Rationing Health Care Flashcards
Rationing definitie (Breyer,2013)
to limit beneficial health care and individual desires by any means- price or non-price, direct or indirect, explicit or implicit
dismal science
- desires and needs are infinite, yet sources are limited
- scarcity
- available resources used to maximize outcomes
- rationing is inevitable due to scarcity
scarcity
never enough resources to satisfy all human wants and needs
optimality economic
equilibrium equals supply and demand
markets do not result in optimal outcomes in health care due to specific characteristics
- uncertainty and consequences of insurance
- information asymmetry between consumers and suppliers
- existence of externalities
rationing outside health care
money can be used for education, safety, infrastructure etc
rationing inside health care
money can be used for displacement
we ration because of opportunity costs; the same resources can produce more health or wellbeing elsewhere
Weale 1998 three wishes
basic principle of many health care systems is to offer
comprehensive
high quality medical care
to all citizens
inconsistent triad
the three wishes; comprehensive, high quality medical care, to all citizens, cannot be fulfilled at the same time
beneficial
when a treatment is PROVEN to give a positive effect on the health or quality of life
continuous; more or less beneficial
reimbursement model
- premium from consumer to insurer
- reimbursement from insurer tot consumer
- provider payment from consumer to provider
- vulnerable to failures of cost containment; moral hazard
contract model
premium from consumer tot insurer
provider payment from insurer tot provider
voluntary insurance
- problems with equity: low incomes and high risks have difficulties buying insurance
- premiums often risk related or community rated
- adverse selection
consequences of rationing
- patient: health/wellbeing
- social environment: family effect: informal care
- health systems: dissatisfaction: waiting lists
- society: inequities, higher costs, safety
supply side rationing
- through introducing closed end budgets
- common in public systems where government involvement in health care is strong
- results: a system that’s naturally restricted in its capacity tot treat people: waiting lists
waiting times
waiting times can be a mismatch between supply and demand: demand >
- can be caused by built in design: demand free but restricting supply care
hidden demand
becomes visible when the price of care is lowering or the waiting time reduces
cost sharing equity
- if we reduce care consumption relatively strong in low income groups, we create inequity. care use not in line with care need
evaluation criteria for limiting the basic benefits package
necessity
effectiveness
cost effectiveness
feasibility
CUA
cost utility analysis
ICER
cost effectiveness
ct : Qi
where to draw the line?
80000 or 75000 per qaly
market failure due to
- uncertainty and consequences of insurance
- information asymmetry between consumers and suppliers
- existence of externalities
why is health care rationing such an issue
- health care is a special good
- central to human fluorishing, capabilities and utility
- strong feelings of solidarity
- in many countries much health care is free
- setting limits to acces or coverage seen as unjustified
four forms of rationing (Lamm)
price
quantity
chance
prioritization
implicit rationing
only sets the limits/budget but does not indicate how the scarce resources should be allocated.
- the lower people (doctors)make the decisions
- con: potential differences between hospitals
- society determines the health care budget
explicit rationing
sets limits to resources available in combination with choices on how the scarce resources should be allocated
- making explicitly clear who gets what
- budget can be more flexible
- rules and guidelines who gets what treatment
- government decides
- resistance in society, difficulty of specifying general rules
- society determines the rules that determine under which circumstances a patient can claim medical services
breyer indicated three topics to be important in moving towards explicit
- cost effectiveness
- patient age: if people are older, they should have less priority: should you treat people differently?
- novelty: innovation: should we pay extra for it?
hard rationing
if you can not have it publicly, you cannot have it
soft rationing
if you cannot have it publicly; you may be able to buy it elsewhere
supply side rationing
restricts the supply of care
- budget constraints, limiting numbers of doctors
demand side rationing
restricts the demand of care
- limiting the types of health care interventions covered by health insurance
different scenarios effect waiting times (koopmanschap)
- people stay the same, health outcome doesnt change if they wil be treated later or sooner
- waiting times get worse, but when you are treated, you will be completely healthy
- it will take longer to get back to completely healthy
- the effect of the operation is not the samen anymore. complete health will not be achieved
Conceptual framework of waiting time (OECD)
- Emergency arrivals will lead to fast care
- Through GP, whether or not to place a person on a waiting list
- two systems when allowed to see a specialist
- health status and severity will determine if you will be placed on the waiting list
- the longer the list, the longer the time -> specialist will put less people on the list
emergency treatment
first sign of distribution based on need. You will be helped right away
positive aspects waiting
- reduces need to use other rationing mechanisms
- longer waiting induces lower demand
- unnecessary care is restricted
- prioritisation
- can reduce refferals
waiting negative aspects
- loss of quality of life during waiting
- health state may worsen
- recovery time may increase with waiting time
- higher medical costs due to worse cases
- dissatisfaction in society
- uncertainty in patients about when they will be treated
optimal waiting times
long enough to discourage demand but short enough to limit negative aspects from waiting
problem optimal waiting times
differs per disease, situation and individual.
what works to reduce waiting times?
