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Samenvatting colleges en literatuur keuzevak Rationing Healthcare (GW301)
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Rationing health careInhoudsopgave
Week 1 .......................................................................................................................................................................................... 1
Lecture 1.1 Introduction to rationing health care ............................................................................................................................. 1
Literatuur 1.1 ................................................................................................................................................................................... 15
Lecture 1.2. Rationing health care: different systems, different ways ............................................................................................ 23
Literatuur 1.2 ................................................................................................................................................................................... 36
Week 2 ........................................................................................................................................................................................ 42
Lecture 2.1 Supply side rationing: Advantages and disadvantages ................................................................................................ 42
Literatuur 2.1 ................................................................................................................................................................................... 51
Lecture 2.2 Demand side rationing: Advantages and disadvantages ............................................................................................. 60
Literatuur 2.2 ................................................................................................................................................................................... 67
Week 3 ........................................................................................................................................................................................ 71
Lecture 3.1 Equity weighting in economic evaluations.................................................................................................................... 71
Literatuur 3.1 ................................................................................................................................................................................... 78
Lecture 3.2 Rationing in the Netherlands ........................................................................................................................................ 79
Literatuur 3.2 ................................................................................................................................................................................... 83
Week 4 ........................................................................................................................................................................................ 84
Lecture 4.1 Rationing in the United Kingdom .................................................................................................................................. 84
Literatuur 4.1 ................................................................................................................................................................................... 90
Lecture 4.2 Rationing in Germany ................................................................................................................................................... 91
Literatuur 4.2 ................................................................................................................................................................................... 97
Week 5 ........................................................................................................................................................................................ 98
Lecture 5.1 Rationing in Belgium ..................................................................................................................................................... 98
Literatuur 5.1 ................................................................................................................................................................................... 98
Lecture 5.2.a Rationing health care in times of the COVID-19 pandemic ..................................................................................... 102
Lecture 5.2.b Rationing health care in times of COVID-19 pandemic: ICU beds and vaccines ...................................................... 105
Literatuur 5.2 ................................................................................................................................................................................. 108
Week 1
Lecture 1.1 Introduction to rationing health care
Rationing health care
• Perhaps the most difficult topic of them all
• Rationing - somehow limiting the amount of care provided and consumed often in order to control / optimize healthcare
expenditures.
• “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.” (Maynard, 1999)
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, • To limit the beneficial health care an individual desires by any means – price or non-price, direct or indirect, explicit or
implicit (Breyer, 2013)
• Universal theme, relevant across the world
• Level and intensity of rationing differs given levels of health care spending
Rationing?
• As Alan Maynard (1999) noted: rationing evokes images of war or crisis in which the limited supply of essentials was
distributed ... in relation to ownership of and willingness to trade a ‘coupon’ or certificate of ‘right’ to access the market
• Might we be exaggerating the problem of rationing in health care?
As Maynard already wrote in 1999 if you talk about the word rationing many people think about a war or a very acute crisis in which
there is an absolute shortage of things and therefore we need to ration so you could get a coupon to get particular materials or
products in a supermarket and you might consider given how much we're spending on healthcare that we might be actually
exaggerating a bit the whole problem of rationing given what is going on in many developed countries where actually there's quite a
lot of money going around and just to indicate that these are the spending figures coming from the OECD figures from 2019 where
the latest figure was on 2018 which indicates that we roughly spend about 10% of our total wealth on healthcare in the Netherlands
an if you look at most of these other countries they are spending quite a bit of money as well and of course those countries who
actually have less money to spare spent less so once a country becomes more wealthy they're not only spending more in absolute
terms on healthcare but also in relative terms so this percentage goes up an as you can see America is an outlier over there with
almost 17% of spending of their GDP on health
We live longer and healthier than ever before so not only are we spending more but actually that translates also at least to some
extent that the health care system contributes to life expectancy in quality of life to how long and healthy we live an as you can see
you can see it here all the whites white dots is life expectancy in 1970 and all the red dots are the life expectancies in 2015 or the
nearest year for those different countries and what you see there is actually there's a huge increase in our life expectancy over
those decades and we live indeed longer and healthier than ever before so is it actually reasonable to talk about rationing in such a
context
But stil WWW: World Wide Worries
• In some countries, people die while waiting for appropriate care
• In some countries, substantial copayments are charged to patients, leading to discussions of accessibility of care
• In some countries, certain types of care are not covered under collectively financed health insurance (basic benefits
package) – financial access limited
• In the US millions of people are uninsured
• In New Zealand, for a while, a guideline on end stage renal dialysis, indicated people over 75 were normally not eligible for
treatment
• For many people in low income countries, essential medicines are unaffordable
Because we still have WWW worldwide worries so in some countries people die while waiting for appropriate care and you might
think that that would be the case in far far away countries you'll hear a bit more also during this course on different countries and
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,how they deal with rationing and one of the countries that you'll be hearing about is the United Kingdom and in the United Kingdom
waiting lists are actually quite long leading people actually to die while waiting in some instances in some other countries there are
substantial copayments charged to patients and they lead to discussions about Accessibility of care and one of the countries very
close by that have a different tradition in how to deal with copayments is for instance Belgium and you hear about that country later
during this course as well and then there are some countries in which certain types of care actually brought ranges of care are not
covered under collectively financed health insurance systems and you could of course think about the US and as we speak there are
millions and millions of people in the US still uninsured an actually there will be new lawsuits against the Affordable Care Act that
Obama introduced a number of years ago that would actually push about 20 million additional people over the edge of being
uninsured in that country in New Zealand for awhile there was a guideline saying that end stage dialisis should not be offered
anymore for people over 75 if you know anything about renal dialysis you would know that if you stop treating people that actually
need dialisis that is almost as close as a death sentence for those people it's a very expensive treatment and the idea was that
beyond the age of 75 we may not be able to afford giving that treatment to these people anymore and if we talk about low and
middle income countries in especially low income countries there is a vast group of countries in which many of the citizens do not
have access to very essential medicines so there the level of rationing is even much worse then in our situation
Imagine…
• Imagine being in much pain, having difficulties walking and performing usual activities. After waiting for a diagnosis (for 3
months) the operation you need is scheduled… for over 5 months…
• Imagine you have a rare disease, causing your muscles to deteriorate. A new drug has come on the market (costing
$200,000 per patient per year). Your government decides not to reimburse it…
• Imagine living on a very tight budget. The washing machine just broke down. Your GP says you should have an x-ray (for
which you pay 385 euros out of pocket).
