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Reference: Paying for Cures: Perspectives on Solutions to the “Affordability Issue” Karlsberg Schaffer K et aljournal

This weeks paper of the week is brought to you by Professor Sir Muir Gray, 3V Executive Director.

Bottom line

‘We conclude that there is a mismatch between the enthusiasm in the academic literature for developing new approaches and the scepticism of payers that they can work or are necessary. For the foreseeable future, affordability pressures will continue to be handled by aggressive price bargaining, high co-pays (in systems in which this is possible), and restricting access to subgroups of patients. Of the mechanisms we explored, outcomes-based payments were of most interest to payers, but the costs associated with operating such schemes, together with implementation challenges, did not make them an attractive option for managing affordability.’

Implications for value improvement 

Ken Arrow’s impossibility theorem ( demonstrated once again. There is no single formula nor any single ethical principle that can make these decisions for us. We have to make them as well as we can, and if we are to rely on one principle it is that we need to be accountable for the fairness and reasonableness of our decision making process as described by Daniels and Sabin.

Accountability for reasonableness is the idea that the reasons or rationales for important limit-setting decisions should be publicly available.   In addition, these reasons must be ones that ‘fair-minded’ people can agree are relevant to pursuing appropriate patient care under necessary resource constraints (Daniels & Sabin, 1998b).

This is our central thesis, and it needs some explanation.

‘By ‘fair-minded’, we do not simply mean our friends or people who just happen to agree with us.   We mean people who in principle seek to cooperate with others on terms they can justify to each other.   Indeed, fair-minded people accept rules of the game – or sometimes seek rule changes – that promote the game’s essential skills and the excitement their use produces.’

Source:   Daniels, N. and Sabin, J.E.   (2008)   Setting Limits Fairly,  Learning to Share Resources for Health.    Oxford University Press.   (p.44).