- supply side expansion: reducing budgetary/capacity restraints, rewarding productivity
- demand side reduction: less referrals, less demand
- regulations: improving utilization facilities, maximum waiting time guarantees, choice
Hidden demand
becomes visible when waiting times are reduces
Influence of reduced waiting times on demand
demand increases; hidden demand
however, the increase in demand is relatively small (Martin and smith)
Lower the amount of waiting time (Siciliani and Hurst)
we can lower the amount of waiting time by increasing the amount of physicians working in the system.
however, very expensive
Combined policies
with sanctions and competition the effect on waiting times will be strong
Consequences maximum waiting time
We are transferring the low need people to the high priority group. Not because of the fact they need the help, because they are waiting to long. bad thing
Dutch waiting times
- waiting times important topic in the netherlands during 90s
- more restrictions in quantities and prices through
- deliberate rationing to limit care consumption; budget
- 1994; fee for service abolished
- 1995: number of specialist positions fixed
- shortage in personnel in mid 90s
- waiting times became source of dissatisfaction
Waiting list fund
-implementation in 1997
- specific subsidy to reduce waiting lists
- evaluation showed however that it had almost no effect on the waiting lists and times
- production and demand increased
- perverse incentives: it was profitable to have long waiting lists
wny less waiting after 2000?
- system changes; lifting budget restrictions and regulated competition
- caused decreasing waiting times
other dutch measures after 2000
- transparency of waiting times; but people hardly acted on it
- changing rigid referral flows of GP’s; making them aware of differences in waiting times, but proved difficult
- raising clinical thresholds
- better organisation within hospitals; optimal use of capacity
recent dutch figures
many waiting times reasonable and within treek norms
but some waiting times still too long; youth/mental health care
is waiting a health hazard
longer waiting times for emergency and urgent procedures are associated with worse health outcomes
different scenario’s when treatment is postponed (Koopmanschap)
- people stay the same, doesnt change if they will be treated later or sooner
- things get worse, but when you are treated, you will be completely healthy again
- will get to the completely healthy again but it will take them longer to get there
- the effect of the operation will be the samen, but you will never get to the situation where you were before. Because you had to wait longer
what should determine priority?
- severity when presenting to doctor
- forecast of health with and without treatment
- cost-effectiveness of treatment
- age
- having dependents
- work status
- culpability (debt)
- reciprocity
- willing to pay
possible explanations for socio-economic inequity (OECD)
- people with higher SES engage more actively with the system and exercise pressure when there are long delays
- may have better social netwotks and use them to gain priority
- may have a lower probability of missing scheduled appointments
- may articulate their wishes and needs better and more forcefully
Hurst (2004) countries with and without waiting imes
the countries which do not report waiting times, on average spend more in health care, have higher capacity and implement more frequently forms of activity-based funding for hospitals and fee for service systems for doctors
Hurst (2005) demand and supply
demand: health status of population, state of medical technology
supply: public and private capacity and the productivity with which the capacity is used
employee-clinics
- possible way to attract additional funding for health care
- aimed at a group whose time is valuable for employers
- employers willing and able to pay for expanding hospital capacity
- efficient and equitable
why overconsumption
- full insurance: individual consumers do not experience costs of care
- price=0
- insurance premiums often do not directly relate to health care consumption
- thus a stimulation for overconsumption
definition overconsumption
consuming beyond the point where benefits exceed costs; welfare losses
ex ante moral hazard
less prevention and more risk
ex post moral hazard
demand more and more expensive care
cost sharing
a part of the costs is paid by the patient
- a decreased stimulation for consumption and moral hazard
- poor react stronger than the rich do
- aim is to control cost to reduce less necessary care
asymmetric information
- patient cannot determine own demand (self diagnose)
- people may choose not to consume necessary care and continue to consume unnecessary care
- use of care may be based on income and wrong information
- copayments reduce use of care in which patients dont believe in
RAND HIE(1974-1977)
- RCT in households with co payments
- people are indeed sensitive to prices
- the poor more than the rich
Is the RAND experiment relevent for current European systems?
