Who should decide? Qualitative analysis of panel data from public, patients, healthcare professionals, and insurers on priorities in health care
BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7100.92 (Published 12 July 1997) Cite this as: BMJ 1997;315:92
- Karien Stronks, lecturer in public healtha,
- Anne-Margreet Strijbis, research assistanta,
- Johannes F Wendte, senior lecturer in social medicinea,
- Louise J Gunning-Schepers, professor in social medicinea
- a Institute of Social Medicine, Academic Medical Centre, University of Amsterdam, 1105 AZ Amsterdam, Netherlands
- Correspondence to: Dr Stronks
- Accepted 10 April 1997
Abstract
Objective: To explore the arguments underlying the choices of patients, the public, general practitioners, specialists, and health insurers regarding priorities in health care.
Design: A qualitative analysis of data gathered in a series of panels. Members were asked to economise on the publicly funded healthcare budget, exemplified by 10 services.
Results: From a medical point of view, both panels of healthcare professionals thought most services were necessary. The general practitioners tried to achieve the budget cuts by limiting access to services to those most in need of them or those who cannot afford to pay for them. The specialists emphasised the possibilities of reducing costs by increasing the efficiency within services and preventing inappropriate utilisation. The patients mainly economised by limiting universal access to preventive and acute services. The “public” panels excluded services that are relatively inexpensive for individual patients. Moreover, they emphasised the individual's own responsibility for health behaviour and the costs of health care, resulting in the choice for copayments. The health insurers emphasised the importance of including services that relate to a risk only, as well as feasibility aspects.
Conclusions: There were substantial differences in the way the different groups approached the issue of what should be included in the basic package. Healthcare professionals seem to be most aware of the importance of maintaining equal access for everyone in need of health care.
Key messages
Interest in the opinions of different parties concerned with the process of prioritisation of health services is high
This study aimed at understanding the arguments underlying the opinions of the public, patients, healthcare professionals, and insurers
There seem to be substantial differences in the way the different parties approach the issue of what services should be collectively funded
The main difference seems to be the extent to which the parties took the principle of equal access into consideration
Including all the different parties in the decision making process will therefore not necessarily lead to more equitable or broadly supported outcomes
Introduction
As the costs of health care continue to increase and will do so even more as our populations age the question of what services a society can afford to offer to its citizens continues to occasion debate. Recently readers of the BMJ were confronted with a discussion of the Swedish report on prioritising health care1 and on Dworkin's thought experiment on creative rationing.2 Central to this debate of course is the notion that there are choices to be made. Previous studies have shown that among the parties involved (public, professionals, patients), no consensus exists for these choices.3 4 5 This raises the question of whether the arguments used to defend the different choices are consistent.
To develop some understanding about the arguments underlying the opinions of different parties we carried out a study with panels of five parties that might be concerned in prioritising: the public and patients, health insurers, and two groups of healthcare professionals—general practitioners and medical specialists. We report on their preferences but focus on the criteria developed to select services to be included in a basic package as well as the arguments used in specific instances.
Subjects and methods
The study took place in the Netherlands. In the Netherlands the (public) debate on prioritising health care started almost 10 years ago. Several reports on this issue have been published since then, the best known of which is the report of the Dunning committee, named after its chairman Professor Dunning.6 The public debate has been stimulated by the government—for example, by means of a campaign aimed at making people aware of the necessity of making choices.
In this study, six panels (box), consisting of about nine people each, were asked to play the part of a parliamentary committee with the decision to select services that would continue to be funded from a severely cut health budget. The list consisted of 10 different services, selected to represent different aspects of physical health care (table 1). The decisions to be made were restricted to those who receive public insurance, which currently covers about two thirds of the Dutch population.
The panels
Patients:
People representing national patient groups
The public:
University students
Civil servants not working on health
(None of the members of these panels suffered from a chronic illness or handicap)
Healthcare professionals:
General practitioners, in the last stage of their training
Specialists in an academic hospital
Health insurers:
Employees working in a health insurance company
Services included in list and summary of the information given to panel members
The panels were given two sources of background information: the selection criteria as proposed in the Dunning report, Choices in Health Care: Necessary Care, Effectiveness, Efficiency, Too Expensive for the Indi- vidual (the criteria are summarised in the box on the next page)6; and a file on each of the services under consideration, containing information on its nature, the number of people affected (now and in the future), costs, and current restrictions. This information is summarised in table 1. In addition, they received a few papers stating the views of supporters and opponents of public funding.
