891
PUBLIC HEALTH
Priority setting: lessons from Oregon
The state of Oregon has developed a unique method to set priorities for health services. The method is based on a cost-utility formula but also incorporates public attitudes and values. Using an explicit process, the Oregon Health Services Commission has completed the ranking of 714 conditiontreatment pairs. The background, methods, and criticisms of the Oregon approach highlight key questions for managers and physicians in other health services when they allocate limited resources.
From
April 1, 1991, the regional health authorities and district health authorities (DHAs) of the British (RHAs) National Health Service began to shift their funding from a system based on historical patterns of service to one based on the size and composition of the populations served.’ This, and a new distinction between purchasers and providers, will encourage RHAs and DHAs to make more explicit choices about what services they can afford to purchase for their populations. Evidence that this is already beginning to happen is the advice from North East Thames RHA that its districts should curtail five treatments-for varicose veins, non-malignant "lumps and bumps", wisdom teeth, tattoo removal, and in-vitro fertilisation-when there is no "overriding" clinical need.2,3 Regional officers and physicians are busy preparing a list of procedures that might not be offered in the future, and the NHS Chief Executive is encouraging other regions to follow suit.4 As the NHS considers more carefully how to distribute its resources, it should give thought to recent events in the USA. On Feb 20, 1991, the state of Oregon released a priority list which ranked over 700 treatments. 5,6 The list is the culmination of a unique and highly visible process for setting health care priorities-initiated by a 1989 law7 designed to rationalise the distribution of health resources. Senate Bill 27 (SB 27) created a Health Services Commission charged with formulating an explicit method for setting priorities in medical services-based, in part, on public input.
Background In 1987, Oregon withdrew Medicaid coverage for organ transplantation (bone marrow, heart, liver, and pancreas) and chose instead
to
extend coverage
to an extra
1500 poor
and children.8 Medicaid (the health insurance programme for the poor) was targeted because it is the only US insurance programme for which individual states have women
substantial financial responsibility and control. In the past, Oregon had rationed Medicaid resources in much the same way as the other 49 states, by limiting eligibility and by lowering provider reimbursement. Both reduce access for the poor. The decision to stop organ transplantation marked a new strategy-rationing of the benefits provided. The initial media coverage was negligible, but national attention was attracted in November, 1987, when a seven-year-old boy with acute lymphocytic leukaemia failed to qualify for a bone marrow transplant and died before funds could be raised for treatment in the transplant facility. A state senator, Robert Shoemaker, described the rationale of the legislative decision: "There is only so much money. If you balance a bone marrow transplant for one boy against prenatal care for hundreds of poor, pregnant women, you 9 come out in favour of poor, pregnant women".9 The decision to stop funding the transplantation programme was made with little input from either the public or health professionals. John Kitzhaber, state senate president and local emergency-room physician, acknowledged the arbitrary nature of the decision. Kitzhaber drew up SB 27 to ensure that decisions on the distribution of public dollars would be made more rationally and openly.
Legislation SB 27
acts to
increase
access to
health
care
for the poor while
controlling costs. It expands Medicaid eligibility to all persons with income below the federal poverty level-an extra 120 000 new Medicaid recipients. Furthermore, it facilitates access by increasing Medicaid reimbursements closer to costs incurred by physicians: Oregon previously had one of the lowest reimbursement rates in the US. The bill encourages efficiency by promoting prepaid managed health care contracts for all the services funded under the bill.10 In addition, it calls for the development of a health service priority ranking to help define a benefit package for recipients.
ADDRESSES Commonwealth Fund, New York, NY, USA; and North West Thames Regional Health Authority, UK (J. Dixon, MB, MSc); Departments of Medicine and Community and Family Medicine, Dartmouth Medical School and White River Junction VA, White River Junction, Vermont, USA (H G Welch, MD, MPH). Correspondence to Dr J Dixon, Harkness Fellow, Commonwealth Fund, 1 East 75th St, New York, NY 10021-2692, USA.
892
Under SB 27, all medical services available under Medicaid are listed in order of priority by the Health Services Commission. The legislature then decides how much of the list can be afforded, starting with the highest priority services, but (under SB 27) cannot alter the ranking order. The level of funding will defme the total benefit package-dwindling resources allocated to health care will reduce the benefits, but not the number of total recipients. If there is not enough money to pay for the whole list, lower-priority services will be dropped from the package. Politicians therefore, by choosing the level of funding, would have the final say in deciding which benefits would be eliminated. The earlier political decision of eliminating transplantation coverage could be reversed if the procedure was ranked sufficiently high.
OREGON’S RANKING OF SELECTED CONDITION-TREATMENT PAIRS I
Ranking methodology How exactly to draw up priorities was left to the eleven-member Health Services Commission. SB 27 did not specify a ranking methodology-only that there must be public input. Before the bill was passed, a demonstration project illustrated to the Commission and the legislature how one method to set priorities might work." The Medicaid population was divided into four
segments-children aged 0-17 years, women of reproductive age, adults aged 18-64, and the elderly (age 65 years and older). A panel of health care professionals and community volunteers ("focus group") was assigned to each of the four population segments and prepared a list of services typically offered to that population. Each focus group then ranked the services in order of effectiveness of the treatment using a consensus methodology. An executive group blended the rankings from all four focus groups in one master list. Interestingly, transplantation was at the bottom, near cosmetic surgery.
