College aantekeningen
College aantekeningen Rationing Healthcare
- Instelling
- Erasmus Universiteit Rotterdam (EUR)
Dit bestand bestaat uit de college aantekeningen van het keuzevak Rationing Healthcare (incl. Nederlandse vertaling).
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Voorbeeld 4 van de 59 pagina's
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Voorbeeld van de inhoud
College aantekeningen Rationing Health CareCollege 1
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)
• To limit the beneficial health care an individual desires by any means – price or non-price,
direct or indirect, explicit or implicit (Breyer, 2013) (Om de gunstige gezondheidszorg die een
individu wenst op welke manier dan ook te beperken - prijs of niet-prijs, direct of indirect, expliciet
of impliciet).
• Universal theme, relevant across the world
• Level and intensity of rationing differs given levels of health care spending
• 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?
10% van het gdp gaat naar gezondheidszorg in Nederland. De levensverwachting is de afgelopen
jaren enorm toegenomen, maar er zijn nog steeds grote zorgen (WWW).
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 (Belgium)
• In some countries, certain types of care are not covered under collectively financed health
insurance (basic benefits package) – financial access limited (USA)
• 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
Resistance (weerstand):
• People typically do not like rationing: even the ‘R word’ is often avoided
• Some think rationing can be avoided but economists might say that there are always limits to
what we can do
• This is more difficult in the context of health care: because of nature of health and health care
and the way health care systems are financed
• The difficulty comes in deciding how to limit health care, on what basis, in general and in
individual cases, and how to make it work in practice
Rationing from an economic perspective…
• John Kenneth Galbraith: Economics is extremely useful as a form of employment for economists.
• Oscar Wilde (cynic): An economist knows the price of everything but the value of nothing.
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,Als je andere dingen hebt die je beter kunt doen, waarom ben je dan hier? Dat zouden economen
zeggen. De tijd die je naar het college aan het kijken bent, krijg je niet meer terug (opportunity cost).
Als je het geld uitgeeft aan de ene patiënt, dan kun je het niet aan de ander uitgeven.
Economics:
• Economics concerned with the efficient allocation of scarce resources over alternative uses and
the equity implications (Economie die zich bezighoudt met de efficiënte toewijzing van schaarse
middelen over alternatieve toepassingen en de implicaties voor billijkheid/gelijkheid).
• Efficiency relates to maximizing of welfare (happiness) - (Efficiëntie heeft betrekking op het
maximaliseren van welzijn (geluk)).
• Equity relates to notions of fair distributions (of welfare) – (Eigen vermogen heeft betrekking op
noties van eerlijke uitkeringen (van welvaart))
• Equity and efficiency issues cannot be solved independently (Arrow, 1963)
• Both very important when it comes to health and health care
Dismal science (sombere wetenschap)
• Core assumptions: desires/needs are infinite, yet resources are limited
• Scarcity (schaarste) - never enough resources to satisfy all human wants and needs
• Available resources used to maximize outcomes/goal (e.g. happiness, welfare, health)
• In decisions with effects across people, equity plays a role as well
• Rationing at core of economics - a dismal science?
• Rationing is inevitable due to scarcity (Rationing is onvermijdelijk vanwege schaarste)
• For economists the fact that we need to ration is unsurprising
• We always need to ration in all sectors of public and private life
• There are never enough resources to fulfil all our wishes and needs
• Normally, preferences, prices and budget restrictions determine outcomes
• Individuals maximize utility and make own choices about own consumption and take income and
prices as given
• 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).
Perfect market: many buyers and many suppliers
Optimality
• Markets steer, through price mechanism, towards an equilibrium
• Equilibrium equals supply and demand (Evenwicht is gelijk aan vraag en aanbod)
• Under a number of (strict) assumptions, such an equilibrium can be seen as optimal (i.e. welfare
maximizing, Pareto optimal)
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,• Individuals maximize own utility, are best judges of own welfare, have perfect knowledge about
prices and characteristics of all available goods
• Income distribution is not questioned and determines purchasing power
Health care is different….
• The assumptions underlying economic textbooks are not valid for health care
• Many deviating characteristics cause that leaving health care provision to market forces will not
lead to optimal outcomes (veel afwijkende kenmerken zorgen ervoor dat het overlaten van de
zorg aan de marktwerking niet tot optimale uitkomsten leidt).
