardized for these decisions
170
Q

Threshold ICER based on!!!!!!!!

A
  1. oppertunity costs of services deplaced
  2. The societal WTP for health gains
  3. goals about the level of healthcare spending; how much to spend while quality

Most used is the oppertunity approach

171
Q

other aspects considered in rationing on science

A
  • bridging the gap between therapies
  • quality of life improvement
  • Absence of other therapeutic options of proven benefit
    -Evidence that a sub-group may derive specific or extra benefit
172
Q
A

h

173
Q

arguments against rationing by science

A
  • Accepts higher CEA treshold than for current therapies
  • price drugs as manufacturer just below this treshold
  • focusing on marginal benefit could divert attention from broader healthcare needs
174
Q

tools for price negociation

A
  • Price to high reduce price in negociation to be more cost effective
  • Risk sharing agreements; not effective manifucturer steps in
175
Q

Public financed systems

A

Acces based on
- need and cost effectiveness

176
Q

Private financed systems

A

Based on willingness and ability to pay for health
- Inequalities

177
Q

Adjustment of weight QALY when

A
  • end of life decision
  • young or old
  • severity
  • rare cases
178
Q

rationing of tax funded healthcare system

A

Public health act (PGW), Social support act (WMO), Youth act (JW)
Implicit rationing

  • Allocation of the fixed budget; a distribution key to determine how much to which municipality (supply side)
  • Maximum level of copayment determination (demand side)
179
Q

Muncipalities responsible for

A
  • ensuring timely care, customized and high quality care
  • early signaling of care needs and action
180
Q

Advantages of a tax based system rationing

A
  • objective distribution key to allocate resources
  • councils democratically elected; act on the need of the society
  • early signaling mau reduce need of secondline care
  • Copayments reduce moral hazard
181
Q

Cons of a tax based system rationing

A
  • Each municipality own budget, can lead to unequal access, because of different filling of policies
    (implicit rationing, postcode rationing, horizontal inequity)
182
Q

Horizontal inequity

A
  • People with the same need don’t have acces to the same Resources within care
  • Copayments are income dependent and may lead to inequalities
  • fixed budget may increase waiting times as the market has to deal it on his own
183
Q

public health act

A
  • Tax funded

Focusses on individual an collective prevention, health promotion and public health treats

184
Q

JW

A

Tax funded

Focus on support and care for young people and their families coping with parenting and developmental issues, psychological problems and disorders

185
Q

WMO

A
  • Tax funded

Focus on providing support to people with (physical or mental) disabilities, increasing people’s self-reliance, ability to live at home, and be productive

186
Q

insurance based healthcare acts

A
  • WLZ
  • ZVW; health insurance act

explicit rationing; strict guidelines and rules how to allocate the resources and what is covered and what not

187
Q

Long term care act and sort rationing

A

Focus on most vulnerable groups in society (people with severe physical or intellectual disabilities, long-term psychiatric disorders) who need 24-hour care

Demand side rationing
- access based on need and assessment is provided individually bij CIZ
- income dependent copayment

188
Q

Zvw and sort rationing

A

Focus on curative healthcare services and secondary and tertiary prevention
- Copayments; deductible and copayment
- Limiting the BBP

More flexible budget than taxed based system

189
Q

advantages of insurance based system rationing

A
  • copayments reduce moral hazard
  • one budget, equal access
  • Income dependent subsidy to reduce inequality
  • Government democratically elected and influenced policy
190
Q

Cons of insurance based system rationing

A
  • Flexible budget, cost containment difficult
  • explicit rationing; policies apply for everyone, but may not agree
  • trade off between equity and efficiency; distributing fairly and maximize health for society
  • many stakeholders with different ideas
191
Q

Phases of BBP allowance

A
  • Selection
  • assessment
  • Appraisal
  • Policy decision
192
Q

Fourth stage; policy decision

A

In line with ZiN advice
- minister of health
-

193
Q

inpatient pharmaceuticals!

A

Advanced, specialized medications used in hospitals to treat severe or complex conditions like cancer or ALS.

194
Q

Outpatient pharmaceuticals!

A

Medications you can pick up at a pharmacy (with a prescription. They are typically for regular or ongoing care.

