March 5, 2009
By Linda Gorman
To our knowledge, the Oregon Health Plan is the first government health care program anywhere in the world that has drawn up a formal procedure for rationing. After comment from interested parties, this state health program for low-income people ranks treatment for various diseases and conditions, currently from 1 to 680, in order of priority. The health care dollars available determine which priorities are met. As program costs have grown, the list of covered procedures has become shorter.
In 2009, the state will pay only for the first 503 procedures. It won’t pay to remove ear wax, treat vocal cord paralysis, or repair deformities of one’s upper body and limbs. It will fund therapy for conduct disorder (age 18 and under), selective mutism in childhood (a prolonged refusal to talk in social situations where talking is normal), pathological gambling, and mild depression and other mood disorders.
Reordering Priorities. Surprisingly, between 2002 and 2009 there was a fairly radical reordering of the plain language priorities. A great many life-saving procedures that ranked high in 2002 have been relegated to a much lower position in 2009, while procedures that are only tangentially related to life and death have climbed to the top. (While extensive code lists define actual treatment, most people must rely on the plain language to judge list adequacy.)
For example, medical treatment for Type I diabetes, which ranked second in 2002, was demoted to 10th place in 2009. Oddly, given that not providing treatment for Type I diabetes is a death sentence, it has been placed behind spending on smoking cessation, sterilization and drug abuse treatment. And this is not an isolated case.
Routine and Preventive Care First. As of 2009, the rapid and complete treatment of medically correctable problems and diseases has taken a back seat to routine and preventive care. For instance:
Bariatric surgery for people with Type II diabetes and a 35 or greater Body Mass Index (BMI) number is ranked 33rd.
This means that the rationing board thinks that stomach surgery to control obesity is more important than surgery to repair injured internal organs (88), a closed hip fracture (89), or a hernia showing symptoms of obstruction or strangulation (176).
Abortions rank 41st, indicating that the state considers using public money for abortions more important than treating an ectopic pregnancy (43), gonococcal infections and other sexually transmitted diseases (56), or an infection or hemorrhage resulting from a miscarriage (68).
In 2002, when treatments through 566 were funded, there was far more emphasis on actual medical care and measurable interventions that save lives and improve individual functioning. Various interest groups have spent the last seven years reordering the political priorities embodied in the list.
The Ethics of Rationing Are Not so NICE. The Oregon Health Services Commission Web site explains that the 2009 list emphasizes preventive care and chronic disease management because these services are less expensive and often more effective than treatment later in the course of a disease. However, there is no evidence that preventive care will reduce expenditures for the general population. Good evidence for the cost-effectiveness of disease management programs beyond those currently offered by physicians, individuals, insurers and patient groups also remains elusive. Top 15 Priorities in 2009
What is driving the move away from procedures to save lives in immediate danger? Oregon’s prioritized list is drifting toward increasing expenditures for politically popular care. This means preventive care for the healthy and treatment of diseases with active political constituencies. This drift in rationing appears to be unavoidable when political processes are given control over medical decision making.
In Britain, the National Health Service uses the National Institute for Clinical Effectiveness (NICE) to determine which treatments it will offer. Utilitarian analyses of medical cost effectiveness often produce results in conflict with the “rule of rescue,” the presumption that saving the life of someone in imminent danger of dying is more important than improving the quality of life of someone else whose life is not in immediate danger, or of saving hypothetical future lives through prevention efforts.
In 2006, 21 of 27 participants representing the public on the NICE Citizens Council recommended that NICE consider the rule of rescue in making rationing decisions. Their reasoning was simple: Death is final, and the science of preventing disease, prolonging life and promoting health starts with saving life. Although this does not mean that lives must be saved at any cost, it does mean that individuals in desperate circumstances should sometimes receive more help than can be justified by a purely utilitarian approach.
In the summer of 2008, NICE officials officially rejected the advice of the Citizens Council, removing the rule of rescue from any status in its decisions about health care rationing, asserting that “NICE and its advisory bodies must use their own judgement to ensure that what it recommends is cost effective and takes account of the need to distribute health resources in the fairest way within society as a whole.”
Conclusion: Before ceding control of health care rationing to government, Americans should consider the priorities of the political bodies in charge of health programs in Oregon and Britain.
This article originally appeared in the National Center for Policy Analysis, February 19th, 2009.