Both the focus groups and the executive group referred to decision principles drawn up by Oregon Health Decisions-a community-based organisation which had elicited public values on health care in the past. These principles took into account the trade-off between length of life and quality of life, efficiency and equity, and the cost and benefit of the service. The project demonstrated to legislators that priority setting was possible. But soon after its inception the Commission rejected the consensus approach used because it was not explicit enough. In its place, a cost utility method was used. In addition the Commission wanted to solicit public input to guide the ranking. The cost utility method takes into account three principal factors--(a) how much a treatment costs; (b) what improvement in a person’s quality of life it is likely to produce; and (c) how many years that improvement will probably last. The costs of treatments were obtained from the agency that runs Oregon’s Medicaid programme. The quality of life both with and without treatment and the duration of treatment with therapy were obtained by consulting medical specialists and from medical publications. These outcomes for different diagnoses were also weighted by a factor that formally incorporated public attitudes towards disability.
Public
input
Public input to guide the ranking was sought in three areas. First, public satisfaction with a variety of disability states was obtained from a random telephone survey of over one thousand Oregonians. In this survey, respondents were asked to rate 26 disabling states on a scale of 1-100 according to how happy/satisifed they would be with the disability. Examples of disabling states included: "You can be taken anywhere but have to be in bed or in a wheelchair controlled by someone else, need help to eat or go to the bathroom, but have no other health problems"; and "you can go anywhere and have no limitations of physical or other activity, but you cough, wheeze or have trouble breathing". The results were collated into a weighting factor per level of disability and applied to the closest probable outcome in the cost utility formula. Second, values placed on nine broad service categories (for example, "treatment of conditions which are fatal and can’t be cured-the treatment will not extend the person’s life for more than five years"; and "treatment for alcoholism or drug addiction") were obtained from 47 public meetings held across the state. Oregon
*Categories. 2 = maternity care (including care for newborn m first 28 days of life), 5=chromc fatal conditions (treatment improves lifespan and wellbeing); 11= chronic, non-fatal conditions (one-time treatment improves wellbemg), 15 = infertility services; and 17 = fatalor non-fatal conditions (treatment produces little or no improvement in wellbeing). tProcedures which may no longer be offered in North East Thames R HA (removal of tattoos and removal of non-malignant lumps and bumps do not appear on the list)
Health Decisions organised each meeting.12 The participants were asked to assign each service category into one of three groupsessential, very important, or important. The values that guided the groupings were then identified and discussed. From experience at the meetings, Oregon Health Decisions distilled thirteen fundamental values, including "quality of life", "prevention", and "cost effectiveness". Although over a thousand Oregonians attended, two-thirds were college graduates and fewer than 50 were Medicaid recipients. More than two-thirds were health care employees.12 These thirteen values guided the Commission in the construction of the priority list. Third, input on any specific service was solicited at seven public hearings held by the Commission. This allowed special pleading by individuals and interest groups. The results of this process were also used to shape the final ranking.
Results After some delay, in May, 1990, a preliminary computergenerated priority list was released. The list ranked 1600 medical treatments and contained serious flaws. The major difficulties related to inaccurate cost and effectiveness data. This led to some widely criticised rankings: reconstructive breast surgery was ranked more highly than treatment for open fracture of the thigh, and treatment for crooked teeth came higher than treatment for Hodgkin’s lymphoma. Transplantation was again near the bottom of the list as was treatment for AIDS—primary care was near the top. There was widespread unhappiness with the ranking both inside and outside Oregon. Some local figures suggested that the list should be abandoned. Commission member, Rick Wopat, MD, voiced a general frustration: "The data are so inadequate... if we want to use the formula system, we have to start collecting data all over again"."
893
Others, including some members of the Commission, felt it
might be better to separate the overall list into categories of treatment and rank each category-to make the ranking more meaningful and manageable. Private insurance firms were asked to advise on the pricing of certain treatments. The Commission decided to split into two subcommittees to work separately towards creating a priority list. One, headed by Wopat, looked at new methods for drawing up priorities, including a consensus-building approach. The other subcommittee tried to find a way to make the cost-utility method work. The priority list was fmalised by the Commission on Feb 20,1991, and contains 714 condition-treatment pairs. Both cost-utility and consensus approaches were used. All the condition-treatment pairs to be ranked were subdivided into 17
categories-for example, maternity
care;
infertility
services; chronic fatal conditions (treatment improves and quality of wellbeing); chronic non-fatal conditions (one-time treatment improves quality of wellbeing); and fatal or non-fatal conditions (treatment produces little or no improvement in quality ofwellbeing).6 In each category, the Commission first ranked conditiontreatment pairs according to the benefit produced by treatment only, and then incorporated the cost of treatment and duration of benefit. A final ranking for each category was arrived at by incorporating public values (obtained from the public meetings and hearings) and the consensus view of Commission members. The categories were then blended into one list and amended by the "clinical and public policy judgement" of the Commission.6 The table gives some examples of Oregon’s fmalised rankings. Of the five treatments recommended for exclusion by North East Thames RHA, two (varicose veins and in-vitro fertilisation) appeared in the lower third of Oregon’s ranking, and removal of wisdom teeth (non-infected) appeared in the middle third. The remaining two (removal of tattoos and non-malignant lumps and bumps) do not appear on the list. In contrast with earlier rankings, heart, liver, and bone marrow transplantation generally appeared in the middle third of the list. However, liver transplantation in alcoholic patients received a low rank. According to the Commission’s executive director, Paige Sipes-Metzler, this poor ranking was mostly due to low effectiveness of the procedure in these patients. Cataract removal and hip replacement, both having relatively long waiting lists in the UK, appear in the middle third of Oregon’s ranking. Mental health disorders and treatments have not yet been assigned priorities. Even if the priority list is acceptable, the legislature must decide how much of it can be afforded. Oregonians have lately voted for a property tax limitation and additional federal monies are not forthcoming; thus, state revenues have declined sharply. The legislature hopes to have the plan operational by July, 1992.