A particular problem why should this be the focus of so much attention and in fact be the focus of a full course well just imagine you
would be in much pain you would have difficulties walking you would have difficulties performing usual activities after waiting for a
diagnosis for three months the operation that you need is now being scheduled for over 5 months just imagine what this would do
with your life just imagine how you would look at the healthcare system to which you have turned for help and this is the help that
you get worse still imagine you would have a rare disease causing your muscles to deteriorate and new drug comes on the market
however it costs $200,000 per patient per year and your government has decided that this is simply too much money to spend on
this particular disease per patient what would that do that means that the process of deterioration all your hopes you had for the
future are down the drain not because there's nothing people could do but because people decided that they did not want to do it
given the costs imagine you live on a very tight budget the washing machine just breakdown and your GP says you should have an X
Ray and of course you would then need to pay 385 euros out of your own pocket it's almost a choice between a new washing
machine or next rate is it OK to have those types of choices in a country is it OK to leave that up to individuals all kinds of questions
that are not only hypothetical but these are situations that are actually happening not only in our country but certainly also in many
other countries
RAM
Remote access to medical facilities if you look at the pictures you might think that these are pictures taken in low or middle income
countries well actually this is in the US people waiting for free healthcare because they cannot afford to go to medical centers
where they actually have to pick up the bill themselves often these are people with in the lower income groups often also without
jobs trying to find medical care when they need it
See that much if you are interested I can already indicate that once you go on to do the Masters and of course let me already
expressed the hope that I do hope that you will do a Masters with us as well where you could look a bit more into global health
issues and global health economics where you would talk a bit more about the choices that need to be made in countries like some
of those low income countries in Africa where the level of rationing and the problems that people face are way beyond the troubles
that we see in our parts of the world
Cultural differences
Such an interesting topic and such a difficult topic is that there are clear cultural differences in how we look at the whole problem of
rationing both in terms of whose problem this actually is. Is it the problem of an individual? Is it the problem of the government?
And is it OK to impose certain measures for all people on a on a population like we do in most of Western Europe but where you see
that for instance in the United States people respond much less favorable to government intervention in the field of health care so
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, it's not only about the problem as such but it's also how this problem is perceived and which of the solutions that you might bring to
the table for the problem of rationing are actually accepted in a particular cultural environment and there the United States clearly
is different than Europe Europe is also different between different countries so rationing as a word already is normally not used in
many of the countries like for instance France and some of these other countries people normally do not like the whole word
rationing and the whole concept of rationing in countries like the UK and the he Netherlands we normally talk about these problems
and these issues of where to draw a line around our healthcare system abit more openly which of the two you prefer of course is a
personal matter
“Ellie calls for drug access”
This is Ellie who suffers from spinal muscular atrophy since the age of 12 and there is a medicine that helps these people it's called
spinraza also has been quite debated in the Netherlands and one of the features of spinraza is that it works the other feature of
spinraza is that it's quite expensive and at a certain stage they decided in the UK to prescribe spinraza only in children people under
18 and not over 18 which means that Eli would have to go without that particular drug and this is just some of the things that she
mentions in this newspaper article she said so far there's been no explanation offered about why there are age restrictions to the
drug and then she says I have wondered what the criteria were in making that decision one part of me thinks maybe there was
scientific reason or maybe they just want to focus on younger people because they think older people are worth are not worth the
trouble or the expense so just let that set in for one moment this is a person who has suffered from this since she was 12 but at that
moment that she was a child the drug was not yet available now it is available but people are saying well but now you're too old to
get it which means that there's no hope for
any type of relief from the problems that this
disease is causing her and we're rationing
here on the basis it seems from this news
article also of age is that a reasonable thing to
do should we actually distinguish between
younger people and older people when we
make rationing decisions one of the things
that we'll address a bit further during this
course as well just to follow up on the case of
Eli there was a lot of discussion about
spinraza also in the UK an at a certain stage
nice did recommends to fund spinraza for all
these patients therefore including Eli
They say NICE which is the body in the UK who has to make
these types of decisions on whether or not to fund a very
expensive drug had earlier recommended against the use of
spinraza because it was about 100,000 pounds as a list price
judging it to cost at least £400,000 per quality adjusted life
here so this if you would translate it to euros costs about half
a million per quality per perfectly perfectly healthy life year
gained now that's a lot of course and that's the reason why
they actually decided against it in the 1st place but then they
had commercial discussions as they call it to come to an
agreement with the producer of spinraza and now they do
recommend it seemingly because there was a lowering of the
price in the UK by which nice came to the conclusion that now
it was OK to fund spinraza for all these different patients to
some extent unfortunately we don't know exactly the price that was negotiated because these things are normally confidential like
is the case in the Netherlands
Conclusion: decided to fund spinraza
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