Search

Many new cancer drugs provide only limited benefits, but at very great cost, for example, $200,000-$300,000 per quality-adjusted life year produced. By most standards of value or cost-effectiveness, this does not represent good value. I first review several of the causes of this value failure, including monopoly patents, prohibitions on Medicare's negotiating on drug prices, health insurance protecting patients from costs, and financial incentives of physicians to use these drugs. Besides value or cost-effectiveness, the other principal aim in health care resource allocation should be equity among the population served. I examine several equity considerations-priority to the worse off, aggregation and special priority to life extension, and the rule of rescue-and argue that none justifies greater priority for cancer treatment on the grounds of equity. Finally, I conclude by noting two recent policy changes that are in the wrong direction for achieving value in cancer care, and suggesting some small steps that could take us in the right direction.

Basic economic theory suggests that health insurance coverage may cause a reduction in prevention activities, but empirical studies have yet to provide much evidence to support this prediction. However, in other insurance contexts that involve adverse health events, evidence of ex ante moral hazard is more consistent. In this paper, we extend the analysis of the effect of health insurance on health behaviors by allowing for the possibility that health insurance has a direct (ex ante moral hazard) and indirect effect on health behaviors. The indirect effect works through changes in health promotion information and the probability of illness that may be a byproduct of insurance-induced greater contact with medical professionals. We identify these two effects and in doing so identify the pure ex ante moral hazard effect. This study exploits the plausibly exogenous variation in health insurance as a result of obtaining Medicare coverage at age 65. We find evidence that obtaining health insurance reduces prevention and increases unhealthy behaviors among elderly men. We also find evidence that physician counseling is successful in changing health behaviors.

Many countries have imposed strict regulations on the genetic information to which insurers have access. Commentators have warned against the emerging body of legislation for different reasons. This paper demonstrates that, when confronted with the argument that genetic information should be available to insurers for health insurance underwriting purposes, one should avoid appeals to rights of genetic privacy and genetic ignorance. The principle of equality of opportunity may nevertheless warrant restrictions. A choice-based account of this principle implies that it is unfair to hold people responsible for the consequences of the genetic lottery, since we have no choice in selecting our genotype or the expression of it. However appealing, this view does not take us all the way to an adequate justification of inaccessibility of genetic information. A contractarian account, suggesting that health is a condition of opportunity and that healthcare is an essential good, seems more promising. I conclude that if or when predictive medical tests (such as genetic tests) are developed with significant actuarial value, individuals have less reason to accept as fair institutions that limit access to healthcare on the grounds of risk status. Given the assumption that a division of risk pools in accordance with a rough estimate of people's level of (genetic) risk will occur, fairness and justice favour universal health insurance based on solidarity.

Background: The primary objective of this pilot study is to understand the relationship between physicians' characteristics and physicians' management decisions about pain. The secondary aim is to understand how patient characteristics, including race/ethnicity and socioeconomic status (SES) may affect these treatment decisions in chronic low back pain., Methods: We conducted a double-blinded randomized controlled study using a survey instrument. Ninety physicians were randomly allocated one of two scenarios of a patient with chronic low back and lower extremity pain. In one version, the patient is a Caucasian male with Blue Cross health insurance. In the other version, the patient is an African American male with Medicaid. All other aspects of the survey scenarios are identical. The physicians were subsequently presented with questionnaires about their treatment plans. We analyzed the physician demographic variables in addition to patient ethnicity and SES to differentiate which variables affected treatment preferences., Results: Based on bivariate analysis, physician specialty, gender, ethnicity, and professional status significantly affected treatment plans, including analgesic prescription and referrals for invasive therapy. Patient ethnicity/SES trended toward significance for the prescription of opioids., Conclusion: Our study is the first randomized controlled study assessing patient and treatment variables in the management of chronic pain. It suggests that physicians' demographic variables and perhaps patient demographic variables influence pain management decisions.

Coverage with evidence development (CED) is an evolving method of providing provisional access to novel medical interventions while generating the evidence needed to determine whether unconditional coverage is warranted. In this article we review the policy rationale for CED and present a normative analysis that addresses ethical concerns and policy implications.

Genomics provides information on genetic susceptibility to diseases and new possibilities for interventions which can fundamentally alter the design of fair health policies. The aim of this paper is to explore implications of genomics from the perspective of equal opportunity ethics. The ideal of equal opportunity requires that individuals are held responsible for some, but not all, factors that affect their health. Informational problems, however, often make it difficult to implement the ideal of equal opportunity in the context of healthcare. In this paper, examples are considered of how new genetic information may affect the way individual responsibility for choice is assigned. It is also argued that genomics may result in relocation of the responsibility cut by providing both new information and new technology. Finally, how genomics may affect healthcare policies and the market for health insurance is discussed.

I will focus on Dworkin's use of idealisation in his "Prudent Insurance" Ideal for healthcare. Dworkin identifies problems with the circumstances under which people make their insurance decisions in the current United States healthcare system and he sees these as being the cause of strange resource allocation outcomes. He therefore imagines idealising away these prima facie unjust circumstances to develop a hypothetical market in which people are able to make better decisions (Section "Idealisation of Circumstance"). I will identify two further idealisations that Dworkin relies on in his theory. The first is to idealise people to be perfectly prudent (Section "Idealisation of Prudence"), which I consider to be justifiable, but difficult to actually apply in practise. The second is to idealise people to be perfectly self-interested (Section "Idealisation to Self-interest"). I do not see this as a justifiable idealization since it ignores principles of altruism and citizenship, which would seem to be deeply relevant to a theory of justice.

Genetic-specific nondiscrimination laws have been enacted in most states, but the laws are ineffective and increase the stigma of genetic conditions. Whether these laws are better than no new legislation depends on their consequences and a recognition of their limitations.

Universal access to health care has historically faced strident opposition from political conservatives in the United States, although it has long been accepted by most conservatives in the rest of the industrialized world. Now, in a global economy where American business is crippled by the rising cost of market-based health care, the time may be ripe for change. The key to fostering a new mindset among American conservatives is to show why universal access fulfills many of the basic values that all conservatives hold.

Uniform, risk-independent insurance premiums are accepted as part of 'managed competition' in health care. However, they are not compatible with optimality of health insurance contracts in the presence of both ex ante and ex post moral hazard. They have adverse effects on insurer behaviour even if risk adjustment is taken into account. Risk-based premiums combined with means-tested, tax-financed transfers are advocated as an alternative.