lifespan
Criticisms Criticisms of Oregon’s plans abound. US Congressman
Henry Waxman, who chairs the house subcommittee that oversees the Medicaid programme, has repeatedly indicated his opposition and refuses to hold public hearings until the benefit package is defined by the state legislature. US Senator Al Gore criticised the state for failing to examine wasteful expenditures in health care, for not raising new taxes, and for refusing to shift money from other state programmes. 14 Others have pointed out that the bill does not apply to all the Medicaid population, but just to poor women and
children, and that the elderly are exempted. Some suggest that the elderly have been left out because of their political influence,15 while others maintain that the service provided to these groups by Medicaid is generally long-term care that has not been ranked."
Furthermore, Oregon’s plans have rekindled an old debate over denial of medical care. There is disagreement whether improving efficiency will be enough for an affordable health care system or whether setting limits is necessary.1S,17-19 Victor Fuchs, a prominent US economist, argues that rationing of care exists already and ought to be more systematic, but should be done implicitly at the patient-physician level.10 Senator Kitzhaber, however, rejects an implicit approach because it reflects no social policy and is done "silently and by default".21 The priority-setting process itself has attracted criticism. Many are unhappy with the concept of rationing based only on cost and benefit data. Arnold Relman argues that any rationing process ought to have ethical input as well. 18 There are worries that the effectiveness data required by a formula approach are seriously inadequate and may always be so. The inevitable difficulty of making a formula sensitive to individual patients22 creates a dilemma for physicians and denies a voice to the patient. While the criticisms of Oregon’s plans are plentiful, alternative solutions have been conspicuously absent.
Analysis Although Oregon’s plan is being applied only to one segment of the population, the experience is relevant to a universal health programme such as the NHS and flags up three questions for managers and physicians. Should rationing be implicit or explicit? While the debate over whether or not to set limits to health rages endlessly in the US, the NHS has always had to grapple with a fixed budget. Faced with limited resources, the health service is always making choices. Whether or not we accept the word rationing, it must be acknowledged that underfunding of services, long queues, and "never-never lists" are an implicit means to limit services. The Oregon experiment offers an alternative: make the choices explicit, and base them on systematic rather than ad-hoc methods. Implicit rationing (or limit setting) in the NHS has the advantage of being more politically expedient and more flexible than Oregon’s explicit priority list. But, while it concentrates decision-making in the hands of physicians, it also forces physicians to set the limits. Explicit rationing in the NHS, on the other hand, would have the advantage of being universally applied (within regions) and would free physicians from having to discriminate among patients. Simply by being explicit, this type of rationing will foster energetic public and professional debate about societal care
priorities. Not only were Oregon’s priorities explicit, but so was the process used to identify them. This is in distinct contrast with North East Thames
RHA, where the list of excluded
produced by an unidentified process. If other regions use hidden methods to exclude services, widely differing priorities could result, and treatment-shopping (by general practitioners and patients) across regional or district boundaries might become troublesome. While this may be a feature of the internal market, it will lead to a less equitable service. An explicit methodology may make choices more services
was
consistent.
894
Despite the criticisms of Oregon’s experiment, some services may well be suitable for explicit rationing. A BBC survey of 75 public health directors in England and Wales showed wide agreement that liver transplantations and aggressive treatment for advanced lung cancer are low priorities.4 One British practitioner has suggested treatments for minor, self-limiting, and self-inflicted conditions as potential candidates for explicit rationing.23 Should public input be solicited in priority setting?
Although processes exist for public input in health service planning in Britain (for example, the community health councils), there has been no systematic attempt to obtain information about societal preferences for medical treatments. The notion that "money will follow the patient" in a reformed NHS promises that public choices about medical treatments will be expressed in an internal market. But patients may instead follow the money24 and their choices may be altered by many factors before being expressed as consumer demand. Because a free market is neither feasible nor desirable, there is a case for involving the public in guiding the DHAs and RHAs in the services they ought to be buying, how much of them and where. By its use of random telephone surveys and structured public meetings, the state of Oregon demonstrates how public consensus on health issues might be developed.25 We agree with others26 that these efforts are laudable. By focusing on broad values (towards general services and disability states), organisers of the process tried to avoid personal interests and inherent prejudice. Their experience, however, points to a potential pitfall of the process: participants in open meetings may not be representative of the population at large and may include a disproportionate number of health care employees. Any effort to transfer Oregon’s approach to soliciting public input across the Atlantic
should
include
mechanisms
to
ensure
representative sampling. DHAs are already conducting wholesale "needs assessment"-why not a "public choice" assessment? Can priority setting be made more quantitative?
