Decision making from two distinct points of view: patients and society

by

. . .

A part of my talk will consider the paper entitled:Different views on health care rationing the main principles mentioned in the choice and

.

PORTUGAL

18-19 November 2014, Siófok, Hungary

OUTLINE

AN OVERVIEW AT HEALTH SYSTEM

THE PRESENT SCENARIO OF DIABETES IN EUROPE

Different views on health care rationing the main principles mentioned in the choiceMOTIVATIONMETHODOLOGYOBJECTIVESQUESTIONNAIRESAMPLE DESCRIPTIONRESULTSMAIN CONCLUSIONSFUTURE RESEARCH

In the development countries, we notice that the weight of health expenditures grew. Despite the deceleration since 2009, the weight of health expenditure in relation to GDP, on OECD countries, increased from 7,8%, in 2000, to 9,3% in 2011. In this moment, the OECD countries devoted 9,3% of GDP to health.

AN OVERVIEW AT HEALTH SYSTEM

Uni

ted

Sta

tes

Net

herla

nds

Fra

nce

Ger

man

y

Can

ada

Sw

itzer

land

¹

Den

mar

k

Aus

tria

Bel

gium

New

Zea

land

Por

tuga

l

Japa

n ²

Sw

eden

Uni

ted

Kin

gdom

OE

CD

34

Spa

in

Nor

way

Ital

y

Gre

ece

Icel

and

¹

Fin

land

Aus

tral

ia ²

Irel

and

Bra

zil ¹

Slo

veni

a

Sou

th A

fric

a ¹

Slo

vak

Rep

ublic

Hun

gary

Isra

el ¹

Chi

le

Cze

ch R

epub

lic

Kor

ea

Pol

and

Luxe

mbo

urg

Rus

sian

Fed

erat

i...

Mex

ico

¹ ²

Tur

key

³

Est

onia

Chi

na ¹

Indi

a ¹

Indo

nesi

a ¹

0

2

4

6

8

10

12

14

16

18

20

17.7

11.9

11.6

11.3

11.2

11.0

10.9

10.8

10.5

10.3

10.2

9.6

9.5

9.4

9.3

9.3

9.3

9.2

9.1

9.0

9.0

8.9

8.9

8.9

8.9

8.5

7.9

7.9

7.7

7.5

7.5

7.4

6.9

6.6

6.2

6.2

6.1

5.9

5.2

3.9

2.7

Current Capital

% GDP

Health expenditure as a share of GDP, 2011 (or nearest year)

Source: OECD Health Statistics, 2013.

In nearly all OECD countries, the public sector is the main source of health care financing. Around three-quarters of health care spending was publicly financed in 2011. In Denmark, the United Kingdom and Sweden, the central, regional or local governments finance more than 80% of all health spending. In Hungary 64,5% was the share of public health spending (8,5% by the government and 56,0% by Social Security).

Expenditure on health by type of financing, 2011 (or nearest year)

Source: OECD Health Statistics, 2013.

Net

herla

nds

Nor

way

Den

mar

k

Cze

ch R

epub

lic

Luxe

mbo

urg

Uni

ted

Kin

gdom

¹

New

Zea

land

Japa

n

Sw

eden

Icel

and

Est

onia

Ital

y ¹

Aus

tria

Fra

nce

Ger

man

y

Bel

gium

Fin

land

Slo

vak

Rep

ublic

Slo

veni

a

Spa

in

Tur

key

OE

CD

34

Pol

and

Can

ada

Aus

tral

ia

Irel

and

¹

Gre

ece

Por

tuga

l

Sw

itzer

land

Hun

gary

Isra

el

Kor

ea

Uni

ted

Sta

tes

Mex

ico

¹

Chi

le

1. D

ata

refe

r to

...

0

10

20

30

40

50

60

70

80

90

100

8

7385

5 9

8375

9

82

51

11

78

32

4 7 10

60

7 2

68

2735

6

69 68 67

24

64

198

17 11 6

2238

77

12

79 74

8

73

30

69

45

73 70 65

15

67 71

5

4637

65

1

42

1

4656

4546

4325

7

615 13 15 12 10 11 15 17 18 18 18 17

8 12 20 20 2412

21 19 20 2416 20 18

31 29 26 27 25 37

12

4938

62 0

3 5 2 1 514 10

4 214

6 6 113 8 12

3 5 9 3 106

35

417

General Government Social Security Private out-of-pocket Private insurance Other

% o

f cu

rren

t e

xp

en

ditu

re

AN OVERVIEW AT HEALTH SYSTEM

Spending on inpatient care and outpatient care combined accounts for a large proportion of health expenditure in Hungary around 53% of current health expenditure. A further 37% of health spending was allocated to medical goods, 4% on long-term care and the remaining 6% on collective services, such as public health and prevention services and administration.

