How does the operation of PHARMAC's 'Community Exceptional ...

Another form of decision making used by PHARMAC to determine allocations
under the ‘Community Exceptional Circumstances’ policy has been the use of
the definition of rarity, referred to in this thesis as the “10 cases” rule. This rule
was applied to some claims and not applied to others. There was no rational
basis for choosing this rule. A key informant interviewee said he/she felt the
number 10 was a good idea and it “felt about right”’. Many contributors to this
research stated that this was a mechanism for managing PHARMAC’s budgets
rather than a definition of the term exceptional. Contributors said that it would
be better for PHARMAC to drop the ‘10 cases’ rule and instead, where
Community Exceptional Circumstances claims cannot be afforded PHARMAC
should be open and say this is the real reason for the decision. Such an action
would not please Ministers of Health, because pressure would be then directed
at the government, implying that PHARMAC is not being provided with
adequate resources to meet these exceptional needs.
The second part of test-question 3 asks if there has been general agreement
on how these substantive opportunities have been assessed. Theme 4,
PHARMAC - No Stated Philosophy demonstrated that there was a range of
opinion in New Zealand about how one should measure the costs and benefits
of such spending. Behind any measure of good, value for money or a general
public good, is a value proposition of the social conditions (Cheyne et al.,
2008), the nature of the problem and the remedy which should prevail. No one
philosophical position is agreed to manage such a proposition, other than the
broad acceptance that PHARMAC is doing a good job and so its processes are
reasonably effective and reasonably fair.
Many contributors considered that the personal costs and benefits (to
themselves and their families) should also be considered in the QALY
measurement of the value of providing for meetable needs (Gillon, 2006)
PHARMAC claims that the model must remain blind to a claimant’s personal
circumstances because to do otherwise would create unfair, un-measurable
and incomparable results and this would invalidate the cost-utility analysis.
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