Oregon’s cost-utility approach represents a first attempt to operationalise a medical/scientific solution to resource allocation.27,28 Unfortunately, even simple questions such as "what works?" and "what does it cost?" require data. Trying to incorporate the dual concerns of quality of life and public values compounds the difficulties-not only because of the dearth of data on these inputs but also because it is unclear how best to give them mathematical weight. But decisions must and will be made. They cannot wait for perfect data and perfect methods. The efforts in Oregon are to be commended for giving some method a try. It is on those who say this method does not work18,22,29 to come up with some alternative. While methods to improve efficiency are rightly being pursued and will free resources for use elsewhere in the NHS, they do not obviate the need to make priorities. The Department of Health is now encouraging RHAs to consider a quality-adjusted-lifeyear approach to making choices.4 If such choices are to be explicit, the process that produces them ought to be public and systematic (though not necessarily mathematical). One place to start would be to ask how North East Thames RHA chose to advise its DHAs to curtail treatment for varicose veins, non-malignant lumps and bumps, wisdom teeth, tattoos, and in-vitro fertilisation.
incumbent
REFERENCES 1. Working for Patients. London: HM Stationery Office, 1989. 2. Brindle D. Patients face rationing for treatment. Guardian Weekly Feb 3, 1991. 3. Dean M. End of a comprehensive NHS? Lancet 1991; 337: 351-52. 4. Dean M. Is your treatment economic, effective, efficient? Lancet 1991; 337: 480-81. 5. Egan T. Oregon shakes up pioneering health plan for the poor. New York Times Feb 22, 1991. 6. Health Services Commission. The prioritised health services list. Salem: HSC, February, 1991. 7. Senate Bill 27, Oregon Legislative Assembly, 1989. 8. Welch HG, Larson EB. Dealing with limited resources: the Oregon decision to curtail funding for organ transplantation. N Engl J Med 1988; 319: 171-73. 9. Shoemaker R. Quoted in: Legislation in Oregon to ration health care for the indigent. Med Ethics Advisor 1989; 5: 88-91. 10. Welch WP. Giving physicians incentives to contain costs under Medicaid. Health Care Financing Rev (in press). 11. The Oregon Medicaid Priority-Setting Project. Portland: Medical Research Foundation of Oregon, 1989. 12. Health care in common-report of the Oregon Health Decisions community meetings process. Portland: Oregon Health Decisions, 1990. 13. O’Neill P. State health plan for the poor stalls. The Oregonian, June 15, 1990. 14. Gore A. Oregon’s bold mistake. Academic Med 1990; 65: 634-35. 15. Vladeck BC. Simple, elegant and wrong. President’s letter, United Hospital Fund of New York, September, 1990. 16. Packwood B. Oregon’s bold idea. Academic Med 1990; 65: 632-33. 17. Callahan D. Rationing medical progress-the way to affordable health care. N Engl J Med 1990; 322: 1810-13. 18. Relman AS. The trouble with rationing. N Engl J Med 1990; 323: 911-13. 19. Reagan MD. Health care rationing and cost containment are not synonymous. Policy Studies Rev 1990; 9 (winter): 219-31. 20. Fuchs VR. The rationing of medical care. N Engl J Med 1984; 311: 1572-73. 21. Kitzhaber J. Discussion paper Senate Bill 27. August, 1989. 22. Schwartz WB, Aaron HJ. The Achilles heel of health care rationing New York Times July 9, 1990. 23. Ford S. Rationing health care. Br Med J 1991; 302: 288. 24. Quam L. Improving clinical effectiveness in the NHS: an alternative to the white paper. Br Med J 1989; 299: 448-50. 25. Cranshaw R, Garland M, Hines B, Anderson B. Developing principles for prudent health care allocation: the continuing Oregon experiment. West J Med 1990; 152: 441-46. 26. Kelly G. Rationing health care. Br Med J 1991; 302: 288. 27. Duggan JM. Resource allocation and bioethics. Lancet 1989; i: 772-73. 28. Kitzhaber J. The Oregon health initiative. Lancet 1989; ii: 106. 29. Hollingsbaum F. Rationing health care. Br Med J 1991; 302: 288-889.
From The Lancet Bank notes and infection
Passing from hand to hand among all classes of the people, it would be strange, indeed, if money, and especially paper money, did not in its transit become from time to time the vehicle of infectious disease. Even the crisp "fiver" of the Bank of England no doubt has often borne the germs of fever in its folds, and how much more then the greasy, discoloured, and well-thumbed one pound note, or the paper fraction of some foreign currencies. Higher values have here a distinct advantage. Less common, less in keeping of the overcrowded poor, less handled and soiled therefore they may, perhaps, in many cases run their circuit without having done much mischief. There are, indeed, preservative circumstances which guard the sanitary credit of all paper currency. One is the very freedom of circulation and the ventilation this ensures. Smoothness of surface is another; and a third, which operates in a minor degree, is found in the fact that adults, not children, are chiefly concerned in the business of exchange. These qualifications may suffice to justify, at least by a negative verdict, the employment of paper money from a sanitary standpoint. Still, a certain risk remains, and careful persons will do well to note this, and on occasion to disinfect even their bank notes. The danger, such as it is, should also, in our opinion, be allowed some weight in deciding the question whether a small note currency hitherto not found to be indispensable should or should not be generally adopted. (Feb 7, 1891)
PUBLIC HEALTH
Priority setting: lessons from Oregon
The state of Oregon has developed a unique method to set priorities for health services. The method is based on a cost-utility formula but also incorporates public attitudes and values. Using an explicit process, the Oregon Health Services Commission has completed the ranking of 714 conditiontreatment pairs. The background, methods, and criticisms of the Oregon approach highlight key questions for managers and physicians in other health services when they allocate limited resources.