Current health expenditure by function of health care, 2011 (or nearest year)

Source: OECD Health Statistics, 2013.

Isra

el

Portu

gal

Sweden

United

Sta

tes

¹

Eston

ia

Finlan

d

Czech

Rep

ublic

Japa

n

Greec

e

New Z

ealan

dSpa

in

Poland

Austri

a

OECD27

Luxe

mbo

urg

Denm

ark

Switzer

land

Sloven

ia

Icela

nd

Germ

any

Franc

e

Korea

Norway

Belgium

Slovak

Rep

ublic

Canad

a

Hunga

ry

Nethe

rland

s0

10

20

30

40

50

60

70

80

90

100

26 27 2818

31 30 32 32 3731 26

35 3629 27 29 28 32 29 29

3725 30 30

22 20 25 30

48 45 4251

36 36 35 33 2734 38

28 2833 35 33 34 28 31 30

2233 26 26

33 35 28 22

82 8 6

4 10 4 91

15 11 615 12

21 24 209

1912 11 12

2921

015

4

24

1523 16

14 24 17 24 2231

11 21 2617 20

12 1111

2418

20 21 23

1117

3820

37

15

3 4 6 11 5 7 6 5 410 5 4 5 6 5 3 7 7 4 9 9 7 3 6 6 10 6 9

Inpatient care* Outpatient care** Long-term care Medical goods Collective services%

AN OVERVIEW AT HEALTH SYSTEM

We notice that the costs of healthcare increase in a rhythm superior of the wealth creation. This situation can put in case the sustainability of health systems and of the social welfare.

THE PRESENT SCENARIO OF DIABETES IN EUROPE

It costs Europe EUR 100 – 150

billion annually to manage and treat

diabetes.

Diabetes has a large economic burden on society.

The true cost of diabetes is unknown, as productivity loss is also not precisely

calculated. However, there are wide variations between

the regions of Europe on diabetes spending.

Diabetes and other chronic diseases combined are the cause of 86% of

deaths in Europe.Source: Health Consumer Powerhouse, Euro Diabetes Index, 2014.

SDR, diabetes, all ages, per 100.000

Source: WHO HfA database, April 2014.

THE PRESENT SCENARIO OF DIABETES IN EUROPE

Source: Source: Health Consumer Powerhouse, Euro Diabetes Index, 2014.

• Encourage prevention of disease is one of the most effective health policies. In the last data of Euro Diabetes Index 2014, we observe:

THE PRESENT SCENARIO OF DIABETES IN EUROPE

In general, in most countries, we observe: Scarcity of resources. Threats the right of the healthcare.

Need of Rationing or Priority Setting.

MOTIVATION

Level: micro and

macro

Who should be involved: health professionals,

economists and management and

society.

Carried out: discretionary or

based on technical criteria

RATIONING IN

HEALTH

In general, in most countries, we observe: Scarcity of resources. Threats the right of the healthcare. Need of Rationing or Priority Setting.

MOTIVATION

Discussion: How to establish priorities, mainly between patients?

Over the past decades health economists through the concept of opportunity cost developed technical evaluation methods that compares costs and benefits. The formal allocation method, the cost-effectiveness method, commonly referred cost-utility analysis (CUA) which uses a weighting combination of life expectancy and quality of life (QALY) as a measure of benefit in health.

In accordance with CUA health resources should be allocated such that guarantee the maximization of QALY’s for unit of costs. Utilitarianism principle is implicit in this method by assuming that the best distributive scheme is one that maximizes the number of years of life (healthy) for a given budget.

MOTIVATION

When rationing is evaluate in society point of view, these economic evaluation techniques do not have full acceptance.

In the moment of establishing priorities between patients, besides clinical effectiveness, the society value essentially: Personal characteristics of patients; Gravity of health conditions; Reduction inequalities in health.

