Effizienz und Fairness: Bevölkerungspräferenzen für die Allokation von Ressourcen

Zusammenfassung

Traditionell orientiert sich die Gesundheitsökonomie in der Frage, wie knappe Ressourcen im Gesundheitssystem verteilt werden sollen, an dem Effizienzkriterium. Die begrenzten Mittel sollen so eingesetzt werden, dass damit die in der Bevölkerung zusätzlich erzielbare Gesundheit maximiert wird. Der gesundheitliche Nutzenzuwachs (Lebenslänge, Lebensqualität) wird damit zum Maximand. Eine rein Effizienz-orientierte Ressourcenallokation kann jedoch eine starke Verteilungswirkung entfalten, die von vielen Menschen als unfair oder ungerecht empfunden und daher abgelehnt wird. Inzwischen liegt umfangreiche empirische Evidenz dazu vor, welche alternativen oder zusätzlichen Kriterien für die Mitglieder der Bevölkerung in der Bewertung des Nutzens medizinischer Massnahmen bedeutsam sind. Drei dieser möglichen Kriterien werden exemplarisch vorgestellt und in ihren Konsequenzen diskutiert. Zwar ist der Zuwachs an Gesundheit ein wichtiges, vielleicht sogar zentrales Kriterium, aber ein schlechter Gesundheitszustand, ein limitiertes Gesundheitspotenzial sowie weitere persönliche Faktoren der betroffenen Patienten kompensieren – zum Teil erheblich – für erzielbare Gesundheitsverbesserungen. Von der Bevölkerung akzeptierte und solidarisch getragene Systeme zur Nutzenbewertung müssen zukünftig explizit verschiedene Faktoren des gesellschaftlichen und individuellen Nutzens von Gesundheitsleistungen berücksichtigen und ihr relatives Gewicht zueinander abwägen.

Abstract

Traditionally, health economics have been orientated on the question as to how the limited resources should be allocated, on the efficiency criterion. The limited resources should be used in such a way that the additionally achievable health in the population is maximised. The increased health benefits (life expectance, quality of life) are the factor to is maximised. A purely efficency-orientated allocation of resources can, however, have a strong distribution effect that would be considered as unfair and unjust by many people and consequently not be accepted. In the meantime there is a body of empirical data evidence about the alternatives or additional criteria that are important for members of the population in the assesment of utility of medical interventions. Three of these possible criteria are discussed as examples here. Although the improvement in health is an important, perhaps even central criterion, a poor state of health, a limited health potential as well as other personal factors for the afflicted patient may, in part considerably, compensante for the achievable improvement in health. Systems for the evaluation of utility that will be accepted and supported by the general public must in future take into consideration the various explicit factors of the societal and individual benefits of health-care interventions and balance their relative importances.

Schlüsselwörter

Ressourcenallokation - Prioritätensetzung - gesellschaftliche Präferenzen - qualitäts-adjustiertes Lebensjahr

Key words

allocation of resources - setting priorities - societal preferences - quality-adjusted life expectancy

