Transcript Developing a Principled Framework for Decision Making

Developing a Principled
Framework for Decision-Making
Gopal Sreenivasan
Arthur Ripstein
University of Toronto
Medicare Basket

what medical services should
be covered by Canada’s
medicare system?
what should be in?
 what should be out?
 how should this be decided?

‘values’ sub-project

what medical services should
be covered by medicare?

how should this be decided?
 on
basis of what principles?
 on basis of what values?
 ‘Canadian’
values
Romanow report

values served by medicare
equity, fairness [i.e., justice]
 solidarity
 responsiveness
 responsibility
 efficiency
 accountability

focus for today

focus here on justice
 connect
to other Romanow
values in larger paper

what are the requirements of
justice in relation to our health
care system?
justice

what does justice require of a
health care system?
1.
universal access to health care

everyone is entitled to health
care on the basis of need,
without regard to ability to pay
‘universality’

in Canada, ‘universality’ of
health care has two meanings
1.
2.
everyone is entitled to access
ban on tiering (no 2 tier system)

no parallel private sector
 certainly not in financing
 also not in delivery?
justice

what does justice require of a
health care system?
1.
2.
universal access to health care
no tiering (parallel private
provision) in health care
financing
justice
1.
2.

universal access
no tiering (in financing)
this tells us that everyone is
entitled to the same health care
 but not how much care
everyone is entitled to

two questions to ask here
two questions

how much health care should
be covered?
1.
2.
what should the national health
budget be?
what services should be
covered by this budget?
medical ‘necessity’

how much health care should
be covered?
2. whatever services are
‘medically necessary’
1. budget should be sum of cost
of services actually required
mistake

justice actually rejects this
answer, for any strictly medical
definition of ‘necessity’

health is not the only good

balance of goods implies some
independent limit on health
spending
the ordering matters

how much health care should
be covered?
1.
2.
what should the national health
budget be?
what services should be
covered by this budget?
simplification

how much health care should
be covered?
1.
what should the national health
budget be? what % of GDP?


assume 10% (= current %)
or OECD average (9%)
fixed budget

how much health care should
be covered?
1.
2.
what should the national health
budget be?
what services should be
covered by this budget?
priority setting

hence, justice itself requires
some form of rationing from a
fixed budget


that is, priority setting
medical necessity is not a
complete criterion

for inclusion in medicare basket
justice includes efficiency

for inclusion in medicare
basket, justice requires
1.
2.
medical necessity
cost-effectiveness

within limits, does not compete
with justice

cf. ‘efficiency’ as separate value
what else?

for inclusion in medicare basket,
justice requires
1. medical necessity
2. cost-effectiveness
3.
what else?

leave as open question
already implies reform

inclusion in basket requires
1.
‘medical necessity’
already implies reform

inclusion in basket requires
1.
‘medical necessity’


scientific determination
not post hoc label for sectors the
system already covers
already implies reform

inclusion in basket requires
1.
2.
‘medical necessity’
cost-effectiveness

how to define?
 moral assessment of existing
methodologies
 December workshop
reform
1.
2.

‘medical necessity’
cost-effectiveness
criteria apply equally to decisions
 to add a service to basket
 to continue covering a service
already in the basket

same question in justice
example

consider (non-hospital
administered) pharmacare

presently outside of medicare
basket, which is

restricted to ‘hospital and
physician services’
example

pharmacare (outside hospital)

is it ‘medically necessary’?



in scientific sense: yes
in CHA sense: no
but this reflects wrong logic

historical accident vs. principled
rough truth

what follows?

pharmacare should be on a par
with other medically necessary
services

i.e., within the medicare basket
objections

pharmacare should be within
the medicare basket
1.
2.
how is this different from
Romanow and Kirby?
isn’t this simply too expensive?
different from R & K?

they only propose to include
(some form of) catastrophic
coverage for pharmacare

an inferior version of ‘without
regard to ability to pay’

to first dollar coverage by public
single payer insurance
objection 2

pharmacare should be within
the medicare basket
2.
isn’t this simply too expensive?

e.g., won’t this push us over our
assumed budget cap of 10% of
GDP?
too expensive?
i.
even if so, there is no
principled basis for applying
the point only to pharmacare

and not to rest of hospital and
physician services
too expensive?
i.
even if so, there is no
principled basis for applying
the point only to pharmacare

and not to rest of hospital and
physician services

revisit meaning of ‘without
regard to ability to pay’?
too expensive?
ii.
the 10% of GDP figure is total
spending on health


(a) public and (b) private
 7% + 3%
some (most?) pharmacare $ will
just be shifted from (b) to (a)

painless tax increase!
less rough truth
iii.
being on a par with other
medically necessary services


actually means being subject to
a cost-effectiveness criterion
not all pharmacare may qualify

but same applies to rest of (i.e.,
existing) medicare basket