MOTIVATION

In the literature review different equity considerations such as: the rule of rescue, the fair-inning, substantive equality of opportunities lottery.

Additionally, the preferences regarding equity criteria to establish priorities between patients vary from country to country.

A possible way to overcome this difficulty would be reconciling technical criteria with a political process of priority setting which would include the participation of all social actors → there is no consensus in the public participation in prioritization decisions.

MOTIVATION

Efficiency versus Equity → challenge.

As the budgetary restraints of countries are becoming more demanding and rationing at the micro level assumes proportions of inevitability it becomes relevant to know which distributional criteria are shared by society as a whole.

The study, that I will present, was carried out in Portugal and explore, through quantitative and qualitative analysis, the ethical principles advocated by society in microallocation of the scarce health care resources.

MOTIVATION

The database resulted from the questionnaire which was available for students (180) and health professionals (60).

The questionnaire is composed by two parts:

i) includes a hypothetical scenario used in another work conducted by Cookson and Dolan (1999), which are presented four patients with different characteristics and health conditions;

ii) socio-demographic description of respondents.

METHODOLOGY

The exercise consists in making an ordering four patients in a context of scarce financial resources and in which only one can be treated.

Additionally should be detailed the reasons that led to these choices.

METHODOLOGY

The main objectives of the paper: Compare the results obtained with Cookson and Dolan

(1999); Explore to which of the rationing principles Portuguese

citizens reveal a major support; Explore if Portuguese distributive concerns conform

with international findings; Explore if public ethical principles differ from those of

health professionals.

OBJECTIVES

The differences of our paper with Cookson and Dolan (1999):

we did an anonymous questionnaire that includes a request for justification. Thus, we obtain a larger number of respondents with no opportunity for discussion of choices.

we applied a qualitative and quantitative analysis; highlight the differences in the responses of students

and health professionals.

OBJECTIVES

This is an individual exercise to highlight the dificculty in prioritising the allocation of scarce resourses. You’ve got 6.500€ which will fund one of the scenarios described – what would spend the money and why?

Patient 1: John is 18 years old and suffered a road traffic accident which resulted in severe facial scarring and psychological problems. Plastic surgery would correct the scarring.

Patient 2: Mary is 45 years old, is single, with no children. She was diagnosed with hepatitis B as a result of their long years of drug consumption. Mary does not consume drugs for 5 years. There is a treatment available, which is 75% effective and it will provide years of quality life.

Patient 3: Rosalina is 65 years old and is almost blind. She is waiting 3 years for a surgery to remove cataracts. Her blindness has worsened over time and soon she will no longer be able to live alone. She has no family. The operation will allow she to be independent.

Patient 4: Peter is 8 years and leukemia. The probability of survival is of 50%. But there is a new treatment available that it has been partially tested in a few cases.

QUESTIONNAIRE

SAMPLE DESCRIPTION

Variables PercentageStudents 75%Course: Economics 29% Law 1% Management 19% Psychology 18% Medicine 8%Health professionals 25%Jobs: Doctors 9% Nurses 8% Pharmaceutical 3% Health technicians 5%GenderFemale 56%Male 44%Age[18, 24] 53%[25, 34] 26%[35, 44] 12%> 44 years old 9%Net monthly incomeLess or equal 850€ 7%[851 and 1500€] 35%[1501€ and 2500€] 28%> 2500€ 30%Lives at urban centerYes 57%No 43%Health Status PerceivedVery good 33%Good 57%Fair 10%Poor 1%Very Bad 0%Serious illness (own person and Yes 55%No 45%ReligiousYes 75%No 25%Tobacco consumptionYes 21%No 65%Occasionally 15%Alcohol consumptionYes 9%No 27%Occasionally 64%Political orientationPCP 1%BE 3%PS 14%PSD 29%PP 20%None 34%

Table 1 – Descriptive statistics

Table 2 - Ranking of the four patients given by students and health professionals, Frequencies and Mann-Whitney tests

Notes: * Significant at the p < 0.05 level; ** significant at the p < 0.01; *** significant at the p < 0.001 level.

