Principles versus procedures in making health care coverage decisions: addressing inevitable conflicts

Abstract

It has been suggested that focusing on procedures when setting priorities for health care avoids the conflicts that arise when attempting to agree on principles. A prominent example of this approach is "accountability for reasonableness." We will argue that the same problem arises with procedural accounts; reasonable people will disagree about central elements in the process. We consider the procedural condition of appeal process and three examples of conflicts over coverage decisions: a patients' rights law in Norway, health technologies coverage recommendations in the UK, and care withheld by HMOs in the US. In each case a process is at the center of controversy, illustrating the difficulties in establishing procedures that are widely accepted as legitimate. Further work must be done in developing procedural frameworks.

Public participation in decision-making on the coverage of new antivirals for hepatitis C

“…Regardless of where priority-setting takes place, it is concerned with making decisions that provide a good quality, and a fair, health service while ensuring that the health system is sustainable. The extant literature suggests that public input into the choices made should be included as one important criterion against which to assess the fairness of prioritization decisions (Sibbald et al, 2009;Kapiriri and Martin, 2010;Sabik and Lie, 2008). However, barriers to public involvement exist (Goold et al, 2005) and little empirical evidence is available on the effect of PPI generally, and different modes of PPI such as deliberative processes specifically (Mitton et al, 2009;Abelson et al, 2003).…”

“…Because more than one relevant consideration generally bears on priority-setting questions, relevant considerations often conflict and there is no consensus among decision-makers, commentators or the public at large as to how to trade them off against each other. Daniels and Sabin give PPI a role in ensuring fair process and many commentators argue that it should take center-stage (Emanuel, 2002;Friedman, 2008;Rid, 2009;Sabik and Lie, 2008 The article proceeds by providing a brief conceptual overview of health priority-setting and PPI, the methods and data for the case studies, the new HCV medicines generally, and of sofosbuvir particularly. These sections set the scene for the discussions of the country case studies and the conclusion in the latter parts of the article.…”

Accountability for reasonableness: the relevance, or not, of exceptionality in resource allocation

“…For a discussion of the latter issue see Sabik and Lie (2008). mindedness presents a significant challenge to implementing the relevance condition.…”

Publish or be damned: Individual Funding Requests and the publicity condition

“…Some have questioned whether A4R's conditions encapsulate the requirements of procedural justice, whether it is an account of procedural justice15 and, most piercingly, whether it truly offers a route around substantive questions of distributive justice 16–18. Questions have been raised about the sufficiency of the conditions,15–17 19 20 their clarity and their practical application 15 16 18 21. However, there is little suggestion that the conditions that Daniels and Sabin have formulated are irrelevant to healthcare funding decision-making.…”