From
April 1, 1991, the regional health authorities and district health authorities (DHAs) of the British (RHAs) National Health Service began to shift their funding from a system based on historical patterns of service to one based on the size and composition of the populations served.’ This, and a new distinction between purchasers and providers, will encourage RHAs and DHAs to make more explicit choices about what services they can afford to purchase for their populations. Evidence that this is already beginning to happen is the advice from North East Thames RHA that its districts should curtail five treatments-for varicose veins, non-malignant "lumps and bumps", wisdom teeth, tattoo removal, and in-vitro fertilisation-when there is no "overriding" clinical need.2,3 Regional officers and physicians are busy preparing a list of procedures that might not be offered in the future, and the NHS Chief Executive is encouraging other regions to follow suit.4 As the NHS considers more carefully how to distribute its resources, it should give thought to recent events in the USA. On Feb 20, 1991, the state of Oregon released a priority list which ranked over 700 treatments. 5,6 The list is the culmination of a unique and highly visible process for setting health care priorities-initiated by a 1989 law7 designed to rationalise the distribution of health resources. Senate Bill 27 (SB 27) created a Health Services Commission charged with formulating an explicit method for setting priorities in medical services-based, in part, on public input.
Background In 1987, Oregon withdrew Medicaid coverage for organ transplantation (bone marrow, heart, liver, and pancreas) and chose instead
to
extend coverage
to an extra
1500 poor
and children.8 Medicaid (the health insurance programme for the poor) was targeted because it is the only US insurance programme for which individual states have women
substantial financial responsibility and control. In the past, Oregon had rationed Medicaid resources in much the same way as the other 49 states, by limiting eligibility and by lowering provider reimbursement. Both reduce access for the poor. The decision to stop organ transplantation marked a new strategy-rationing of the benefits provided. The initial media coverage was negligible, but national attention was attracted in November, 1987, when a seven-year-old boy with acute lymphocytic leukaemia failed to qualify for a bone marrow transplant and died before funds could be raised for treatment in the transplant facility. A state senator, Robert Shoemaker, described the rationale of the legislative decision: "There is only so much money. If you balance a bone marrow transplant for one boy against prenatal care for hundreds of poor, pregnant women, you 9 come out in favour of poor, pregnant women".9 The decision to stop funding the transplantation programme was made with little input from either the public or health professionals. John Kitzhaber, state senate president and local emergency-room physician, acknowledged the arbitrary nature of the decision. Kitzhaber drew up SB 27 to ensure that decisions on the distribution of public dollars would be made more rationally and openly.
Legislation SB 27
acts to
increase
access to
health
care
for the poor while
controlling costs. It expands Medicaid eligibility to all persons with income below the federal poverty level-an extra 120 000 new Medicaid recipients. Furthermore, it facilitates access by increasing Medicaid reimbursements closer to costs incurred by physicians: Oregon previously had one of the lowest reimbursement rates in the US. The bill encourages efficiency by promoting prepaid managed health care contracts for all the services funded under the bill.10 In addition, it calls for the development of a health service priority ranking to help define a benefit package for recipients.
ADDRESSES Commonwealth Fund, New York, NY, USA; and North West Thames Regional Health Authority, UK (J. Dixon, MB, MSc); Departments of Medicine and Community and Family Medicine, Dartmouth Medical School and White River Junction VA, White River Junction, Vermont, USA (H G Welch, MD, MPH). Correspondence to Dr J Dixon, Harkness Fellow, Commonwealth Fund, 1 East 75th St, New York, NY 10021-2692, USA.
892
Under SB 27, all medical services available under Medicaid are listed in order of priority by the Health Services Commission. The legislature then decides how much of the list can be afforded, starting with the highest priority services, but (under SB 27) cannot alter the ranking order. The level of funding will defme the total benefit package-dwindling resources allocated to health care will reduce the benefits, but not the number of total recipients. If there is not enough money to pay for the whole list, lower-priority services will be dropped from the package. Politicians therefore, by choosing the level of funding, would have the final say in deciding which benefits would be eliminated. The earlier political decision of eliminating transplantation coverage could be reversed if the procedure was ranked sufficiently high.
OREGON’S RANKING OF SELECTED CONDITION-TREATMENT PAIRS I
Ranking methodology How exactly to draw up priorities was left to the eleven-member Health Services Commission. SB 27 did not specify a ranking methodology-only that there must be public input. Before the bill was passed, a demonstration project illustrated to the Commission and the legislature how one method to set priorities might work." The Medicaid population was divided into four
segments-children aged 0-17 years, women of reproductive age, adults aged 18-64, and the elderly (age 65 years and older). A panel of health care professionals and community volunteers ("focus group") was assigned to each of the four population segments and prepared a list of services typically offered to that population. Each focus group then ranked the services in order of effectiveness of the treatment using a consensus methodology. An executive group blended the rankings from all four focus groups in one master list. Interestingly, transplantation was at the bottom, near cosmetic surgery.
