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

For more than 12 years, the debate has continued as to how ideas of value can
be represented by analytical tools such as cost-benefit analysis. For example,
analytical QALYs systems or programme budgeting and marginal analysis
(PBMA) can reach a just and fair decision about who should receive care and
when (Ashton, et al., 1999). These methods are often the subject of criticism
for promoting efficiency over equity, fairness and justice. The use of QALY
league table has become a quantitative approach which gives health
economists comfort that there is rigour in priority setting (Hamilton, 2003).
However, Ham and Coulter (2000) argue that QALY league tables used for
priority setting should come with a ‘large print warning’ about the sometimes
fragile basis for the construction of such tables and the overuse and misuse of
the QALY. This is because QALY’s are being misunderstood and used more
widely to make conclusions than cannot possibly be justified (Hadorn & Brook,
1991).
Research into Micro-Level Rationing
There are many qualitative and quantitative systematic reviews which have
researched how physicians implicitly ration health services to their patients.
The studies generally involve large cohorts of doctors across several
participating countries. The studies attempt to understand how clinical decision
makers meet perceived needs in an environment where calls are being made
on the services which are perceived to be greater than the funders’ ability to
supply services. The importance of these studies is that they extract
anonymously the decisions doctors may make without advising the patients or
their families.
Hurst, Slowther, Forde, Pegoraro, Reiter-Theil, Perrier, Garrett-Mayer and
Danis (2006) surveyed the attitudes of 656 internist doctors to bedside rationing
in Norway, Switzerland, Italy and the United Kingdom. The doctors were asked
about their attitudes towards bedside rationing. In the questionnaire sent to the
participants of the study, bedside rationing was defined as any implicit or explicit
mechanism that allows people to go without beneficial services (Ubel, 2000).
The results of the study showed that 82% of the respondents showed some
degree of agreement with rationing and 56% said that they had rationed health
care in the past (Hurst, et al., 2006).
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