RHC Week 1

Question 1

Rationing

Answer 1

= somehow limiting the amount of care provided and consumed often in order to control/optimize healthcare expeditures

Question 2

Rationing (Breyer)

Answer 2

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

Question 3

explicit

Answer 3

vb ‘im going to say that this pill is not available to any of you’

Question 4

implicit

Answer 4

vb. anything goes, but this is the budget and this cannot buy anything for everyone who wants it

Question 5

RAM

Answer 5

(Remote Access medicine) = they stand in line to see a GP or dentist or something. Because they are not insured and cannot afford these types of care

Question 6

scarcity

Answer 6

= never enough resources to satisfy all human wants and needs

(als er geen schaarste was, zouden er geen economen zijn. In normale markten ration je jezelf. Het opgeven van iets anders als je bijv de nieuwste iphone koopt, dit geld kan je niet aan iets anders uitgeven)

available resources used to maximize outcomes/goals (e.g. happiness, utility, welfare, health)

Rationing is inevitable due to scarcity

Question 7

Markets do not result in optimal (efficient) outcomes in health care due to specific characteristics (See Arrow, 1963)

Answer 7

1. uncertainty and consequences of insurance –> will lead to a higher level of welfae, our demand becomes infinite when we are insured
2. information asymmetry between consumer and suppliers –> informatieassymetrie tussen dokter en jij, je vertrouwt je dokter
3. existence of externalities –> 90% gevaccineerd, 10% heeft er ook voordelen van. overheid moet hier op inspelen, individuele keuzes gaan het niet alleen redden

Question 8

NHS

Answer 8

(National Health Service) It refers to the Government-funded medical and health care service that everyone living in the UK can use without being asked to pay the full cost of the service

Question 9

Weale (1998): basic principle of many health care systems is to offer

Answer 9

comprehensive (covers everything), high quality medical care (it has to be perfect), to all citizens

given scarcity, these 3 basic wishes represent what logicians call an inconsistent triad: you cannot fulfil all 3 wishes at the same time

Question 10

Define benefit/need

Answer 10

..something that is proven to be effective for the heath. Means many different things to many different people.
is it related to:
- an immediate danger to life?
- the risk of a severe and lasting health impairment or
- any, even only temporary, deterioration of health

Question 11

Beyer about benefit and need

Answer 11

The choices are not a clearcut. They are not dichotomous, rather continious. Everyone needs to decide where they draw the line between what is necessary and what is not. even within one treatment. Any type of improvement will count as a benefit. In the most general definition, all these things apply.

Question 12

Price Rationing

Answer 12

= common allocation principle on many markets. Breyer distinguishes it from non-price rationing

Question 13

Primary rationing

Answer 13

= involves limiting (collectively financed) health care (sets a budget, dit is het budget waarmee de gezondheidszorg het moet doen)

it involves determining (directly or indirectly) the budget available for health care. How much are we willing to spend on health care and how should we determine this?

Question 13

Secondary Rationing

Answer 13

= once the budget has been set there is scarcity in the system (note- ideally other way around)

–> then, rationing procedures need to be in place (e.g. prioritizing on waiting lists, or choices regarding which interventions to fund)

Question 14

Allocating resources associated with ‘natural’ scarcity

Answer 14

= also labelled secondary rationing (e.g. organ transplantable organs)

Question 14

Implicit & supply

Answer 14

Implicit rationing is often associated with supply side rationing (leaving demand in a direct sense unaffected)

consequences –> waiting lists

Question 14

Pro’s and con’s implicit

Answer 14

• no rules to potential harm,
  -potential differences between hospitals / professionals
• difficult choices left to lower levels
• avoids a great deal of fundamental discussions

Question 14

Implicit rationing

Answer 14

= just setting the budget; trust the health care system will do the right things with the money. Leavving the choices unspecified what you do with the budget.

–> sets limits to resources, but does not indicate how the scarce resources should be allocated

Question 15

Explicit Rationing

Answer 15

= sets limits to resources available in combination with choices on how the scarce resources should be allocated (setting the rules to which types of health care have to live up to in order to be reimbursed)

Question 15

Explicit & demand

Answer 15

explicit rationing is often associated with demand side rationing (leaving supply in a direct sense unaffected)

consequences –> limited entitlements / coverage and own payments

Question 16

Implicit or explicit?

