D ecision making from two distinct points of view: patients and society by . . .

1. Decision making from two distinct points of view: patients and society by . .. A part of my talk will consider the paper entitled: Different views on health care rationing the main principles mentioned in the choice and . PORTUGAL 18-19 November 2014, Siófok, Hungary

2. OUTLINE AN OVERVIEW AT HEALTH SYSTEM THE PRESENT SCENARIO OF DIABETES IN EUROPE Different views on health care rationing the main principles mentioned in the choice MOTIVATION METHODOLOGY OBJECTIVES QUESTIONNAIRE SAMPLE DESCRIPTION RESULTS MAIN CONCLUSIONS FUTURE RESEARCH

3. AN OVERVIEW AT HEALTH SYSTEM • In the development countries, we notice that the weight of health expenditures grew. Despite the deceleration since 2009, the weight of health expenditure in relation to GDP, on OECD countries, increased from 7,8%, in 2000, to 9,3% in 2011. In this moment, the OECD countries devoted 9,3% of GDP to health. Health expenditure as a share of GDP, 2011 (or nearest year) Source: OECD HealthStatistics, 2013.

4. AN OVERVIEW AT HEALTH SYSTEM • In nearly all OECD countries, the public sector is the main source of health care financing. Around three-quarters of health care spending was publicly financed in 2011. In Denmark, the United Kingdom and Sweden, the central, regional or local governments finance more than 80% of all health spending. In Hungary 64,5% was the share of public health spending (8,5% by the government and 56,0% by Social Security). Expenditure on health by type of financing, 2011 (or nearest year) Source: OECD HealthStatistics, 2013.

5. AN OVERVIEW AT HEALTH SYSTEM • Spending on inpatient care and outpatient care combined accounts for a large proportion of health expenditure in Hungary around 53% of current health expenditure. A further 37% of health spending was allocated to medical goods, 4% on long-term care and the remaining 6% on collective services, such as public health and prevention services and administration. Current health expenditure by function of health care, 2011 (or nearest year) Source: OECD HealthStatistics, 2013.

6. THE PRESENT SCENARIO OF DIABETES IN EUROPE • We notice that the costs of healthcare increase in a rhythm superior of the wealth creation. This situation can put in case the sustainability of health systems and of the social welfare. Diabetes has a large economic burden on society. It costs Europe EUR 100 – 150 billion annually to manage and treat diabetes. The true cost of diabetes is unknown, as productivity loss is also not precisely calculated. However, there are wide variations between the regions of Europe on diabetes spending. Diabetes and other chronic diseases combined are the cause of 86% of deaths in Europe. Source: HealthConsumerPowerhouse, Euro Diabetes Index, 2014.

7. THE PRESENT SCENARIO OF DIABETES IN EUROPE SDR, diabetes, all ages, per 100.000 Source: WHO HfA database, April 2014.

8. THE PRESENT SCENARIO OF DIABETES IN EUROPE • Encourage prevention of disease is one of the most effective health policies. In the last data of Euro Diabetes Index2014, we observe: Source: Source: Health Consumer Powerhouse, Euro Diabetes Index, 2014.

9. MOTIVATION • In general, in most countries, we observe: • Scarcity of resources. • Threats the right of the healthcare. • Need of Rationing or Priority Setting. RATIONING IN HEALTH

10. MOTIVATION • In general, in most countries, we observe: • Scarcity of resources. • Threats the right of the healthcare. • Need of Rationing or Priority Setting. Discussion: How to establish priorities, mainly between patients?

11. MOTIVATION • Over the past decades health economists through the concept of opportunity cost developed technical evaluation methods that compares costs and benefits. The formal allocation method, the cost-effectiveness method, commonly referred cost-utility analysis (CUA) which uses a weighting combination of life expectancy and quality of life (QALY) as a measure of benefit in health. • In accordance with CUA health resources should be allocated such that guarantee the maximization of QALY’s for unit of costs. Utilitarianism principleis implicit in this method by assuming that the best distributive scheme is one that maximizes the number of years of life (healthy) for a given budget.

12. MOTIVATION • When rationing is evaluate in society point of view, these economic evaluation techniques do not have full acceptance. • In the moment of establishing priorities between patients, besides clinical effectiveness, the society value essentially: • Personal characteristics of patients; • Gravity of health conditions; • Reduction inequalities in health.

13. MOTIVATION Efficiency versus Equity → challenge. • In the literature review different equity considerations such as: • the rule of rescue, • the fair-inning, • substantive equality of opportunities • lottery. • Additionally, the preferences regarding equity criteria to establish priorities between patients vary from country to country. • A possible way to overcome this difficulty would be reconciling technical criteria with a political process of priority setting which would include the participation of all social actors → there is no consensus in the public participation in prioritization decisions.

