Principles versus procedures in making health care coverage decisions: addressing inevitable conflicts

The ethical canary: narrow reflective equilibrium as a source of moral justification in healthcare priority-setting

Healthcare priority-setting institutions have good reason to want to demonstrate that their decisions are morally justified-and those who contribute to and use the health service have good reason to hope for the same. However, finding a moral basis on which to evaluate healthcare priority-setting is difficult. Substantive approaches are vulnerable to reasonable disagreement about the appropriate grounds for allocating resources, while procedural approaches may be indeterminate and insufficient to ensure a just distribution. In this paper, we set out a complementary, coherence-based approach to the evaluation of healthcare priority-setting. Drawing on Rawls, we argue that an institutional priority-setter's claim to moral justification can be assessed, in part, based on the extent to which its many normative commitments are mutually supportive and free from dissonance; that is, on the ability to establish narrow reflective equilibrium across the normative content of a priority-setter's policy and practice. While we do not suggest that the establishment of such equilibrium is sufficient for moral justification, we argue that failure to do so might-like the proverbial canary in the coalmine-act as a generalised warning that something is awry. We offer a theoretical argument in support of this view and briefly outline a practical method for systematically examining coherence across priority-setting policy and practice.

Integrating health technology assessment and the right to health: a qualitative content analysis of procedural values in South African judicial decisions

South Africa's move towards implementing National Health Insurance includes a commitment to establish a health technology assessment (HTA) body to inform health priority-setting decisions. This study sought to analyse health rights cases in South Africa to inform the identification of country-specific procedural values related to health priority-setting and their implementation in a South African HTA body. The focus on health rights cases is motivated in part by the fact that case law can be an important source of insight into the values of a particular country. This focus is further motivated by a desire to mitigate the potential tension between a rights-based approach to healthcare access and national efforts to set health priorities. A qualitative content analysis of eight South African court cases related to the right to health was conducted. Cases were identified through a LexisNexis search and supplemented with expert judgement. Procedural values identified from the health priority-setting literature, including those comprising Accountability for Reasonableness (A4R), structured the thematic analysis. The importance of transparency and revision-two elements of A4R-is evident in our findings, suggesting that the courts can help to enforce elements of A4R. Yet our findings also indicate that A4R is likely to be insufficient for ensuring that HTA in South Africa meets the procedural demands of a constitutional rights-based approach to healthcare access. Accordingly, we also suggest that a South African HTA body ought to consider more demanding considerations related to transparency and revisions as well as explicit considerations related to inclusivity.

Solidarity and cost management: Swiss citizens' reasons for priorities regarding health insurance coverage

Context

Approaches to priority‐setting for scarce resources have shifted to public deliberation as trade‐offs become more difficult. We report results of a qualitative analysis of public deliberation in Switzerland, a country with high health‐care costs, an individual health insurance mandate and a strong tradition of direct democracy with frequent votes related to health care.

Methods

We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex health‐care allocation decisions into easily understandable choices, for use in Switzerland. We conducted focus groups in twelve Swiss cities, recruiting from a range of socio‐economic backgrounds in the three language regions.

Findings

Participants developed strategic arguments based on the importance of basic coverage for all, and of cost‐benefit evaluation. They also expressed arguments relying on a principle of solidarity, in particular the importance of protection for vulnerable groups, and on the importance of medical care. They struggled with the place of personal responsibility in coverage decisions. In commenting on the exercise, participants found the degree of consensus despite differing opinions surprising and valuable.

Conclusion

The Swiss population is particularly attentive to the costs of health care and means of reducing these costs. Swiss citizens are capable of making trade‐offs and setting priorities for complex health issues.

Public participation in decision-making on the coverage of new antivirals for hepatitis C

Purpose - New hepatitis C medicines such as sofosbuvir underline the need to balance considerations of innovation, clinical evidence, budget impact and equity in health priority-setting. The purpose of this paper is to examine the role of public participation in addressing these considerations. Design/methodology/approach - The paper employs a comparative case study approach. It explores the experience of four countries - Brazil, England, South Korea and the USA - in making coverage decisions about the antiviral sofosbuvir and involving the public and patients in these decision-making processes. Findings - Issues emerging from public participation ac tivities include the role of the universal right to health in Brazil, the balance between innovation and budget impact in England, the effect of unethical medical practices on public perception in South Korea and the legitimacy of priority-setting processes in the USA. Providing policymakers are receptive to these issues, public participation activities may be re-conceptualized as processes that illuminate policy problems relevant to a particular context, thereby promoting an agenda-setting role for the public. Originality/value - The paper offers an empirical analysis of public involvement in the case of sofosbuvir, where the relevant considerations that bear on priority-setting decisions have been particularly stark. The perspectives that emerge suggest that public participation contributes to raising attention to issues that need to be addressed by policymakers. Public participation activities can thus contribute to setting policy agendas, even if that is not their explicit purpose. However, the actualization of this contribution is contingent on the receptiveness of policymakers.

Accountability for reasonableness: the relevance, or not, of exceptionality in resource allocation

Accountability for Reasonableness has gained international acceptance as a framework to assist with resource allocation within healthcare. Despite this, one of the four conditions, the relevance condition, has not been widely adopted. In this paper I will start by examining the relevance condition, and the constraints placed on it by Daniels and Sabin. Following this, I review the theoretical limitations of the condition identified to date, by prominent critics such as Rid, Friedman, Lauridsen and Lippert-Rasmussen. Finally, I respond to Daniels and Sabin's enthusiasm for testing the accountability for reasonableness framework in different contexts, by evaluating the challenges of implementing the relevance condition within the NHS. I use the funding of treatments for patients on the basis of their exceptional circumstances as a case study to examine whether the relevance condition could be applied in practice.

