Health rationing debate poised for launch

How much should we spend to keep a person in good health? Keystone

Healthcare costs are rising and personnel is at a premium in Switzerland, a situation unlikely to improve and leading to questions whether treatments should be rationed.

But two new studies could be a first step towards opening the debate on medical rationing, looking at potential criteria for evaluating costs and benefits.

The Swiss healthcare system faces two major challenges. First, costs are steadily increasing and already around one third of the Swiss population needs financial aid to pay their health insurance bills.

The other concern is the lack of healthcare personnel trained in Switzerland. There are, for example, currently only 22.1 new doctors every year joining the workforce for 1,000 practising physicians, a figure that would have to be 50 per cent higher just to maintain current staffing levels.

These factors would tend to encourage some form of medical rationing. But few doctors are prepared to entertain the idea openly, even if some of them admit that de facto rationing is already taking place simply because of a lack of staff.

Doctors must also often decide if a patient can benefit from a treatment and if it is worth the cost, but they lack clear guidelines. An unsatisfactory situation, according to Daniel Scheidegger, chief anaesthetist at Basel University hospital.

“For me it is a societal and political problem,” he told Swiss public radio. “I don’t think that these decisions should lie in the hands of a few doctors. We as a society must discuss this.”

Politicians are wary so far of walking into a potential minefield and as recently as 2010 the government stated it was opposed to the idea.

However, a Federal Court decision earlier that year that a treatment costing up to SFr600,000 ($654,000) per year was excessive, and setting a limit of SFr100,000, brought rationing to the forefront.

That decision has been criticised as arbitrary, setting a maximum cost on a person’s suffering. But it has also forced healthcare specialists to consider how best to evaluate the benefits of treatments.

Setting thresholds

A first step has been made with two separate studies recently presented in Bern by the Swiss Academies of Arts and Sciences (SAAS) and the Swiss association of pharmaceutical firms (VIPS), looking at potential criteria for evaluating those benefits.

The first, carried out by researchers at the universities of Basel and Zurich, looked at so-called QALYs, or quality-adjusted life-years, and their use in other medical systems. The VIPS study, carried out by research firm Infras, looked at the use of threshold values.   

At its simplest, a QALY assumes that one year of life in perfect health has a value of one. Any health problems push that value below one. It could also mean for example that a treatment might be rejected even if increases life expectancy considerably because the quality of life is considered low.

Among its advantages are patient input and the fact that it incorporates “social” values. However those elements are also to some extent subjective, and just what they represent and how they can be quantified must be discussed by all concerned to reach a consensus, admit the study’s authors.

QALYS are also the result of mathematical operations, meaning an identical result can be reached with different data.

Threshold values are based on cost effectiveness of treatments as well as their benefits for patients and are more closely linked with the concept of rationing.

Discriminatory?

While used as criteria in certain countries where basic healthcare is funded by taxes, the study published by the pharmaceutical association shows that economic factors alone cannot be used to fix fair guidelines.

The risk is that some groups of patients such as the elderly, those with rare diseases and the disabled may be discriminated against, contradicting the often stated claim of access to healthcare for all.

Just who should be treated is not always clear-cut as Scheidegger points out. An elderly person whose life can be saved or significantly improved has a better case than a youngster whose death will be postponed for a short time at best.

The authors of both studies reached the conclusion that neither system can be applied to Swiss healthcare as such and that the Federal Court’s decision was not grounded in scientific fact nor shown to provide any measurable benefit.

However, threshold values or QALYs could be applied if adapted to Swiss realities, including an open and public discussion as to what is acceptable or not in terms of treatment as well as social and ethical criteria not considered in the Federal Court decision.

Death panels

It seems though that launching a public debate concerning rationing healthcare is some way off, if unavoidable in the long term.

“You mention the word ‘rationing’ and the issue becomes much too emotional,” says Thomas Zeltner, former head of the Federal Health Office. “We don’t want discussions concerning so-called death panels like it happened in the United States.”

“Before we can talk about that, we have to explore every avenue for the optimisation of our healthcare services. There is still room for improvement.”

For Rolf Iten of Infras, a need for rationing must be clearly demonstrated for it to be considered, and resources must be distributed to ensure the widest possible impact for society.

Matthias Schwenkglenks, a medical economics specialist at Basel and Zurich universities who led the SAAS study, says a first step would be the creation of a health technology assessment (HTA) system.

Its role would be to evaluate treatments based on their usefulness and cost while taking into account ethical, social and legal aspects. It would also have to relate to standards agreed by the Swiss population, respect the preferences of insurance holders and guarantee universal healthcare.

The Swiss government has already begun moves towards establishing a HTA agency. Concrete proposals are expected in the coming weeks, but Zeltner warns not to expect a quick result.

“The discussion will not just be technical, but also highly political,” he added. “There will be no institute for quality and patient safety before 2017 at the earliest.”

Healthcare concerns

The QALYs study was prompted by steadily increasing healthcare costs and the lack of medical staff.

Switzerland spent 11.4% of its GDP on health in 2009, well above the Organisation for Economic Co-operation and Development’s average of 9.6%.

According to other figures compiled by the OECD, Switzerland also fares poorly at training new practitioners, well below its member states’ average. Neighbouring Austria manages to produce 2.5 times more doctors per year.

On top of this are also concerns about an ageing population, the increasing number of people suffering from chronic diseases, fewer physicians in rural areas and the merging of hospital services.

The Infras research institute’s threshold study was prompted by the Federal Court decision to limit the acceptable cost of treatments.

The government has been looking at ways of reducing costs by tighter surveillance of insurance companies as well as pharmaceutical firms and making patients shoulder a larger share of the financial burden.