14. MOTIVATION • As the budgetary restraints of countries are becoming more demanding and rationing at the micro level assumes proportions of inevitability it becomes relevant to know which distributional criteria are shared by society as a whole. • The study, that I will present, was carried out in Portugal and explore, through quantitative and qualitative analysis, the ethical principles advocated by society in microallocation of the scarce health care resources.

15. METHODOLOGY • The database resulted from the questionnaire which was available for students (180) and health professionals (60). • The questionnaire is composed by two parts: • includes a hypothetical scenario used in another work conducted by Cookson and Dolan (1999), which are presented four patients with different characteristics and health conditions; • socio-demographic description of respondents.

16. METHODOLOGY • The exercise consists in making an ordering four patients in a context of scarce financial resources and in which only one can be treated. • Additionally should be detailed the reasons that led to these choices.

17. OBJECTIVES • The main objectives of the paper: • Compare the results obtained with Cookson and Dolan (1999); • Explore to which of the rationing principles Portuguese citizens reveal a major support; • Explore if Portuguese distributive concerns conform with international findings; • Explore if public ethical principles differ from those of health professionals.

18. OBJECTIVES • The differences of our paper with Cookson and Dolan (1999): • we did an anonymous questionnaire that includes a request for justification. Thus, we obtain a larger number of respondents with no opportunity for discussion of choices. • we applied a qualitative and quantitative analysis; • highlight the differences in the responses of students and health professionals.

19. QUESTIONNAIRE Patient 1: John is 18 years old and suffered a road traffic accident which resulted in severe facial scarring and psychological problems. Plastic surgery would correct the scarring. Patient 2: Mary is 45 years old, is single, with no children. She was diagnosed with hepatitis B as a result of their long years of drug consumption. Mary does not consume drugs for 5 years. There is a treatment available, which is 75% effective and it will provide years of quality life. Thisisan individual exercise to highlightthedificculty in prioritisingtheallocationofscarceresourses. You’vegot 6.500€ whichwillfundoneofthescenariosdescribed – whatwouldspendthemoneyandwhy? Patient 3: Rosalina is 65 years old and is almost blind. She is waiting 3 years for a surgery to remove cataracts. Her blindness has worsened over time and soon she will no longer be able to live alone. She has no family. The operation will allow she to be independent. Patient 4: Peter is 8 years and leukemia. The probability of survival is of 50%. But there is a new treatment available that it has been partially tested in a few cases.

20. SAMPLE DESCRIPTION Table 1 – Descriptivestatistics

21. RESULTS Table 2 - Ranking of the four patients given by students and health professionals, Frequencies and Mann-Whitney tests Notes: * Significant at the p < 0.05 level; ** significant at the p < 0.01; *** significant at the p < 0.001 level.

22. RESULTS Table 3. Statistics of the more frequent arguments by occupation

23. RESULTS Table 4 – The six rationing principles, Mann-Whitney tests Notes: * Significant at the p < 0.05 level; ** significant at the p < 0.01; *** significant at the p < 0.001 level.

24. RESULTS Table 5 - The determinants of the choice of the patient, Kruskal-Wallis tests

25. CONCLUSIONS • Rationing of healthcare has revealed a complex and controversial issue especially at the micro level where choices require treating some patients instead of others. • In our results, we verify that the respondents, both students and health professionals, do not refused to establish priorities among patients. • The society is favorable to become involved in these themes and it can open the opportunity for the development of an explicit process to elaborate a systematic and transparent criteria to establish health priorities.

26. CONCLUSIONS • We also verify that our results converge to rationing principles internationally accepted. • Respondents value the utilitarian criterion of obtaining the maximum benefit in terms of health, but also to provide for the equitable allocation criteria according to the severity of the health state (rule-of-rescue) and age equalization (fair-inning). • Despite this evidence, it should be noted that the population in general seems more receptive to the principle of fair-inning doctors, who show complacent about the effectiveness of treatments.

27. FUTURE RESEARCH • Research in progress: in order to overcome the limitation of our sample of the study presented here, we use the same hypothetical rationing scenario (developed elsewhere by Cookson e Dolan, 1999) but collected data through an on-line questionnaire allowing widening participation to other social actors and the collection of a larger sample. • Future research: it would be interesting to replicate this same test in other countries in order to explore cultural differences and eventually trace pattern common distributive principles.

28. Thanks for your attention!!! Ana Pinto Borges, PhD e-mail: anapintoborges@hotmail.com Twitter: @AnaPintoBorges 18-19 November 2014, Siófok, Hungary