Developing a Principled Framework for Decision-Making Gopal Sreenivasan Arthur Ripstein University of Toronto
Dec 24, 2015
Developing a Principled
Framework for Decision-Making
Gopal SreenivasanArthur 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 meanings1. everyone is entitled to access2. 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. universal access to health care
2. no tiering (parallel private provision) in health care financing
justice1. universal access
2. 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. what should the national health
budget be?
2. 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. what should the national health
budget be?
2. 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. what should the national health
budget be?
2. 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 requires1. medical necessity2. 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. ‘medical necessity’
2. cost-effectiveness how to define?
moral assessment of existing methodologies December workshop
reform ‘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 basket1. how is this different from
Romanow and Kirby?
2. 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 basket2. 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