195
Q

Stage 1; Selection

A

Horizon scan
- Overview of all inpatient and outpatient drugs to come on the market

selection of inpatient and outpatient for assesment

196
Q

Outpatient pharmaceuticals inclusion

A

Through closed entry system;
- Medicine reimbursement System (GVS)
- therapeutic value
- Only high risk to have impact on the budget; that have large impact

Take into account annex
- Limited reimbursement for interchangable
- Unique pharmaceuticals full imbursement
- unique and expensive treatment if you meet conditions

197
Q

closed end entry system

A

Only specific treatments or drugs that meet strict criteria are allowed into the system.

198
Q

Open entry system

A

No strict criteria are required for access or inclusion.

199
Q

Outpatient full assesment when

A
  • p*q = 1 and 10 million
  • 50.000 p p year
200
Q

Inpatient entry

A

Via an open entry system
- Established medicial science and medical practical science (Evidence based)
- belonging to the area of medical specialists

2023; more closed system and more assesment criteria higher; assesment more likely and placed in the sluis
- treatment is more than 50.000 a year and p*Q is more than 20 million

201
Q

Stage 2; assesment stage

A

Funnel of Dunning
- Necessity
- Effectiveness
- Cost effectiveness
- Feasibility

202
Q

Necessity of reimbursement- questions

A

Can you it out of the pocket?
- vit D

Depends on the severity disease; cancer patients weight higher than a cold;
- proportional; more interesting for CEA
- Absolute

203
Q

Why proportional shortfall more interesting for CEA

A

Proportional shortfall is relevant for cost-effectiveness because it shows the health gained relative to the health lost, making it easier to prioritize treatments fairly and efficiently.

204
Q

Effectiveness - questions

A

Being evidence based
- Medical practice
- Medical evidence
- Belonging to the expertise of medical specialists

205
Q

QALY shortfall proportional

A

Disease - related QALY loss (without treatment)/ remaining QALY expectation of the disease

  • starting point begin of disease
  • QALY of 1 for the loss in the down
  • QALY los gaat om verlies let op
  • Teken uit
206
Q

Absolute shortfall

A

is equal to the disease related quality loss
- Bovenste deel breuk

207
Q

If QALY shortfall proportional is close to 1

A

Higher deterioration of quality of life

208
Q

Cost effectiveness- questions

A

ICER ratio? delta ct/ delta Qi
- ICER must be below the Vi (societal valuation)
Decision rule: Δct / ΔQi < v
- usage of proportional qaly shortfall

209
Q

Tresholds QALY shortfall

A

0- 0,10; 0
0,11- 0,40 - 20.000
0,41- 0,70 - 50.000
0,71 - 1 - 80.000

210
Q

Feasability - Questions

A

Is it possible and sustainable to include a pharmaceutical in the BBP? What is the impact on the:
- Healthcare workforce
- Climate and environment
- Organisation of healthcare
- Budget (e.g., in relation to saving- or substitution effects, market share)

211
Q

Possible reasons for including a cost-ineffective pharmaceutical:

A
  • it is used to treat children
  • It is used to treat patients with a rare disease (e.g., Zolgensma)
  • There is an unmet need/no alternative available
  • it is an important innovation.
211
Q

WAR

A

Wetenschappelijke advies raad; explains the outcome of the assesment to reimburse or not

212
Q

Possible reasons for exclusion of a cost-effective pharmaceutical:

A
  • It is used for cosmetic improvements (e.g., Botox)
  • It is used for lifestyle improvements (e.g., Viagra)
  • it can be paid out-of-pocket (e.g., vitamin D)
213
Q

Normative theories about equity considering the disease severity

A
  • Absolute shortfall
  • Proportional shortfall
214
Q

Vi consists of

A

W* V
-w = weight of equity (higher; is for treating patients with a higher proportional shortfall)
- Weight high Vi higher treshold
- V social valuation

215
Q

ACP and perception

A

Advisory committee of insurance package
- patients who are eligible for reimbursement
- Who pays premium
- patients with other conditions (oppertunity costs)

216
Q

When drug discussed in appraisal stage

A
  • Uncertainty about long term effectiveness
  • High price
  • really innovative
  • Additional evidence needed?
217
Q

When to reimburse with ACP considerations and argumentes

A
  • Invest in advance or wait for competition to do its work
  • What is already on the market
218
Q

Two CEA perspectives

A

-Healthcare perspective; maximize health under budget constraint - Claxton

  • Welfare economics; societal perspective, also look at work and labour; Werner Brouwer
219
Q