Dunning criteria
Publicly funded services should meet the following criteria:
Necessary care—care which is neceassary to maintain or to restore health, defined as the ability to function normally in the community
Effectiveness—this has to be proved and documented
Efficiency—efficient delivery, based on the results of cost effectiveness studies
Individual responsibility—too expensive for the individual
The panels were asked to economise nearly one third of the total budget. They had to decide whether a certain service should be included in the basic package (that is, provided with public funds) or removed from the package, totally or partially. More importantly, they had to give arguments for each choice. They were given five hours to complete their task. One panel member led the discussion. The discussions were observed by one of the researchers and a facilitator structured proceeding as necessary. To check the unanimity of the outcomes of the discussion the panel members were asked to fill out a questionnaire afterwards concerning their private opinions. All discussions were tape recorded and transcribed verbatim.
The panels were not chosen to be a representative sample of the population but were selected on purpose. They represented five distinct parties in health policy. The individual members of the panels were selected by someone who was familiar with one of the selected parties. The main selection criteria were: interest in the subject, willingness to spend a full day on the experiment, and availability. The “patient” panel was the only one in which the members were also formal representatives as they were all active officers of national patient associations. There were two “public” panels, one of which consisted mostly of university students, who were thus on average younger than the other panel members. Moreover, all participants were well educated, which made it possible for them to assess the information given even though they were not familiar with it.
Results
All panels fulfilled their task, although with great difficulty. It was obvious that most services could not be easily excluded from coverage in a basic package and that the budget cuts to be achieved were high. Table 2 summarises the choices made by each panel.
Choices made by each panel as to whether service should be publicly funded
General practitioners
The general practitioners especially found themselves in a dilemma as they could not really envision any of the services being reduced without affecting patients in real need of them. They therefore tried to achieve cost reductions by limiting access to services, either to those most in need of them or to those who cannot afford to pay for them. For example, they discussed restricting travel allowances to low income groups and decided to pay for in vitro fertilisation only when a woman has no or only one child. In addition, they decided to restrict the universal accessibility of home care to nursing care only, but the answers to the questionnaire they filled in afterwards showed that most of the panel members felt very uncomfortable about this decision. It is remarkable that “responsibility of the individual” was not used by this panel as an argument for exclusion of services. This underlies the unanimous choice to include treatment of sport injuries in the benefit package.
Specialists
The medical specialists also thought that most of the services were necessary. Their criteria for inclusion were the most explicit: prevention or curing of a disease or caring for sick people. In their eyes infertility was a disease thus in vitro fertilisation was included in the basic package. Using that same argument, however, they went on to exclude oral contraceptives. A second argument used in that discussion emphasised that most of the cuts proposed would affect old people. The panel thought that excluding oral contraceptives was one way to spread the effect more equitably over age groups. They emphasised possible economies from increased efficiency within the existing services, such as home care and prevention of inappropriate use of travel allowances. Compared with the other panels, the specialist were more concerned about prevention and hence included breast cancer screening.
Patients
The patients made a clear distinction between those suffering from a long term or chronic illness and those with an acute disease or healthy people. They thought that especially health services for the former should be publicly funded as chronically ill people have no other option but to rely on health care. They therefore firmly rejected cutting costs of long term home care and travel allowances. On the other hand, they (partly) excluded preventive services as well as severely cut acute care (including short term home care after hospital discharge) and health care needs related to individual behaviour (such as treatment of sport injuries).
Public
Both panels representing the public looked very carefully at the argument of financial resources of the individual and individual responsibility for health. Those services that were relatively inexpensive or allowed alternative solutions for the individual were (partly) excluded. These included travel allowance, oral contraceptives, and in vitro fertilisation. These choices reflect a high value placed on the principle of individual responsibility, which was confirmed by the answers given in the questionnaire. They proposed copayments for health care in the case of sports injuries and breast cancer screening, a decision consistent with their earlier arguments.
Health insurers
The panel of health insurers introduced two criteria specific to their occupational background. In the first place they separated health risks (for which one can be insured) and inevitable healthcare needs that will eventually be experienced by most of us (home care and homes for elderly people). They thought that the latter should be provided through taxation rather than through insurance. They also emphasised the feasibility of implementation of the measures proposed. For that reason they argued against excluding sports injuries or selecting those in real need for reimbursement of travel allowances and in favour of the total exclusion of oral contraceptives.
All panels
Despite these clearly distinct approaches to the question of priorities, there were also some similarities. All panels argued that homeopathic medicines should be excluded from public funding as their effectiveness has not been proved. They all decided to cut down the costs of the homes for elderly people, the underlying rationale being the wish to deliver services more efficiently. In addition, the panels seem to agree on the value of lifesaving services, as exemplified by lung transplantation. Yet all groups questioned the cost-benefit ratio of this service, which reflects the high value attached to efficiency.