StudentsHealth

professionals Z-test Students

Health professionals

Z-test StudentsHealth

professionals Z-test Students

Health professionals

Z-testMean rank

João 23 16 59 14 56 16 45 12 3,35Maria 4 4 24 3 51 20 93 32 2,46Rosalina 20 8 69 31 55 15 33 5 2,23Pedro 130 30 25 11 15 8 6 10 2,1Did not indicate 3 2 3 1 3 1 3 1 -

-1,145

Rank 1 Rank 2 Rank 3 Rank 4

-2,835** 1,193 -0,514

RESULTS

Principles Arguments Freq. (%) StudentsH.

Professionals

Lottery / Raffle / Arrival Order

TOTAL = 2Equal Priority 2 (0.8%) 1 1

Need = CapacityBenefit = Efficiency

TOTAL = 37

Maximize gains in years / life quality

5 (2.1%) 2 3

Effective treatment / more recovery

24 (10%) 16 8

Greater economic contribution

8 (3.3%) 8 0

Clinic NecessityTOTAL = 48

More urgency30

(12.5%)32 8

Pain / Suffering 6 (2.5%) 6 0

Imminence of death 12 (5.5%) 5 7

Social NecessityTOTAL = 26

Fragility / Vulnerability

11 (4.6%) 9 2

Threat of independence

15 (6.3) 12 3

Equal HealthTOTAL = 94

Fair-inning94

(39.2%)82 12

Substantive Equal Opportunities

TOTAL = 1

Penalty risk behaviours

1 (0.4%) 1 0

RESULTS

Table 3. Statistics of the more frequent arguments by occupation

Table 4 – The six rationing principles, Mann-Whitney tests

Notes: * Significant at the p < 0.05 level; ** significant at the p < 0.01; *** significant at the p < 0.001 level.

Principles Z-test Whole sample

P1. Priority in the order of arrival -0,818 0,01 P2. Efficiency in health care -0,513 0,61 P3. “Rule of rescue” -1,485 0,63 P4. Social effects -0,534 0,14

P5. "Fair innings" -3,505*** 0,39 P6. Equality of opportunity -0,577 0,00

RESULTS

Table 5 - The determinants of the choice of the patient, Kruskal-Wallis tests

Hypothesis RelationChi-Square

testp-value Result

H1 The choice of the first patient depends of the activity (students versus health professionals) in the labour market.

7,809 0,005 Accepted

H2 The choice of the first patient depends on the order of arrival (P1). 0,046 0,830

Not accepted

H3 The choice of the first patient depends on the need for efficiency in health care (P2).

67,702 0,000 Accepted

H4 The choice of the first patient depends on the “rule of rescue” (P3). 21,963 0,000 Accepted

H5 The choice of the first patient depends of the social effects (P4). 2,058 0,151

Not accepted

H6 The choice of the first patient depends of the “fair innings” (P5). 19,574 0,000 Accepted

H7 The choice of the first patient depends of the equality of opportunity (P6).

0,366 0,545Not

accepted

RESULTS

Rationing of healthcare has revealed a complex and controversial issue especially at the micro level where choices require treating some patients instead of others.

In our results, we verify that the respondents, both students and health professionals, do not refused to establish priorities among patients.

The society is favorable to become involved in these themes and it can open the opportunity for the development of an explicit process to elaborate a systematic and transparent criteria to establish health priorities.

CONCLUSIONS

We also verify that our results converge to rationing principles internationally accepted.

Respondents value the utilitarian criterion of obtaining the maximum benefit in terms of health, but also to provide for the equitable allocation criteria according to the severity of the health state (rule-of-rescue) and age equalization (fair-inning).

Despite this evidence, it should be noted that the population in general seems more receptive to the principle of fair-inning doctors, who show complacent about the effectiveness of treatments.

CONCLUSIONS

Research in progress: in order to overcome the limitation of our sample of the study presented here, we use the same hypothetical rationing scenario (developed elsewhere by Cookson e Dolan, 1999) but collected data through an on-line questionnaire allowing widening participation to other social actors and the collection of a larger sample.

Future research: it would be interesting to replicate this same test in other countries in order to explore cultural differences and eventually trace pattern common distributive principles.

FUTURE RESEARCH

Thanks for your attention!!!

Ana Pinto Borges, PhD

e-mail: anapintoborges@hotmail.com

Twitter: @AnaPintoBorges

18-19 November 2014, Siófok, Hungary