Literatur

• 1 Tsuchiya A, Williams A. A “fair innings” between the sexes: are men being treated inequitably?.  Soc Sci Med. 2005;  60 277-286
• 2 Westphal R, Rostermundt A, Raspe H. Significance of selected preventive, therapeutic and rehabilitation services reflected in a population survey.  Gesundheitswesen. 2001;  63 302-310
• 3 Bowling A. Health care rationing: the public's debate.  BMJ. 1996;  312 670-674
• 4 Matschinger H, Angermeyer MC. The public's preferences concerning the allocation of financial resources to health care: results from a representative population survey in Germany.  Eur Psychiatry. 2004;  19 478-482
• 5 Schwappach DL. Resource allocation, social values and the QALY: a review of the debate and empirical evidence.  Health Expect. 2002;  5 210-222
• 6 Dolan P, Shaw R, Tsuchiya A. et al . QALY maximisation and people's preferences: a methodological review of the literature.  Health Econ. 2005;  14 197-208
• 7 Menzel P, Gold MR, Nord E. et al . Toward a broader view of values in cost-effectiveness analysis of health.  Hastings Cent Rep. 1999;  29 7-15
• 8 Dolan P, Cookson R. A qualitative study of the extent to which health gain matters when choosing between groups of patients.  Health Policy. 2000;  51 19-30
• 9 Dolan P, Shaw R. A note on the relative importance that people attach to different factors when setting priorities in health care.  Health Expect. 2003;  6 53-59
• 10 Bryan S, Roberts T, Heginbotham C. et al . QALY-maximisation and public preferences: results from a general population survey.  Health Econ. 2002;  11 679-693
• 11 Nord E. The trade-off between severity of illness and treatment effect in cost-value analysis of health care.  Health Policy. 1993;  24 227-238
• 12 Nord E. Concerns for the worse off: fair innings versus severity.  Soc Sci Med. 2005;  60 257-263
• 13 Cookson R, Dolan P. Public views on health care rationing: A group discussion study.  Health Policy. 1999;  49 63-74
• 14 Ubel PA. How stable are people's preferences for giving priority to severely ill patients?.  Soc Sci Med. 1999;  49 895-903
• 15 Gyrd-Hansen D. Investigating the social value of health changes.  J Health Econ. 2004;  23 1101-1116
• 16 Abellan-Perpinan JM, Pinto-Prades JL. Health state after treatment: a reason for discrimination?.  Health Econ. 1999;  8 701-707
• 17 Schwappach DL. Does it matter who you are or what you gain?. An experimental study of preferences for resource allocation.  Health Econ. 2003;  12 255-267
• 18 Nord E, Street A, Richardson J. et al . The significance of age and duration of effect in social evaluation of health care.  Health Care Anal. 1996;  4 103-111
• 19 Tsuchiya A. Age-related preferences and age weighting health benefits.  Soc Sci Med. 1999;  48 267-276
• 20 Tsuchiya A, Dolan P, Shaw R. Measuring people's preferences regarding ageism in health: some methodological issues and some fresh evidence.  Soc Sci Med. 2003;  57 687-696
• 21 Stolk EA, Pickee SJ, Ament AH. et al . Equity in health care prioritisation: An empirical inquiry into social value.  Health Policy. 2005;  74 343-355
• 22 Rodriguez E, Pinto JL. The social value of health programmes: is age a relevant factor?.  Health Econ. 2000;  9 611-621
• 23 Johri M, Damschroder LJ, Zikmund-Fisher BJ. et al . The importance of age in allocating health care resources: does intervention-type matter?.  Health Econ. 2005;  14 669-678
• 24 Williams A. Intergenerational equity: an exploration of the ‘fair innings’ argument.  Health Econ. 1997;  6 117-132
• 25 Murray CJ, Acharya AK. Understanding DALYs (disability-adjusted life years).  J Health Econ. 1997;  16 703-730
• 26 Murray CJ. Quantifying the burden of disease: the technical basis for disability-adjusted life years.  Bull World Health Organ. 1994;  72 429-445
• 27 Edwards RT, Boland A, Wilkinson C. et al . Clinical and lay preferences for the explicit prioritisation of elective waiting lists: survey evidence from Wales.  Health Policy. 2003;  63 229-237
• 28 Dolan P, Shaw R. A note on a discussion group study of public preferences regarding priorities in the allocation of donor kidneys.  Health Policy. 2004;  68 31-36
• 29 Nord E, Richardson J, Street A. et al . Maximizing health benefits vs egalitarianism: an Australian survey of health issues.  Soc Sci Med. 1995;  41 1429-1437
• 30 Ratcliffe J. Public preferences for the allocation of donor liver grafts for transplantation.  Health Econ. 2000;  9 137-148
• 31 Wittenberg E, Goldie SJ, Fischhoff B. et al . Rationing decisions and individual responsibility for illness: are all lives equal?.  Med Decis Making. 2003;  23 194-211
• 32 Schwappach DLB. Are preferences for equality a matter of perspective?.  Med Decis Making. 2005;  25 449-459
• 33 Schwappach DLB, Strasmann TJ. Quick and dirty numbers. The reliability of an internet-based stated-preference technique for the measurement of preferences for resource allocation.  J Health Econ. 2006;  25 432-448
• 34 Rodriguez-Miguez E, Herrero C, Pinto-Prades JL. Using a point system in the management of waiting lists: the case of cataracts.  Soc Sci Med. 2004;  59 585-594
• 35 Ryan M, Miguel FS, Cabases J. et al. .Using discrete choice experiments to develop prioritisation scoring systems. Paper presented at the iHEA 5th World Congress of Health Economics. Universitat Pompeu Fabra, Barcelona 2005

Korrespondenzadresse