Assumptions of CEA

A
  • Threshold reflect the oppertunity costs; no better alternatives
  • Costs are exogenous; ICER reflexts costs and burden for society not the price

But prices are the biggest factor

220
Q

What is the CAP paying for

A

Value
- Innovation not mean large QALY gains

Effort
- Poor evidence paying more; has to do with sick patietns
Studies poor

Hope
- Extrapolation of effects

221
Q

Brinkhuis et al. 2024

A
  • Faster you say oke to a new drug, the less you get in return on the long run
222
Q

Serra burriel et al 2023

A

Paying more for cancer drugs because of severity; even when there is poor evidence

223
Q

Strategy for new inpatient drugs

A

Demand effort
- Good evidence

Reward value
- new guideliness not more comparison to InCEA
- QALY standard

224
Q

Temporary character of thresholds

A

Threshold of CEA is maximum and temporary, because of the ongoing competition after a while
- Threshold goes down
- Patents –> competition

225
Q

Against intellectual monopoly

A

Competition triggers innovation?

Are patents good

why the right to control an idea or creation

226
Q

Intellectual property

A

Only an abstract idea has no value
- Only when implementing it
- Implementations are property

Right to control an idea and use of the idea
- intellectual property = intellectual monopoly

227
Q

arguments for monopoly with patents

A
  • high fixed costs
  • being a follower better than leader (low risk and no R&D)
  • no innovation otherwise
228
Q

Arguments against monopoly with patents

A
  • Is imitation easy?
  • are monopolies temporary; long time no entery
  • what are the reasons for high costs
  • public investments in research?!!!!
229
Q

Idea to counter the high fixed costs of patents

A

Public finance R&D

230
Q

rent seeking

A

increase share of existing whealth without creating new wealth; influence legislation to protect market position
- Strong protection

231
Q

Evergreening

A

Pat enting modifications on a existing drug

Make doctors prescribe the medical and then make an adjustment which everyone needs to use that is also pattented
- Circle

232
Q

things a manufacturer can do to have market share

A
  • Evergreening
  • Pay competitors to not innovate
233
Q

equity with patents

A

Higher price due to monopoly position
- Higher payments or even copayments

234
Q

Consequences of monopolies

A
  • Barriers to entry; more than accounting profit
  • Profits have no incentive for extra supply, because there are no extra sellers
  • Long term profits only distribute wealth among workers, managers and investors
235
Q

Consequences of patent system

A
  • Increases costs of innovation because of barriers to entry
  • rent seeking; legal protection to protect market position
236
Q

Favour competition because of

A
  • Drives down prices through competition, increases trade and welfare (otherwise less welfare)
  • Long run because so many manifacturers that price is MC
237
Q

current system innovations in drugs

A
  • lot of innovation in me-too drugs; (1innovation lot of products)
  • Rare diseases
238
Q

CEA and patents

A

Without competition only mechanism to drive down prices
- Value based pricing

Low threshold; no innovation
high threshold; innovation

239
Q

Alternative ways to induce innovation Boldrin and Levin

A
  • Pay for ideas and not for patents
  • Public finance RCTS to test; no fixed costs
  • Fundamental research leave it to market
240
Q

Perspectives in rationing supply side

A
  • societal perspective; lowest price for equity
  • producer perspective; profit seeking
  • big pharma perspective (buy of ideas; wait for demand)
241
Q

fiscal sustainability

A

Ability of government to manage resources efficiently without harming future generations

242
Q

intergenerational redistribution

A

Move resources such as premiums and taxes from young to old generations to finance healthcare

243
Q

fiscal mechanisms for financing

A
  • social insurance; percentage of income
  • Healthcare insurance; Household care
  • social care; subscription
244
Q

why public financing of LTHC

A
  1. Independent probabilities (not the same probabilities of getting older)
  2. Probability (At lower ages yes, at higher ages no (chronic diseases)
  3. Probability is estimable
  4. Asymmetric information
    * Moral hazard; more than normal healthcare (can provide housekeeping yourself, but is paid for you)
    - Scope for moral hazard in long term can be very high
245
Q

why moral hazard in LTC scope high

A

Using thing that are unnecessary; because of income for example

246
Q

tail risk

A

you are one of the 5% that stays very long in nursing home which costs lots of money