• That implies that government intervention in the health care sector may be necessary to attain
“better” results
• This holds both for reasons of efficiency and for reasons of equity
• Markets do not result in optimal (efficient) outcomes in health care due to specific characteristics
(See Arrow, 1963)
o Uncertainty and consequences of insurance (onzekerheid en gevolgen van verzekeringen)
o Information asymmetry between consumers and suppliers (informatieasymmetrie tussen
consumenten en leveranciers)
o Existence of externalities (het bestaan van externe effecten). 60% van de mensen die een
vaccinatie hebben gehad beschermen ook de 40% die het niet hebben gehad.
• Moreover, strong concerns for equity in relation to health can make efficient outcomes
unacceptable (i.e. inequitable)
Statement on NHS in UK
• The government ... wants to ensure that in the future every man, woman and child can rely on
getting ... the best medical and other facilities available; that their getting them shall not depend
on whether they can pay for them or any other factor irrelevant to real need. (of ze ze krijgen,
hangt er niet van af of ze ervoor kunnen betalen of van enige andere factor die niet relevant is
voor de werkelijke behoefte).
• This goes beyond correcting some market failures…
• Allocation and rationing no longer ‘up to the market’
Rationing
• Breyer (2013) distinguishes general economic rationing and the type central in this course:
“These methods can be divided into those that make use of the price mechanism (“price
rationing”) and those that do not (“non-price rationing”), the latter being synonymous with
rationing in its narrow sense. More specifically, this latter concept can be defined as the
allocation of limited amounts below market price, which often means “free of charge”.” (Deze
methoden kunnen worden onderverdeeld in methoden die gebruik maken van het
prijsmechanisme ("prijsrantsoenering") en methoden die dat niet doen ("niet-
prijsrantsoenering"), waarbij de laatste synoniem is met rantsoenering in zijn enge zin. Meer
specifiek kan dit laatste concept worden gedefinieerd als de toewijzing van beperkte bedragen
onder de marktprijs, wat vaak 'gratis' betekent.)
• Rationing in this course thus often presupposes (the possibility of) some kind of collective
financing of the good in question, but can still result in types of rationing that leave allocation to
market (e.g. no coverage).
Allocation (toewijzing) and rationing
• In government regulated markets without (full) price mechanisms, also decisions regarding
allocations / priority setting / rationing need to be made somehow
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, • I may not be able to afford a drug that costs $300,000 and would give me some additional
health, but a collectively financed system could still enable me to get it (for free or e.g. a
copayment of $3,000)
• How to we now determine which care should be available for specific groups (and when and
under which circumstances)?
• Or should there be no limit?
The great escape; ethics
“At least as long I am Minister of Health, I shall never lead a debate on rationing or prioritization, for
ethical reasons” (Philipp Rösler 2010).
Ethical position?
“There is a large group of objectors against health economics who believe it is contrary to medical
ethics. In the extreme, these people believe that it is the doctor’s duty to do everything possible for
the patient in front of him, no matter what the costs.
But in a resource-constraint system, ‘costs’ means ‘sacrifice’ (in this case the value of benefits
foregone by the person who did not get treated).
Thus, ‘no matter what the costs’ means ‘no matter what sacrifice borne by others’. This does not
sound to me like a very ethical position to be in.” (Dus ‘ongeacht de kosten’ betekent ‘ongeacht het
offer dat door anderen wordt gedragen’. Dit klinkt mij niet als een erg ethische positie in de oren.”).
Health care rationing
• Health care costs and demands increasing – pressure on budgets
• How to allocate scarce health care resources optimally?
• That means choose what to do and hence what not to do (rationing)
• Scarcity in health care denied (ontkent): ‘The first lesson of economics is scarcity…’ … “… the first
lesson of politics is to disregard the first lesson of economics…”
• All systems deal with scarcity, balancing goals of efficiency, equity, …
• Setting priorities/rationing, implicitly or explicitly, through coverage, budgets, (co)payments,
incentives, waiting times, formal vs informal care, quality, … => the core of this course!
Why is health care rationing such an issue?
• Health (care) is a special good
• Central to human flourishing, capabilities and utility
• Strong feelings of solidarity (esp. in Europe) regarding health
• In many countries much health care is available ‘free’
• Setting limits (esp. by others) to access/coverage seen as indefensible
• ‘If it works, we should reimburse it’…
• Rationing shows a tension around fundamental aim of many systems
Health care as a right?
• Many citizens consider health care to be a right (Van Exel et al., SSM )
• Recent Q methodology study elicited shared views in the general public (n=294) across ten
European countries on appropriate principles for prioritizing health care.
• Five distinct viewpoints were identified, (I) “Egalitarianism, entitlement and equality of access”;
(II) “Severity and the magnitude of health gains”; (III) “Fair innings, young people and maximising
health benefits”; (IV) “The intrinsic value of life and healthy living”; (V) “Quality of life is more
important than simply staying alive”.
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