Both the focus groups and the executive group referred to decision principles drawn up by Oregon Health Decisions-a community-based organisation which had elicited public values on health care in the past. These principles took into account the trade-off between length of life and quality of life, efficiency and equity, and the cost and benefit of the service. The project demonstrated to legislators that priority setting was possible. But soon after its inception the Commission rejected the consensus approach used because it was not explicit enough. In its place, a cost utility method was used. In addition the Commission wanted to solicit public input to guide the ranking. The cost utility method takes into account three principal factors--(a) how much a treatment costs; (b) what improvement in a person’s quality of life it is likely to produce; and (c) how many years that improvement will probably last. The costs of treatments were obtained from the agency that runs Oregon’s Medicaid programme. The quality of life both with and without treatment and the duration of treatment with therapy were obtained by consulting medical specialists and from medical publications. These outcomes for different diagnoses were also weighted by a factor that formally incorporated public attitudes towards disability.
Public
input
Public input to guide the ranking was sought in three areas. First, public satisfaction with a variety of disability states was obtained from a random telephone survey of over one thousand Oregonians. In this survey, respondents were asked to rate 26 disabling states on a scale of 1-100 according to how happy/satisifed they would be with the disability. Examples of disabling states included: "You can be taken anywhere but have to be in bed or in a wheelchair controlled by someone else, need help to eat or go to the bathroom, but have no other health problems"; and "you can go anywhere and have no limitations of physical or other activity, but you cough, wheeze or have trouble breathing". The results were collated into a weighting factor per level of disability and applied to the closest probable outcome in the cost utility formula. Second, values placed on nine broad service categories (for example, "treatment of conditions which are fatal and can’t be cured-the treatment will not extend the person’s life for more than five years"; and "treatment for alcoholism or drug addiction") were obtained from 47 public meetings held across the state. Oregon
*Categories. 2 = maternity care (including care for newborn m first 28 days of life), 5=chromc fatal conditions (treatment improves lifespan and wellbeing); 11= chronic, non-fatal conditions (one-time treatment improves wellbemg), 15 = infertility services; and 17 = fatalor non-fatal conditions (treatment produces little or no improvement in wellbeing). tProcedures which may no longer be offered in North East Thames R HA (removal of tattoos and removal of non-malignant lumps and bumps do not appear on the list)
Health Decisions organised each meeting.12 The participants were asked to assign each service category into one of three groupsessential, very important, or important. The values that guided the groupings were then identified and discussed. From experience at the meetings, Oregon Health Decisions distilled thirteen fundamental values, including "quality of life", "prevention", and "cost effectiveness". Although over a thousand Oregonians attended, two-thirds were college graduates and fewer than 50 were Medicaid recipients. More than two-thirds were health care employees.12 These thirteen values guided the Commission in the construction of the priority list. Third, input on any specific service was solicited at seven public hearings held by the Commission. This allowed special pleading by individuals and interest groups. The results of this process were also used to shape the final ranking.
Results After some delay, in May, 1990, a preliminary computergenerated priority list was released. The list ranked 1600 medical treatments and contained serious flaws. The major difficulties related to inaccurate cost and effectiveness data. This led to some widely criticised rankings: reconstructive breast surgery was ranked more highly than treatment for open fracture of the thigh, and treatment for crooked teeth came higher than treatment for Hodgkin’s lymphoma. Transplantation was again near the bottom of the list as was treatment for AIDS—primary care was near the top. There was widespread unhappiness with the ranking both inside and outside Oregon. Some local figures suggested that the list should be abandoned. Commission member, Rick Wopat, MD, voiced a general frustration: "The data are so inadequate... if we want to use the formula system, we have to start collecting data all over again"."
893
Others, including some members of the Commission, felt it
might be better to separate the overall list into categories of treatment and rank each category-to make the ranking more meaningful and manageable. Private insurance firms were asked to advise on the pricing of certain treatments. The Commission decided to split into two subcommittees to work separately towards creating a priority list. One, headed by Wopat, looked at new methods for drawing up priorities, including a consensus-building approach. The other subcommittee tried to find a way to make the cost-utility method work. The priority list was fmalised by the Commission on Feb 20,1991, and contains 714 condition-treatment pairs. Both cost-utility and consensus approaches were used. All the condition-treatment pairs to be ranked were subdivided into 17
categories-for example, maternity
care;
infertility
services; chronic fatal conditions (treatment improves and quality of wellbeing); chronic non-fatal conditions (one-time treatment improves quality of wellbeing); and fatal or non-fatal conditions (treatment produces little or no improvement in quality ofwellbeing).6 In each category, the Commission first ranked conditiontreatment pairs according to the benefit produced by treatment only, and then incorporated the cost of treatment and duration of benefit. A final ranking for each category was arrived at by incorporating public values (obtained from the public meetings and hearings) and the consensus view of Commission members. The categories were then blended into one list and amended by the "clinical and public policy judgement" of the Commission.6 The table gives some examples of Oregon’s fmalised rankings. Of the five treatments recommended for exclusion by North East Thames RHA, two (varicose veins and in-vitro fertilisation) appeared in the lower third of Oregon’s ranking, and removal of wisdom teeth (non-infected) appeared in the middle third. The remaining two (removal of tattoos and non-malignant lumps and bumps) do not appear on the list. In contrast with earlier rankings, heart, liver, and bone marrow transplantation generally appeared in the middle third of the list. However, liver transplantation in alcoholic patients received a low rank. According to the Commission’s executive director, Paige Sipes-Metzler, this poor ranking was mostly due to low effectiveness of the procedure in these patients. Cataract removal and hip replacement, both having relatively long waiting lists in the UK, appear in the middle third of Oregon’s ranking. Mental health disorders and treatments have not yet been assigned priorities. Even if the priority list is acceptable, the legislature must decide how much of it can be afforded. Oregonians have lately voted for a property tax limitation and additional federal monies are not forthcoming; thus, state revenues have declined sharply. The legislature hopes to have the plan operational by July, 1992.