Answer 16

(Hall, 1994) Many people prefer implict over explicit rationing because the former allows upholding the believe that death is always due to an unhappy fate and never the result of specific rationing decisions, including one’s own decision not to include a certain service in one’s insurance contract.

Question 16

Pro’s and con’s explicit

Answer 16

• resistance in society, - difficulty of specifying general rules
• manageble to judge all elements of a system

Question 17

Moving towards explicit? Breyer indicates 3 topics to be important in that context

Answer 17

1 - Cost- effectiveness: maximizing health/welfae from available resources (often expressed as costs per QALY)
2 - Patient age: if people are older, they should have less priority
3- novelty: medical technology as driver of costs - delay coverage?

Question 18

Hard rationing

Answer 18

= if you cannot have it publicil, you cannot have it at all (e.g. organs)

Question 19

Soft rationing

Answer 19

= if you cannot have it publicly, you may be able to buy it elsewhere (e.g. quicker care, dental care)

Question 20

Rationing and health care goals

Answer 20

• implicit rt (without rules or proof the ‘system’ makes choices in line with this goals) helps to increase affordability
• explicit rationing can help to make choices in line with health system goals while attempting to preserve affordability
• important in rationing is to avoid damage (to efficiency or equity) as much as possible (and monitor the effects of any policy)
• many cost-containment strategies do not consider damage

Question 21

Hurst (1991) typology of health care systems

Answer 21

1: reimbursement model
2: contract model
3: integrated model

Question 22

voluntary health insurance

Answer 22

• reimbursement (private health insurance NL)
• contract model (preferred provides USA)
• integrated model (HMO’s USA)

Question 23

mandatory health insurance

Answer 23

• reimbursement (belgian system)
• contract model (former sickness funds NL)
• integrated model (classical NHS-UK)

Question 24

Voluntary insurances pros/cons

Answer 24

• problems with equity: low incomes and high risks have difficulties buying insurance
• premium often risk-related or community-rated (adverse selection)
• adverse selection (trying to target the relatively healthy people with low risks) & cream skimming
• givien strong support for equity in health care and ensuring universal acces to health care, European countries normally (partly) rely on mandatory insurance (financed through premiums or taxes)

Question 25

Mandatory insurance pros/cons

Answer 25

• The reimbursement model is vulnerable to failures of cost containment (consumer & producer moral hazard);
• The integrated model is vulnerable to failures of microeconomic efficiency (queues, quality gaps);
• The contract model seems to have the potential for combining macro-economic efficiency with micro-economic efficiency.
  Countries are actually looking for the contract model in order to improve the outcomes of health care systems.

Question 26

Supply side rationing

Answer 26

• (Primarily) restricts the supply of care
• Important examples: budget constraints, limiting numbers of doctors (trained or hired), limiting number of hospital beds, etc.
• Supply-side rationing associated with (mandatory) integrated systems like NHS
• By leaving demand (in direct sense) unaffected, a mismatch between demand and supply typically occurs (waiting times often)
• Waiting lists as common consequence (with health damage)

Question 27

Demand side rationing

Answer 27

• (Primarily) restricts the demand of care (consumer can only be limited in the reimbursement model); belgië heeft ‘’remgeld’’ om mensen af te remmen om naar health care suppliers te gaan. Logical to target te consumer because he is the one who seeks care, second you assume the consumers to self-diagnose, they know when they need to go or when they don’t. relying the consumer to make the choices, health hazards can be the problem.
• Important examples: limiting the types of health care interventions covered by health insurance (e.g., limiting basic benefits package) or some form of own payments
• Demand-side rationing associated with (mandatory) contract and reimbursement systems
• By leaving supply (in direct sense) unaffected, a mismatch between demand and supply could occur (with incentives for SID, etc.)
• Own choices may lead to health damage

Question 28

Consequences of rationing

Answer 28

Patient: health/ wellbeing –> continued problems, deterioration (reversible or irreversible), death

Social environment: ‘family effect’ , informal caregiving, increased costs/reduced income

health system: dissatisfaction, though choices in system, pressure and burden (waiting lists)

society: inequities, higher costs of ultimate medical treatments, more absenteeism/ presenteeism, justice/safety (mental health), less financial/ health protection