Hard Choices on Health Care at Home and Away

As spending cuts hit federal and state health programs, policy-makers are obliged to make harder choices about who will receive what health care.

This week brought news of an attempt to set priorities using cost-effectiveness analysis to determine which recipients will gain most years of healthy life via a transplant. Using these criteria, the nation’s organ-transplant network is considering giving kidneys first to younger, healthier people instead of using a waiting list (see here).

The ethical issues are not simple. Such an approach ignores the rule of rescue, which argues that the sickest must be treated first, even when money might be more efficiently spent to improve health in the larger population. It has equity implications, valuing the lives of the young more than the old.

But it is a necessary discussion if the health system is actually supposed to produce “health” and not just services. To deal with the ethical issues, the 30-member UNOS Kidney Transplantation Committee issued a document for public comment and debate.

This is an important development in U.S. health policy – there is both sound economic evaluation and explicit consideration and public consultation on the ethical issues surrounding the recommended decision. It is a baby step out of the “covert rationing” (see here) that currently characterizes the U.S. system towards a simpler, evidence-based and transparent decision-making process. You might not agree with the UNOS recommendation. You should have the opportunity to express and defend your position. But at least you can understand why the decision was taken and appeal if necessary.

The example of the UK’s National Institute for Care and Clinical Excellence (NICE) is often cited along with other European examples, but even less affluent countries are moving faster towards overt priority-setting than the United States.

Colombia, for example, is a middle-income country in Latin America that found itself funding an increasing number of high-cost, low-impact interventions like bariatric surgery while under-funding cost-effective public health interventions. For example, a third of all children are anemic and 14% of children are malnourished. This year, the country created a health technology assessment agency to carry out economic evaluations, consult and deliberate with the public and stakeholders, and recommend interventions and target groups to be included or excluded for public funding under their insurance scheme.

Can the US catch up? At CGD we will be benchmarking priority-setting processes and institutions around the world, identifying opportunities for regional and global public good s in this space. There may be something in there for us gringos. Stay tuned.