lifespan
Criticisms Criticisms of Oregon’s plans abound. US Congressman
Henry Waxman, who chairs the house subcommittee that oversees the Medicaid programme, has repeatedly indicated his opposition and refuses to hold public hearings until the benefit package is defined by the state legislature. US Senator Al Gore criticised the state for failing to examine wasteful expenditures in health care, for not raising new taxes, and for refusing to shift money from other state programmes. 14 Others have pointed out that the bill does not apply to all the Medicaid population, but just to poor women and
children, and that the elderly are exempted. Some suggest that the elderly have been left out because of their political influence,15 while others maintain that the service provided to these groups by Medicaid is generally long-term care that has not been ranked."
Furthermore, Oregon’s plans have rekindled an old debate over denial of medical care. There is disagreement whether improving efficiency will be enough for an affordable health care system or whether setting limits is necessary.1S,17-19 Victor Fuchs, a prominent US economist, argues that rationing of care exists already and ought to be more systematic, but should be done implicitly at the patient-physician level.10 Senator Kitzhaber, however, rejects an implicit approach because it reflects no social policy and is done "silently and by default".21 The priority-setting process itself has attracted criticism. Many are unhappy with the concept of rationing based only on cost and benefit data. Arnold Relman argues that any rationing process ought to have ethical input as well. 18 There are worries that the effectiveness data required by a formula approach are seriously inadequate and may always be so. The inevitable difficulty of making a formula sensitive to individual patients22 creates a dilemma for physicians and denies a voice to the patient. While the criticisms of Oregon’s plans are plentiful, alternative solutions have been conspicuously absent.
Analysis Although Oregon’s plan is being applied only to one segment of the population, the experience is relevant to a universal health programme such as the NHS and flags up three questions for managers and physicians. Should rationing be implicit or explicit? While the debate over whether or not to set limits to health rages endlessly in the US, the NHS has always had to grapple with a fixed budget. Faced with limited resources, the health service is always making choices. Whether or not we accept the word rationing, it must be acknowledged that underfunding of services, long queues, and "never-never lists" are an implicit means to limit services. The Oregon experiment offers an alternative: make the choices explicit, and base them on systematic rather than ad-hoc methods. Implicit rationing (or limit setting) in the NHS has the advantage of being more politically expedient and more flexible than Oregon’s explicit priority list. But, while it concentrates decision-making in the hands of physicians, it also forces physicians to set the limits. Explicit rationing in the NHS, on the other hand, would have the advantage of being universally applied (within regions) and would free physicians from having to discriminate among patients. Simply by being explicit, this type of rationing will foster energetic public and professional debate about societal care
priorities. Not only were Oregon’s priorities explicit, but so was the process used to identify them. This is in distinct contrast with North East Thames
RHA, where the list of excluded
produced by an unidentified process. If other regions use hidden methods to exclude services, widely differing priorities could result, and treatment-shopping (by general practitioners and patients) across regional or district boundaries might become troublesome. While this may be a feature of the internal market, it will lead to a less equitable service. An explicit methodology may make choices more services
was
consistent.
894
Despite the criticisms of Oregon’s experiment, some services may well be suitable for explicit rationing. A BBC survey of 75 public health directors in England and Wales showed wide agreement that liver transplantations and aggressive treatment for advanced lung cancer are low priorities.4 One British practitioner has suggested treatments for minor, self-limiting, and self-inflicted conditions as potential candidates for explicit rationing.23 Should public input be solicited in priority setting?
Although processes exist for public input in health service planning in Britain (for example, the community health councils), there has been no systematic attempt to obtain information about societal preferences for medical treatments. The notion that "money will follow the patient" in a reformed NHS promises that public choices about medical treatments will be expressed in an internal market. But patients may instead follow the money24 and their choices may be altered by many factors before being expressed as consumer demand. Because a free market is neither feasible nor desirable, there is a case for involving the public in guiding the DHAs and RHAs in the services they ought to be buying, how much of them and where. By its use of random telephone surveys and structured public meetings, the state of Oregon demonstrates how public consensus on health issues might be developed.25 We agree with others26 that these efforts are laudable. By focusing on broad values (towards general services and disability states), organisers of the process tried to avoid personal interests and inherent prejudice. Their experience, however, points to a potential pitfall of the process: participants in open meetings may not be representative of the population at large and may include a disproportionate number of health care employees. Any effort to transfer Oregon’s approach to soliciting public input across the Atlantic
should
include
mechanisms
to
ensure
representative sampling. DHAs are already conducting wholesale "needs assessment"-why not a "public choice" assessment? Can priority setting be made more quantitative?
