CURRENT ISSUES

Prioritising healthcare is an economic necessity

- Dr Mo Malek & Tracey Langsdale -

"f"be combined effects of the aging of the population and ongoing technological developments ~ are driving cost inflation in most healthcare systems. Thus, the question becomes not if, but how to ration healthcare resources - this was the central issue discussed at the international conference entitled 'Strategic issues in health care management' [St Andrews, Scotland; March 1994].

The considerable gap in knowledge-based clinical practice and evidence-based healthcare is the single most important obstacle in rational allocation of healthcare resources, according to Professor Alan Maynard from the Centre for Health Economics at the University of York. UK. Currently, it is 'practically impossible 'to define the processes which determine how resources are allocated between competing patients. And despite this ignorance, choices are made every day. What is needed, says Professor Maynard, are explicit techniques that simplify life and death choices.

Prioritisation by age According to Professor Maynard, the American ethicist David Callahan argued that, because of "our insatiable appetite for longer life regardless of expense", there is a need for fair rationing in a manner which sets limits to care. The focus should be on enhanced quality, not quantity, of life. Thus, rationing should be based on a flat age limit (e.g. late 70s) and beyond this point 'the elderly should be deprived of healthcare'. This broad approach has obvious difficulties, notes Professor Maynard: • what is the 'cut-off age' and how is it selected? • should the 'cut-off age' be the same for both sexes?

- this would discriminate against women who live longer, on average

• individuals do not 'depreciate' in an identical way in relation to age; i.e. capacity to benefit is unequal

• capacity to benefit is related to physician skills and technology; e.g. postoperative involvement of anaesthetists improves outcomes in the elderly, suggesting that poor outcomes in this age group reflect poor healthcare and not an inability to benefit.

'Unthinlcing use of age tIS a rationing criterion can kllll to elikrly patients being deprived of CIUY! whose provision may be cost effective' warns Professor Maynard.

Prioritisation by capacity to benefit A well known measure of capacity to benefit is

the QALY. It was developed by the US Office of Technology Assessment in the late 1970s as a measure combining the benefits of enhanced life expectancy and enhanced quality of life. This measure could then facilitate comparison of the impact of different healthcare interventions. This approach has been used to create league tables which rank healthcare interventions. The implication is that resources should be allocated to

interventions with a low costlQALY. There are criticisms of the QALY including a lot of arguing over whether the measures of quality of life used are robust, valid and replicable, points out Professor Maynard.

Prioritisation by 'social utility' An example of this approach is the efforts of the

Oregon Health Services Commission to rank health­care interventions based on cost and effectiveness data. The commission surveyed the literature, consulted expert panels and asked the community about how they valued different health states before producing several league tables over the period 1991-1993. The 1993 Oregon Priorities list contains 745 diagnoses in descending order of effectiveness, as determined by the commission. Treatment will be provided only for patients whose diagnoses are above the budget line.

The major hurdle for the commission was the lack of a knowledge base, says Professor Maynard. The Oregon priorities were essentially 'guesses' about effectiveness and social judgements about 'reasonableness', requiring grouping of some categories without regard to risk and effectiveness, and ignoring costs.

Some practical issues in priority setting

Although specific methodologies for prioritisation exist, there is little discussion or consideration of the wider theoretical and practical issues which 'underpin' the whole process, according to Dr Joanna Coast and Ms Jenny Donovan from the University of Bristol, UK. • Most important, and requiring careful examination, are

the principles behind any method of prioritisation -efficiency, equity, effectiveness, consumerism. If more than one principle is used, the question of how to trade one against the other must be answered.

• Heatthcare purchasers must decide whether to set priorities between individuals or interventions.

• Data requirements should be realistic and practicable. • The prioritisation process must be acceptable to all

parties influencing ns implementation. This can be achieved by increased communication and involvement of the relevant parties. Earlier attempts at setting priorities have often failed

to consider these concepts and they are still being ignored by some of those currently setting priorities. Only after these concepts are recognised and fully defined will n be possible to adopt appropriate and successful methods for setting priorities.

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CURRENT ISSUES

'To make choices properly the value of wluzt is given up (the cost) hils to be

balanced against the value of what is gained (enhanced health status).'

Professor Alan Maynard, Centre for Health Economics at the University of York, UK.

Despite the problems, a ranking was achieved. Now the challenge is to ensure that future lists are based increasingly on knowledge and less on guess work.

Aim for evidence-based healthcare Unfortunately, two factors work together to

ensure that prioritisation cannot be based on cost­effectiveness data, says Professor Maynard; the reluctance of policy makers and practitioners to consider economic evaluation seriously - while ignoring the fact that the cost of ignorance may be higher - and the poor quality of practice in research and development.

A major flaw in economic evaluations arises when economists use clinical data uncritically. This in turn leads to the creation of ambitious economic modelling ' ..• on the sands of inadequate evidence about effectiveness'. 1

[See PharmacoResources 7: 4, 18 Jun 1994] However, new knowledge is accruing and in time will facilitate priority setting, making it more robust than current guess work, says Professor Maynard. And while lack of knowledge slows improvements in calculating QALYs and in setting priorities following the Oregon approach, these methods are explicit and throw up a challenge to do better and further their development.

Using health gain as a focus Priority setting should be based on health gain,

according to Professor Charles Normand from the London School of Hygiene and Tropical Medicine, UK. He lists 3 dimensions to the concept of health gain: • improved life expectancy • improved health-related quality of life • the quality of 'the experience of being a patient'.

Importantly, health gain provides a basis for setting priorities and assisting policy makers to focus on success rather than 'worthy effort'.

'Whereas few would oppose the aggressive use of evidence in assessing the safety of new treatments, there renuzins a greater

wUlingness to see ineffective and relatively ineffective practice and priorities. '

Professor Charles Normand, London School of Hygiene and Tropical Medicine, UK.

A common concern about using health gain as the criterion for prioritisation is the emphasis on efficacy at the expense of equity. In fact. some of the support for less scientific/more political approaches to prioritisation comes from considerations of equity.

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Provided there is no fall in total health gain then consideration of equity may be appropriate, points out Professor Normand. However, if a smaller total health gain is chosen to facilitate a more equal distribution, then this needs to be ta clear and transparent decision', he adds.

'Weak' evidence vs no evidence A common argument is that changes to the use of

healthcare resources should await better evidence. Not so, says Professor Normand - we should prefer 'weak' evidence to no evidence at all. Shifting research and research priorities to meet the needs of healthcare prioritisation is a slow process. Also, mechanisms which give access to high priority patients, and deny it to low priority patients, are needed. And one mechanism that merits more attention is discouragement of patients with a low priority for care.

Constraints to prioritisation on the basis of health gain arise from poor evidence, weak policy levers and political opposition. Encouragment and funding of well-focused research will answer the first point. And while it may be necessary to accommodate 'the political and policy environment', Professor Normand still believes that the aim should be to achieve priorities on the basis of health gain. 1. Freemantle N. et aI. Something rotten in the state of clinical and economic evaluations? Health Economics 3: 63-67, Mar-Apr 1994 """ .. "'"

r"... D; ~o Malek is Director of the Pharmacoeconomics Research Centre at the University of St Andrews,

I Scotland. He is also a reader in Health Policy, % Planning and Management at the university.

I Dr Malek was chairman of the conference faculty. Selected papers from the conference were published

@ by John Wiley & Sons under 'Setting Priorities in Health Care', edited by Dr Malek.

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