247
Q

insurance choice

A
  • tend to underinsure
  • complex products; what you need on your current status
  • uncertainty about need
  • uncertainty about coverage; prices rise
  • People dont think about old age
248
Q

why LTC different from curative care

A
  • Product is different; not curing but meaningfull life (no clear outcomes, but little proces indicators CEA difficult)
  • Partly subsituted by informal care and private acces
249
Q

optimally provide LTC

A
  • Some have financial and informal care network that can provide LTC
  • Some groups not a strong network and no financial leverage

Poorer react stronger and more benefits

250
Q
  • Some have financial and informal care network that can provide LTC
  • Some groups not a strong network and no financial leverage

If you do this what are the risks

A
  • Moral hazard; poor use formal care while because you have acces to informal care would also do
  • Deadweight loss; Public funds are spent on providing services who could have afforded them independently, leading to inefficiency.
    Example: Subsidizing LTC for wealthy individuals who would have paid for it privately.
251
Q

three broader rationing mechanisms

A
  • Eligibilty; criteria for suitable long term care
  • Copayments
  • Waiting lists for the provision of long term care
252
Q

Eligiblity

A

assesment of CIZ for getting acces to LTC
- medical need (limitations)
- preferences

Assessors discretionary power of exogenous variation (Depends on their subjection)
endogenous should be based on case mix

253
Q

lenient

A

likelihood to assign nursing home care

254
Q

eligibility pros

A
  • Decrease in probability of a hospital admission
  • standardized process; guidelines but few differentiation possible
  • can enable aging in place
255
Q

eligibility cons

A
  • variation in acces caused by discretionary power of assessor
  • elgible doenst save medical care spending and mortality
256
Q

waiting lists LTC

A

For the provision of healthcare
- triage based medical need
- Can be way to allocate resources in an equitable manner (who needs it most)

257
Q

waiting lists LTC cons

A
  • Spillover effects
  • Based on medical need but under reporting
  • Delay
  • worsen health state
258
Q

Causes of variation in delay

A

Urgency and observed health
- demand; no information of health
- supply; triage
hospitalization

259
Q

waiting lists LTC pros

A
  • more equitable; based on need
  • resource management; buffers variability in demand
260
Q

Copayments as broader mechanism cons

A
  • Not income dependent can lead to moral hazard
  • Little prevention
  • equity principle
261
Q

Copayments as broader mechanism pros

A
  • Income depedent reduce demand
  • more prevention or informal care
262
Q

Implicit rationing

A

Actors within the system decide on allocation of resources

263
Q

Explicit rationing

A

Specific criteria for services to be claimed

264
Q

Germany healthcare system

A

No systematic healthcare system rationing
- PHI and SHI (stationary)
- PHI voluntary but salary threshold or self-employed
- DJC decides on package

265
Q

FJC

A

German authority to decide on; access, benefits and quality
- decisions on evidence
- What is covered on SHI

IQWIG; evidence and efficiency healthcare
IQTIG; quality perspective

266
Q

Demand side rationing; inclusion in BBP Germany

A

Inpatient drugs; almost every drug included
- Principle; effective services must be covered
- Quick access to the market for patients
- Disproportionate outcomes

267
Q

two hurdles in Germany

A

Inclusion based on additional clinical benefit
- No explicit considerations of costs
- No Qalys

No considerations on cost-efficiency

268
Q

What is used in germany to access inpatient drugs?

A
  • Quality
  • Safety
  • Efficacy + tolerability
269
Q

Benefits german system

A
  • Quick access for patients
  • Less equity considerations
  • Comprehensive BBP
270
Q

Cons of german system

A
  • Costs rise hard
  • Drugs price high as there is no threshold on CEA; price paid for access is high
  • disproportionate outcomes
271
Q

Price of drugs in Germany

A
272
Q

Supply side rationing Germany

A
  • No gatekeeping
  • Underprovision of GP; due to hard criteria
  • Equity concerns on low SES and low GPS
  • To much excessive capacity
273
Q

PHI germany equity

A

Incentive to ask for higher fees
- More wealthier
- can discriminate on pre-existing health

274
Q

PHI and SHI impact on rationing

A

PHI
- Useless care because they are healthier (no rationing)
- Useless care because it costs them more initially (rationing)
- Use more care because they are preferentially treated (rationing)

SHI
- Use more care because they are less healthy (no rationing)
- Use less care because of low access to it (rationing)

ESHPM - Jaar 3 (9 decks)

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