Oregon’s cost-utility approach represents a first attempt to operationalise a medical/scientific solution to resource allocation.27,28 Unfortunately, even simple questions such as "what works?" and "what does it cost?" require data. Trying to incorporate the dual concerns of quality of life and public values compounds the difficulties-not only because of the dearth of data on these inputs but also because it is unclear how best to give them mathematical weight. But decisions must and will be made. They cannot wait for perfect data and perfect methods. The efforts in Oregon are to be commended for giving some method a try. It is on those who say this method does not work18,22,29 to come up with some alternative. While methods to improve efficiency are rightly being pursued and will free resources for use elsewhere in the NHS, they do not obviate the need to make priorities. The Department of Health is now encouraging RHAs to consider a quality-adjusted-lifeyear approach to making choices.4 If such choices are to be explicit, the process that produces them ought to be public and systematic (though not necessarily mathematical). One place to start would be to ask how North East Thames RHA chose to advise its DHAs to curtail treatment for varicose veins, non-malignant lumps and bumps, wisdom teeth, tattoos, and in-vitro fertilisation.
incumbent
REFERENCES 1. Working for Patients. London: HM Stationery Office, 1989. 2. Brindle D. Patients face rationing for treatment. Guardian Weekly Feb 3, 1991. 3. Dean M. End of a comprehensive NHS? Lancet 1991; 337: 351-52. 4. Dean M. Is your treatment economic, effective, efficient? Lancet 1991; 337: 480-81. 5. Egan T. Oregon shakes up pioneering health plan for the poor. New York Times Feb 22, 1991. 6. Health Services Commission. The prioritised health services list. Salem: HSC, February, 1991. 7. Senate Bill 27, Oregon Legislative Assembly, 1989. 8. Welch HG, Larson EB. Dealing with limited resources: the Oregon decision to curtail funding for organ transplantation. N Engl J Med 1988; 319: 171-73. 9. Shoemaker R. Quoted in: Legislation in Oregon to ration health care for the indigent. Med Ethics Advisor 1989; 5: 88-91. 10. Welch WP. Giving physicians incentives to contain costs under Medicaid. Health Care Financing Rev (in press). 11. The Oregon Medicaid Priority-Setting Project. Portland: Medical Research Foundation of Oregon, 1989. 12. Health care in common-report of the Oregon Health Decisions community meetings process. Portland: Oregon Health Decisions, 1990. 13. O’Neill P. State health plan for the poor stalls. The Oregonian, June 15, 1990. 14. Gore A. Oregon’s bold mistake. Academic Med 1990; 65: 634-35. 15. Vladeck BC. Simple, elegant and wrong. President’s letter, United Hospital Fund of New York, September, 1990. 16. Packwood B. Oregon’s bold idea. Academic Med 1990; 65: 632-33. 17. Callahan D. Rationing medical progress-the way to affordable health care. N Engl J Med 1990; 322: 1810-13. 18. Relman AS. The trouble with rationing. N Engl J Med 1990; 323: 911-13. 19. Reagan MD. Health care rationing and cost containment are not synonymous. Policy Studies Rev 1990; 9 (winter): 219-31. 20. Fuchs VR. The rationing of medical care. N Engl J Med 1984; 311: 1572-73. 21. Kitzhaber J. Discussion paper Senate Bill 27. August, 1989. 22. Schwartz WB, Aaron HJ. The Achilles heel of health care rationing New York Times July 9, 1990. 23. Ford S. Rationing health care. Br Med J 1991; 302: 288. 24. Quam L. Improving clinical effectiveness in the NHS: an alternative to the white paper. Br Med J 1989; 299: 448-50. 25. Cranshaw R, Garland M, Hines B, Anderson B. Developing principles for prudent health care allocation: the continuing Oregon experiment. West J Med 1990; 152: 441-46. 26. Kelly G. Rationing health care. Br Med J 1991; 302: 288. 27. Duggan JM. Resource allocation and bioethics. Lancet 1989; i: 772-73. 28. Kitzhaber J. The Oregon health initiative. Lancet 1989; ii: 106. 29. Hollingsbaum F. Rationing health care. Br Med J 1991; 302: 288-889.
From The Lancet Bank notes and infection
Passing from hand to hand among all classes of the people, it would be strange, indeed, if money, and especially paper money, did not in its transit become from time to time the vehicle of infectious disease. Even the crisp "fiver" of the Bank of England no doubt has often borne the germs of fever in its folds, and how much more then the greasy, discoloured, and well-thumbed one pound note, or the paper fraction of some foreign currencies. Higher values have here a distinct advantage. Less common, less in keeping of the overcrowded poor, less handled and soiled therefore they may, perhaps, in many cases run their circuit without having done much mischief. There are, indeed, preservative circumstances which guard the sanitary credit of all paper currency. One is the very freedom of circulation and the ventilation this ensures. Smoothness of surface is another; and a third, which operates in a minor degree, is found in the fact that adults, not children, are chiefly concerned in the business of exchange. These qualifications may suffice to justify, at least by a negative verdict, the employment of paper money from a sanitary standpoint. Still, a certain risk remains, and careful persons will do well to note this, and on occasion to disinfect even their bank notes. The danger, such as it is, should also, in our opinion, be allowed some weight in deciding the question whether a small note currency hitherto not found to be indispensable should or should not be generally adopted. (Feb 7, 1891)