Publish or be damned: Individual Funding Requests and the publicity condition

Many jurisdictions have processes to consider Individual Funding Requests but, with few exceptions, the decisions made with respect to these are not made public. Drawing upon Daniels and Sabin's account of the requirements of procedural justice, Accountability for Reasonableness, this paper considers several arguments for and against publishing individual funding request decisions. After briefly reviewing the case for publicity as a requirement of procedural justice and canvassing several arguments against publicity, we consider whether patient confidentiality justifies suppressing funding decisions. We claim that, with one possible exception, publication of individual funding request decisions does not raise concerns that are different in kind from those that apply to publication of legal judgments relating to healthcare, and that the protections instituted in that setting should be sufficient to allow publication of funding decisions. The discussion concludes with several cautionary notes.

Proceduralism and its role in economic evaluation and priority setting in health

This paper provides a critical overview of Gavin Mooney's proceduralist approach to economic evaluation and priority setting in health. Proceduralism is the notion that the social value attached to alternative courses of action should be determined not only by outcomes, but also processes. Mooney's brand of proceduralism was unique and couched within a broader critique of 'neo-liberal' economics. It operated on a number of levels. At the micro level of the individual program, he pioneered the notion that 'process utility' could be valued and measured within economic evaluation. At a macro level, he developed a framework in which the social objective of equity was defined by procedural justice in which communitarian values were used as the basis for judging how resources should be allocated across the health system. Finally, he applied the notion of procedural justice to further our understanding of the political economy of resource allocation; highlighting how fairness in decision making processes can overcome the sometimes intractable zero-sum resource allocation problem. In summary, his contributions to this field have set the stage for innovative programs of research to help in developing health policies and programs that are both in alignment with community values and implementable.

Priority setting in kidney transplantation: A qualitative study evaluating Swedish practices

Background: Transplantation is the treatment of choice for end-stage renal disease; it increases survival and quality of life, while being more cost-effective than dialysis. It is, however, limited by the scarcity of kidneys. The aim of this paper is to investigate the fairness of the priority setting process underpinning Swedish kidney transplantation in reference to the Accountability for Reasonableness (A4R) framework. Methods: Fifteen semi-structured interviews were carried out with transplant surgeons (7), nephrologists (6) and coordinators (2) representing centers nationwide. Collected data was analysed using thematic analysis. To assess fairness in the priority setting process, identified factors were assessed in the reference to the four conditions (publicity, relevance, revision and appeal, enforcement) forming the accountability for reasonableness framework. Results: Decision-making in assessment and allocation is based on clusters of factors. The factors appeal to various values, which are balanced against each other throughout the kidney allocation process: maximizing benefit, priority to the worst off and equality. The factors described by subjects and the values on which they rest satisfy the relevance condition of the accountability for reasonableness framework. However, two potential sources for unfair inequalities in access to treatment are identified: clinical judgment and institutional policies. Conclusions: The development of national guidelines both for assessing transplant candidacy, and for the allocation of kidneys from deceased donors, would contribute to standardize practices across centres; it will also help to better meet the conditions of fairness in reference to Accountability for Reasonableness. The benefits of this policy proposal in Swedish kidney transplantation merits consideration.

To fund or not to fund: development of a decision-making framework for the coverage of new health technologies

BACKGROUND

Attempts to improve the acceptability of resource allocation decisions around new health technologies have spanned many years, fields and disciplines. Various theories of decision making have been tested and methods piloted, but, despite their availability, evidence of sustained uptake is limited. Since the challenge of determining which of many technologies to fund is one that healthcare systems have faced since their inception, an analysis of actual processes, criticisms confronted and approaches used to manage them may serve to guide the development of an 'evidence-informed' decision-making framework for improving the acceptability of decisions.

OBJECTIVE

The purpose of this study was to develop a technology funding decision-making framework informed by the experiences of multiple healthcare systems and the views of senior-level decision makers in Canada.

METHODS

A 1-day, facilitated workshop was held with 16 senior-level healthcare decision makers in Canada. International examples of actual technology funding decision-making processes were presented. Participants discussed key elements of these processes, debated strengths and weaknesses and highlighted unresolved challenges. The findings were used to construct a technology decision-making framework on which participant feedback was then sought. Its relevance, content, structure and feasibility were further assessed through key informant interviews with ten additional senior-level decision makers.

RESULTS

Six main issues surrounding current processes were raised: (i) timeliness; (ii) methodological considerations; (iii) interpretations of 'value for money'; (iv) explication of social values; (v) stakeholder engagement; and (vi) 'accountability for reasonableness'. While no attempt was made to force consensus on what should constitute each of these, there was widespread agreement on questions that must be addressed through a 'robust' process. These questions, grouped and ordered into three phases, became the final framework.

CONCLUSIONS

A decision-making framework informed by processes in other jurisdictions and the views of local decision makers was developed. Pilot testing underway in one Canadian jurisdiction will identify any further refinements needed to optimize its usefulness.

Health technology appraisal and the courts: accountability for reasonableness and the judicial model of procedural justice

Recommendations issued by agencies undertaking appraisals of health technologies at the national level may impact upon the availability of certain treatments and services in some publicly funded health systems, and, as such, have regularly been subject to challenge, including by way of litigation. In addition to expertise in the evaluation of evidence, fairness of procedures has been identified as a necessary component of a claim to legitimacy in such circumstances. This article analyses the assessment of courts in three jurisdictions of the fairness of decision-making by such agencies and evaluates the judicial reading of procedural justice developed in this particular context against the conditions of ‘accountability for reasonableness’.