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