No, different institutional settings, our co-payments are more complex, excluded elderly, decades ago
defining the basic benefit package
- limiting demand by selecting which treatments are covered
- less coverage means more care is left to own payment or private insurance, or is simply unavailable (depends)
- opportunity costs
health technology
- important driver of costs and health increases
- more health spending not necessarily bad, but should offer value for money
- increase in expensive new treatments, some offering only limited benefits
- difficult question of when to fund
- only fund technology contributing most to efficiency and equity
hesitant countries on the logic of economic evaluations
germany france
undecided countries on the logic of economic evaluations
spain italy
committed countries on the logic of economic evaluations
uk ireland sweden australia netherlands
decision rule
B-C >0
Benefits should be larger than the costs
deltaCT : deltaQ
Delta Qi
the difference in Qalys
Delta ct
the differnce in total costs
explicit rationing
based on efficiency treatments
more health gains per euro
more solidarity with more ill and less with less ill
explicit rationing basic benefits package
- limiting basic benefits package where possible
- elaborate methods and processes in place
- who gets hurt often clear
negative consequences of high cost sharing
can lead to worse compliance with important health care services in turn. Which results in more hospital admissions and other poor health outcomes.
Why is the rationing of organs inevitable from an economic perspective?
- we must make decisions based on for example the need of receiving an organ. Some patients will have a higher need, because maybe they are much younger
- organs are scarce
absolute scarcity
supply of a good is naturally limited
relative scarcity
insufficient goods to satisfy all wants and needs, trade off os necessary
when cost effective?
when incremental cost ratio is below the monetary threshold value
delta ct: delta Q < v
three kinds of cost effective
efficient allocation of resources
- new treatment is more effective and less costly (dominant)
- new treatment is more effectibe and more costly (but < v)
- new treatment is less effective and less costly (but < v)
three kinds of not cost effective
inefficient allocation of resources
- new treatment is less effective and more costly
- new treatment is more effective and more costly (but > v)
- new treatment is less effective and less costly (but > v)
is a treatment always reimbursed when its cost effective?
no, there may be reasons why a new treatment is not reimbursed after all
is a treatment always not reimbursed when its not cost effective?
no, there may be reasons why a new treatment is stil reimbursed
two important normative severity approaches
severity of illness
fair innings
severity of illness
the value of health gains is greater when gained by patients with lower levels of current and future health without the treatment
fair innings
everyone is entitled to have a normal lifespan and therefore the value of health gains is greater when gained by patients who lose a larger share of their lifetime without the new treatment
equal innings argument
those who have not yet had their fair innings, should receive a higher weight
sufficient innings argument
those who have had their fair innings should receive a lower weight
concerns health care system nl
wating times; especially mental healthcare
relatively low number of hospital beds and short lenght of stay
performance health care system nl
we have the lowest level of unmet needs in EU
score quite well in type of mortality rates and cancer detection
consequences in health care system nl when nothing changes
- higher expenditures
- sustainability of health care jeopardized
- risk of crowding out other collective expenditures
- the need for rationing will become even more pressing
two tax based health care acts nl
wmo en jw
two insurance based health care acts nl
wl en zvw
wmo en jw finance
fixed budgets (supply side rationing)
combined with
co payments (demand side rationing)
dutch health care institute ZiN
Advises the ministry of health, welfare and sport on the basic benefits package
wlz
-mandatory income based premium
-premium is fixed percentage
- demand side rationing
- income dependent co-payment
zvw
- mandatory for everyone
- insurance companies obliged to accept anyone at same premium
- demand side rationing
- own risk; minimum 385 euro
four decision criteria for the basic benefits package (ZiN)
- necessity
- effectiveness
- cost effectiveness
- feasibility (budget impact)
open system
automatically included in basic benefits package if it meets the medical science and medical practice criterion
open system nl
expensive new pharmaceuticals are not automatically included, but labelled in transit when:
- cost are > 50000 per treatment per yeat and > 10 million in total
- costs are > 40 million per year in total, irrespective of costs per treatment
only included after price negotiations
how ZiN makes a decision
assessment phase
appraisal phase
assessment phase
collecting, presenting, and assessing information on the four decisions criteria
- WAR assesses and advises ZiN (closed fromt he public)
Appraisal phase
-naming and weighing all relevant arguments
- Insured Package Advisory Commitee advises ZiN on decisions that affect society (open to the public)
- why something should be reimbursed
public involvement
policy makers increasingly seek ways to involve members of the public in reimbursement decisions
-actively involve the public in shaping new policies that affect their lives
-better align outcomes and process of decision making with societal preferences
-increase legitimacy of and societal support for decisions
citizens panel
- 2017 panel on rationing health care in NL
