Allocation of Resources

Philip Boyle, Ph.D.

VP, Mission & Ethics

www.CHE.ORG/ETHICS

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Importance of resource allocation?

• Expresses the moral character of organization

Under what circumstances is it permissible to allocate, & perhaps deny

healthcare services?

1. What kind of health care services will exist?

2. Who will get them and on what basis?

3. Who will deliver them?

4. How will the burdens of financing be distributed?

5. How shall the power & control of these services be distributed?

Related questions

• Is perception of the need for limitations accurate?

• Are denials necessary? Defensible?

• Is there a just way to accomplish?

• Where should allocation occur: bedside or nationally?

• Are there procedural safeguards?

Resource allocation

• Happenstance or intentional

• Different goals– Cost containment, appropriate care

• Different practical responses– Don’t ask, don’t tell– Tell, but don’t ask– Tell, and ask

Ways to distribute healthcare• Macro (public policy)

– Eliminate waste– Identify intelligent way to use resources– Public forum –Oregon– Government constraints: (invisible hand)

• Public funds• Restrictions on private funds• Practice of professionals

– Public criteria• Age• Caring versus curing?• Rationing?• Implicit or explicit?

Done everywhere--micro• Triage• Admission & transfer• Futility• Purchasing• Practice parameters• Formulary• Staffing patterns• Equipment

Micro (at bedside)– First come, first serve

• presupposes access to info

– Status: based on society’s sympathies– Merit: past & future contribution– Quality of life / prognosis: discriminatory?– Neediest/worst-off– Age: natural life span– Lottery: only if all things are equal– Those who can afford it– Alternatives

• Forfeiture • Gate keeping

Allocation at beside• Pro

– Always denied a treatment that does more harm than good; better to have MDs in control than outside influence

– Clinicians are moral agents with professional integrity and judgment

– Patients don’t have an unqualified right to request. – Helps the doctor-patient relationship– Must start somewhere; will occur with practice

guidelines– Could cut the cost of any individual

Allocation at beside

• Con– Applied inconsistently: which pts are

chosen– Challenges the doc-pt relationship– Overrides PT autonomy– Peace dividend? Will the saved resources

be transferred?

• An otherwise healthy 78-year-old man came to the emergency department with a pain in his throat and difficulty swallowing. He was found to have a turkey bone lodged in his throat. When the emergency room physician attempted to remove the bone, the patient’s esophagus ruptured. A surgeon attempted several repairs, starting with a thoracotomy. The patient developed an acute infection and was treated with numerous antibiotics, but became septic. He experienced acute liver and kidney failure and respiratory failure and required mechanical ventilation and hemodialysis. The patient was restless, grimacing, and neurologically unresponsive. The staff believed he should be transferred out of the ICU because he was moribund.

• The issue of appropriate ICU management was raised because staff were aware that for rupture of the esophagus the literature reflects nearly a 100 % mortality rate. The patient’s surgeon has had good-but unpublished-results with patients of this sort; he regularly defends his potion with other consultants who maintain the patient is likely to expire early on during the course of treatment.

1. Vital signs are assessed as stable for the individual patient as agreed upon by the attending physician and nurse caring for the patient four (4) hours prior to transfer.

2. Neurological status is assessed to be either the patient's normal preadmission level or at a level of stability that does not require further critical care nursing interventions for four (4) hours prior to transfer.

3. Respiratory status is assessed to be such that the patient is able to maintain adequate ventilation and oxygenation without mechanical assistance four (4) hours prior to transfer.

4. Cardiovascular status is assessed to be such that the patient's tissue perfusion is adequate.

5. Cardiovascular status is assessed to be such that all life-threatening dysrhythmias have resolved to the point where certain IV cardiac medications which are given only in critical care units are no longer necessary to control the dysrhythmia or regulate vascular tone four (4) hours prior to transfer.

6. Fluid and electrolyte status is assessed to be within reasonable limits for the individual patient four (4) hours prior to transfer.

7. Any patient may be discharged from the critical care unit who is determined to be moribund in the assessment of the attending physician and for whom no extraordinary medical measures will be used to prolong life or prevent death.

Case• 21 day length of stay • Policy: To define assessment criteria (that

constitute safe parameters) for transfer or discharge of patients from a critical care unit.

