Priority setting in Norwegian health care Berit Bringedal, PhD Senior researcher, Institute for Studies of the Medical Profession, Oslo, Norway
Features of the health care system Universal coverage, single payer Private co-payments (annual ceiling 250 Euros) Dental care excluded Drugs: partly private, partly co-paid, some free (in principle based on priority criteria) Private GPs, gatekeepers Contracts with municipalities Income: number of patients on lists and fee for service Hospital trusts, state owned Governed by boards Additional private providers, contracts with the public trusts
Priority principles 1987 Dimensions: Severity of disease, equal opportunity to benefit, efficiency. Discussed: Waiting times, personal responsibility Five priority levels 1. Necessary immediate fatal consequences if postponed/not provided 2. Necessary immediate severe consequences if postponed/not provided 3. Documented beneficial clearly unwanted consequences if postponed/not provided 4. Presumed beneficial clearly less severe consequences if postponed/not provided 5. Zero priority demanded, yet neither necessary nor documented beneficial
Controversial issues Is it right to consider costs in health care? Different levels: priorities at the bed side rationing vs macro level Is priority setting ethically justified at all? Inexplicit priority setting?
Next generation White Paper - Mandate - Increased need for prioritization Health economics role should be considered The system of co-payments? Personal responsibility and priority? Limits to public responsibility?
Priority principles 1997 Dimensions: Severity of disease, medical effect of intervention, cost-effectiveness. Rejected personal responsibility as criterion, accepted copayments. Four priority levels 1. Basic health care severe consequences if withheld, documented beneficial above certain level, reasonable costs relative to benefit 2. Complementary health care lower rank than 1, higher than 3 3. Low priority health care low on severity and medical effect, and high costs 4. Zero priority demanded, yet neither necessary nor documented beneficial
Practical outcomes Legal Patient Right s Act specifying the priority levels Priority council Advisory Clinical guidelines Based on expert groups advice Co-payments new drugs decided on the basis of the priority criteria Established NICE equivalent Open question: Consequences in clinical practice?
Next generation White Paper - Mandate - Severity How should severity be interpreted and count? Threshold What is the threshold for medical effect (benefit)? Cost effectiveness How should it count? Is QALY a good measure? Age Should age count as independent criterion? Rare diseases Should treatment of rare diseases be given special priority? Equal weight? Are the three criteria equally significant?
Specific responses to the mandate Severity Emphasize health loss Threshold Three groups according to health loss Not a specific monetary limit (cost per qaly) Cost effectiveness Cost effectiveness is important Discretion is good Age No; already included through the three criteria Rare diseases No Equal weight Depends on health loss group
Priority principles 2014 Majority of previous principles followed Increased weight on a legitimate decision process Change of concepts Severity of disease: Health loss Medical effect/benefit: Health gain Costs: Resources spent
Controversial issues Age Discrimination of old age? Distinction between levels Bedside vs Ministry of Health Economistic influence (language) calculate a number of marginal values on the pure costeffect ratio, where the marginal values vary between types of intervention. These marginal values are based on the opportunity cost, adjusted for differences in health loss between the chosen intervention and the interventions foregone...
Scholastics? Idea Formulate unambiguous principles and apply equally for all cases on all levels Requires A Leviathan of data and administrative systems Alternative Identify extremes rather than ranking of marginal differences Ragnar Frisch The distinction between a tiger and a wildflower meadow
30 years of good intentions Few practical implications (Plus ça change, plus c est la même chose?) Generous budgets Third party payer Politicians maximize votes Expenditures per capita, 2013 (USD, PPP) USA 8713 Switzerland 6325 Norway 5862 Sweden 4904 Denmark 4553 UK 3235
30 years of good intentions Some reasons for the few practical implications Priority is not a precise concept Fast access to treatment? Amount of the resources? Discretionary criteria «reasonable», «sufficient» Unclear responsibilities responsibility shifting Doctors reluctant Priority principles applied in Law (patient rights and regulation of drugs) To a lesser extent in financing or other steering systems
Examples Belong to low priority group still provided With no documented health effects Ritual circumcision of boys Ultrasound screening during pregnancy Yearly health checks of healthy adults With unclear health effects Mammography screening Preventive drug treatment cardiovascular disease (systolic pressure above 140)
Economic incentives for priorities DRG and fee for service Somatic specialist care DRG and fee for service GPs fee for service Experiences are ambiguous Counter effects (cream skimming, crowding out) Requires data on all types of use Also administrative costs Have anyone seen calculations of the opportunity costs of system reforms?
Thank you for your attention! PS. Will try to take a better photo of the sculpture and send to the leader of the network!