Setting health care priorities in Oregon: cost-effectiveness meets the Rule of Rescue

Article Abstract:

An analysis is presented of the problems encountered during the development of health care services priorities by the state of Oregon, an example that brings into sharp focus the inherent contradiction between cost-effectiveness concerns and the ''Rule of Rescue'' - the duty that human beings feel to save endangered lives whenever possible. In May 1990, the Oregon Health Services Commission published a draft of a priority list, created in response to a state senate bill that allowed expansion of Medicaid coverage to all poor Oregonians, but only for services of rather high priority. The list was greeted with widespread criticism, and a second, final version was generated. A discussion is presented of traditional cost-effectiveness analysis, which assigns priorities by dividing the cost of a service by a measure of the health benefit it should provide (often, quality-adjusted life years). This resulted, in the Oregon case, in high-cost procedures with great benefits (appendectomy) having similar priority rankings to low-cost procedures with minimal quality-of-life benefits (tooth capping). It was felt that such formulations ignore the Rule of Rescue. The revised priority list was constructed by categorizing health benefits of various treatments and assigning medical condition-treatment pairs to the categories; cost was eliminated as a factor. The method is discussed in detail. Problems with the approach are discussed; high-cost and high-benefit services pose a particular dilemma for the priority list. The efforts made by health care specialists in Oregon, while imperfect, should be praised as the first in the nation to attempt to expand medical care to all people. Further work to distinguish between different treatments, patient characteristics, and potential benefits is needed. (Consumer Summary produced by Reliance Medical Information, Inc.)

Laws, regulations and rules, Social policy, Oregon, Medicaid, Medical care needs assessment

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The problem of discrimination in health care priority setting

Article Abstract:

Oregon passed a law in 1990 to extend Medicaid to all those eligible by prioritizing medical treatments. Some people think this plan would violate the Americans with Disabilities Act, which forbids discriminating against the disabled. This is because many diseases and conditions, such as cancer, diabetes, alcoholism and HIV infection are considered disabilities. Oregon officials polled state residents to assign priorities to various treatments, and it is possible that the disabled were underrepresented. But the state intends to add the views of its elderly, disabled and blind to the plan. There is no evidence that the disabled would rate treatments any differently than other groups. Health outcomes that are based on scientific data would not necessarily discriminate against the disabled. All members of the community should be surveyed to identify which treatments should be covered by insurance.

Ethical aspects, Discrimination against disabled persons, Handicapped discrimination, Health care rationing

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The health care resource allocation debate: defining our terms

Article Abstract:

The words used to discuss the cost and distribution of health care must be precisely defined. Three key terms that need to be defined and used consistently are rationing, health care needs and basic benefit plans. Rationing is potentially defined as the denial of beneficial medical services because of an inability to pay. Health care needs can be defined as medical services needed by patients with specific diseases or conditions. Basic benefit plans can be used for health insurance packages that provide coverage for all necessary medical services. These terms should be accompanied by guidelines specifying what services are necessary for the diagnosis and treatment of different medical conditions.

Terminology, Health services administration

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