conclusion: citizens shoud be involved but not have the final say and they created 16 decision criteria
ZiN tasks
-managing the basic health care package
-encouraging improvements in health quality
-funding of health care insurers
PICO(T)
Patient group
Intervention
Comparative treatment
Outcome measure
follow up duration (Time)
BoD
Burden of Disease
qalys lost because of disease : remaining qalys in absence of disease
interpretation BoD
The bigger the proportion of QALYS that might be lost, the bigger the BoD
UHC
- Mission: everyone, everywhere at every age full benefits from vaccines for good health and well being
Major implications: - equity uptake (everyone, everywhere at every age)
- broader than health (well being)
the brick wall
from vaccines to vaccination
from researchers to communities
Full Value Vaccines Assessment (FVVA)
- Articulates the value of the vaccine from the perspective of multiple stakeholders
- Serves as an end to end compendium of available evidence to support advocacy and inform decision making at various stages of product development
- Identifies gaps to guide funding decisions and assessment of risk
Main objectives FVVA
- Country level equitable and sustainable uptake of vaccines
2, strategic decisions - advocacy and communication
Main functions FVVA
Assessment
decision making
communication
Assessment FVVA
Existing methods and tools need to be adapted to include broader benefits of vaccins as well ass opportunity costs borne by stakeholders
decision making FVVA
the increasing focus on the agency of stakeholders and country ownership of decision making and priority setting should be reflected in the deliberative FVVA process to ensure introduction, equitable vaccine acces and coverage, and sustainable impact
Communication FFVA
FVVAs should facilitate communication about the full value of vaccines and enhance alignment and coordination across diverse stakeholders
background health care system Belgium
- broad benefits package
- low membership cost
- private, non profit sickness funds
- NIHDI
- Providers paid fee for service
- Patients largely free to choose their provider
Outpatient care belgium
patients pay full price, and get reimbursed partially afterwards
Inpatient care belgium
Third payer arrangements
NIHDI National Institute for Health and Disability Insurance
- directed by representatives of government, trade unions, providers, sickness fund
- finaced through taxes and social security contributions
- distributes resources between health insurers
- they enforce and set the rules of the game
performance of the healthcare system Belgium
- Every 3 years evaluation by KCE
- high patient satisfaction
is rationing necessary belgium?
- expenditures are increasing
- its all about opportunity costs
- outside health care: less education, safety. culture
- inside health care: displacement, more for some patients less for others
Schokkaert & van der Voorde (2005) closed end budgets
- setting of a global budget (defined by insurers, providers and NIHDI)
- Growth norm, maximum of 1,5%
- possibility for exceptions
-global budget divided in partial budgets
supply side rationing
Budget overruns 2015 Belgium
since 2015 there have been concerns for overruns for pharmaceutical expenditures
- spending exceeds the budget that has been made for the industry
3 different types of quotas belgium
- numerus clausus; fixed number of students allowed to enter medical studies; to match supply and demand
- quota on some hospital/inpatient services; like number of beds
- quota/restrictions on number of hospitals that can provide certain types of care
maximum expenditure threshold
a maximum amount of money that household have to pay before they do not longer have to pay co payments
3 main systems to ration in belgium
closed end budget
supply quota
demand side cost sharing
four players who could ration (Lamm)
- consumers
- health providers
- Bureaucrats and managers
- politicians
Primary rationing
- non price rationing
- society deliberately limits the collectively financed resources for health care, because they compete with other uses such as education or infrastructure
Secondary rationing
The allocation of non-augmenatble resources, such as donor organs or IC beds
- non price rationing
four basic functions of every health system (Murray)
financing
provision
stewardship
resource development
stewardship
setting, implementing and monitoring the rules of the game
How to reduce waiting times supply side (Siciliani &Hurst)
- funding extra activity
- introducing activity related payment
- reforming the contract of specialist
- improving management
- funding extra capacity
- contracting with the privat sector
- increasing choice for patients
How to reduce waiting times demand side (Siciliani & Hurst)
- explicit guidelines to prioritize patients on the list
- raising clinical thresholds
- subsidize private health insurance
Policies acing directly on waiting times (Siciliani & Hurst)
maximum waiting time guarantee
financial and non financial incentives to reduce waiting times
health insurance germany
Statutory health insurance: consisting of competing, not for profit, non-gouvernemental health insurance plans known as sickness fund
and private insurance
unlikely in germany
hospitals and physicians treat all patients regardless of whether they have SHI or private insurance.
health system germany
- highest rates of beds, doctors and nurses in the EU
effectiveness germany
Germany’s rates for preventable and treatable causes of mortality are slightly lower than the EU average
accessibility germany
Germany reports low levels of self-reported unmet medical needs. It provides a broad benefit basket and financial safety nets that cover most health care costs.
resilience germany
future financial sustainability may become challenging as the population ages.