Discussion
The panels were able to reach a consensus, although it was obvious that many of the concepts used and much of the material offered were alien to many of the panel members. It is therefore unlikely that an exercise like this could be easily used to elicit opinions of the general public. Additional evidence to support this view is provided by a recent experiment on citizens' juries among the general public.7 That experiment showed that if the general public is to be involved in decisions on prioritising in health care they need much more time and information than the five hours and the written information that the participants in our study were given.
Given the fact that the panel members were relatively young and highly educated, they were far from random samples. Therefore the panels should not be considered as representing the whole population of patients, general practitioners, etc. It could be questioned whether this threatens the validity of our results. In general demographic characteristics do not seem to be systematically related to the decisions people make in prioritising processes.8 An exception should probably be made for age as a recent study showed that people seem to favour services for their own age group.5 If this is true, the panels probably would have been more reluctant with respect to cutting costs for home care and homes for the elderly if more elderly people had been included. On the other hand, a specific check on the age distribution of the proposed cuts was discussed explicitly by at least one of the panels. Moreover, our aim was to obtain more insight into the arguments underlying the choices of different actors in the decision making process, rather than into the outcome of the prioritisation process. We do not consider it likely that the arguments strongly differ by age or other characteristics.
In view of the limited share of resources that can be devoted to health care, all panels chose to exclude ineffective services from public funding and tried to deliver services more efficiently. Hence the idea of effectiveness and efficiency as necessary conditions for the general accessibility of our future healthcare system seems widely shared. This was confirmed by the data obtained by the questionnaire. In addition, all groups seemed to agree on the value of lifesaving technologies. The discrepancy with the results of other studies suggesting that the public and professionals disagree in this respect3 9 might be explained by the fact that we chose lung transplantation as an example of high technology, a service which mostly benefits young people. Moreover, the costs of this service represented only a small proportion of the total budget.
Observed differences
Besides these similarities we observed substantial differences in the arguments of the groups considered. Patients and health insurers in particular explicitly introduced self interest as a basis for prioritising. The patients, all suffering from a chronic illness, considered care services to be the most important, which corresponds with the results of another study regarding primary healthcare services.4 The choices of the health insurers were guided mainly by their concern for the practical feasibility of the chosen strategy. We found little evidence to suggest that the public or healthcare professionals were guided by personal needs or self interest, which is consistent, as far as the public is concerned, with the results of a previous study.10
Partly because of differences in the approach to the population's best interest, but probably also because of differences in first hand experience with the people using the different services discussed, the main difference between the panels seems to be the extent to which they took the principle of equal access into consideration. This finding seems to be in accordance with that of a previous studies.3 11 Members of the public panel in particular frequently emphasised the importance of individual responsibility. In accordance with this principle, copayments were proposed without paying much attention to whether this might affect the accessibility of health care for low income groups. Although the outcome here may have been biased by their relatively high level of educational and income, the results of a survey among a random sample of the public3 also showed that priorities set by the general public might be contrary to the principle of equity and equal access. In addition, while focusing on a conception of health care in terms of care for the chronically ill, the strategy of the patients might threaten the accessibility for those with an acute illness or healthy people. In contrast, the healthcare professionals, and in particular the general practitioners, explicitly took into account the consequences of their decision for the equal accessibility of services. In addition, the specialists discussed the distribution of the proposed economies across age groups.
Finally, the healthcare professionals were the most pessimistic about the possibilities of cutting down public expense on health care. The strategy of not offering those services under public funding was hardly an acceptable option to them, whereas the possibilities for other strategies, such as restricting access to specific groups, was limited by the high value attached to the principle of equal access. A cynic might argue that doctors would be expected to be most reluctant to cut healthcare costs out of self interest, but the arguments used and the tone of the discussion suggest otherwise. The difficulties encountered by the healthcare professionals in the decision making seem to reflect a more realistic picture of current practice in health care, as well as a greater awareness of the importance of maintaining equal access.
From our results it is not clear that including all the different actors in the decision making process of prioritisation of health services will lead to more equitable or broadly supported outcomes or to better health for the population. It is quite remarkable that it is the medical profession that seemed most concerned about the common good and the distribution of services. The panels representing the public, patients, and insurers had much more trouble weighting the interests of all those concerned. As a result, their decisions might threaten the universal accessibility of core services. As this principle is highly valued in western societies this may be unacceptable for at least professionals, as our results show, but also for policy makers. The arguments put forward by the different groups, however, are well worth considering because they clearly reflect the different perspectives of those affected by prioritisation. We think that they all deserve to be carefully considered by the (democratically elected) bodies that decide on resource allocation in most of our healthcare systems.
Acknowledgments
Funding: This project was partly funded by a grant from the Dutch ministry of public health.
Conflict of interest: None.