• “Any patient may be discharged from the critical care unit who is determined to be moribund in the assessment of the attending physician and for whom no extraordinary medical measures will be used to prolong life or prevent death.”

Allocating Resources• Which resources should be managed?• Who should make the decision?• Formal & informal mechanisms?

– Is informal still used?– Are they applied evenly?

• What was the goal of the mechanism? – Whose goals are they?– Does the Goal meet intended end?– Is goal defensible? Goal meet inted end?

Resource allocation• Formal analysis

– Are the definitions clear?– Are the reasons for why some therapies

are withheld?– Is it clear about who should decide?– Are there checks and balances?– Is the resource allocation just applied only

to the vulnerable dying or to all instances?– Is broad agreement that treatment is not

beneficial or effective?

Possible moral criteriaMeasurement employed

• Medical or social?

• What unit is measured? Single intervention or episode?

• Effectiveness: effective for what, how long, who judges?

• Severity of illness

• Costs: which should count? Length?

• Social measurements?

Resource allocationInformal analysis– Is the policy evenly applied or are there

variable interpretations?– How does the mechanism work?

• Was there a previous informal mechanism?• Who devised & when is it used?• What is the purpose of the mechanism

– What are the goals of the mechanism?• Whose goals?• Does it meet the goal?

• Due process – notice, in this case information why and

what alternatives exist– means of meaningful appeal– consistency in judgment and action– Correction of bias judgments– transparency to the public and all those

who will affected by the choices– checks & balances

Case of Rosemary• 80 year old • Assisted living• 3 vessel coronary artery disease• 90% stenosis of left main coronary• Cardiologist recommends medical

management• Would it make a difference if:

– 40 or 60 years old?– Living situation?– Method of payment

Macro allocation

• Oregon– Method

• Research & expert testimony on effectiveness of treatment

• A formula that considered cost and benefit• Public values: 47 community meetings; 12

public hearings; 1000 telephone survey• Commissioners’ judgment of what is most

important to Oregonians

Oregon

• Listed 709 conditions/treatments

• Developed 17 categories– Essential 1-9– Very Important 10-13– Valuable to certain individuals 14-17

• Acute v. non-acute

• Fatal v. non-fatal

• Effectiveness of outcomes

OregonEvery person entitled to services necessary for

diagnosis

1.Acute fatal: treatment prevents death and allows for full recovery

Appendectomy, whooping cough

2. Maternity care: most newborn disorders

3.Acute fatal: prevents death but not full recovery

Non-surgical treatment of stroke, burns, TBI

4. Preventive care for children:Immunizations

5. Chronic fatal: improves life span and quality of life

Asthma, drug treatment for HIV

6. Reproductive servicesInfertility services, birth control

7. Comfort carePain management

8. Preventive dental care: exams, cleaning

9. Effective preventive care for adults

Very important

10. Acute non-fatal: return to health

11. Chronic nonfatal: treatment improves the quality of lifeHip replacement

12. Acute non-fatal: treatment but no return to baselineDislocated elbow

14. Chronic non-fatal : repetitive treatment improves quality of life

Valuable to certain individuals

14. Acute non-fatal: treatment speeds recovery Viral sore throat

15. Infertility services16. Less effective preventive care

Routine screening for those not at risk

17. Fatal or non-fatal where treatment causes minimal or no improvement in quality of lifeAggressive end-stage care

Allocating Resources• Which resources should be managed?• Who should make the decision?• Formal & informal mechanisms?

– Is informal still used?– Are they applied evenly?

• What was the goal of the mechanism? – Whose goals are they?– Does the Goal meet intended end?– Is goal defensible? Goal meet inted end?

Measurement employed

• Medical or social?

• What unit is measured? Single intervention or episode?

• Effectiveness: effective for what, how long, who judges?

• Severity of illness

• Costs: which should count? Length?

• Social measurements?

• Due process – notice, in this case information why and

what alternatives exist– means of meaningful appeal– consistency in judgment and action– Correction of bias judgments– transparency to the public and all those

who will affected by the choices– checks & balances

Conclusion

• Denied services only when shortage, exhaust all options

• Applied uniformly

• Open process free of bias

• Clear who decides

• Appeals process