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Bottom-up priority setting: The Lübeck project

Country: 
Germany
Partner Institute: 
University of Technology, Berlin
Survey no: 
(16)2010
Author(s): 
Hoffmann, Christine and Busse, Reinhard
Health Policy Issues: 
Public Health, System Organisation/ Integration, Political Context, Quality Improvement, Benefit Basket, Responsiveness
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes yes no no no no no

Abstract

Priority setting as a tool to optimize resource allocation in the health care system has never been subject of serious consideration in Germany. The Lübeck ?Institut für Sozialmedizin? evaluated citizens? opinions on priority setting by organizing a survey and a citizens? round table. This unique approach explores the question of basic values in health care by using civil participation. This bottom-up approach was perceived as a promising possibility for the future.

Purpose of health policy or idea

Priority setting- originally a principle to improve the workflow

The concept of prioritizing emerged within the context of organizing work activities and is driven by the objective of optimal resource allocation. It implies deciding on importance or urgency of competing demands or offers. "Prioritizing" in health care is an idea which was developed in the early 1980s. The basic idea was to organize demands in a similar way as done in work activities. This meant to ask the question of whether certain health care needs are more important than others, and to obtain a ranking of competing demands. In order to make a decision on importance, criteria are needed.

Ethical prioritizing criteria - essential in healthcare but only beside others

In every health care system the concept of health care is ultimately defined by ethics. Thus, a ranking of health care measures usually involves ethical considerations. A long history of ethical discussions on the ranking of demands exists in various countries (e.g. Oregon or New Zealand, see references below), yielding ranking criteria. However, the decision on ethically accepted criteria is only the first step. The application of the chosen criteria requires an extensive use of knowledge from various disciplines, especially medical knowledge, but also e.g. economics. Additional criteria have to be taken from those disciplines.

The Lübeck project - evaluating citizens' opinion

The Lübeck pilot project, initiated by physician and professor of social medicine Heiner Raspe, is a unique approach, as it does not only rely on experts´ opinions, but primarily on citizens' opinions. Raspe wanted to demonstrate that not only experts are able to reflect on the theory and application of prioritizing, but that citizens are capable of forming an opinion on this subject as well, something that is often doubted. The project's goal was to identify a set of sound criteria which are widely accepted for prioritizing. The Lübeck project combined two ways of investigating the political will. First, a survey was conducted which investigated the acceptance of criteria, and, in a second step, a citizens' round table ("Bürgerkonferenz") was organized. The idea of discussing prioritizing with the public is not entirely new, but it had never been realized in Germany before, as prioritizing is a seen as a taboo subject. In this project prioritizing was regarded as a preliminary decision on criteria which were considered to lead to a transparent ranking list. Various criteria were proposed and discussed by the participants. Moreover, some experts could be heard by the group, e.g. a German medical doctor working in Sweden was interviewed on his experience with Swedish prioritizing. As a result, the round table accepted the criteria proposed. The results of the citizens' round table were published as a citizens' vote ("Bürgervotum").

The current state - individual health care measures do not depend on the other insured's demands

In Germany prioritizing care measures are against the social and legal consensus. The social code book V (SBG V) guarantees a necessary, efficient and sufficient treatment for every insured person, independently from the needs of the other insured. Misleadingly, the use of evidence based medicine and health technology assessment in finding the best treatment for one condition is often considered as prioritizing. However, HTA aims at figuring out whether the criteria of the SGB V are fulfilled. The ranking obtained in HTA serves to identify the best treatment for a particular condition, while prioritizing means choosing the most important out of several treatments which are not replacable. In all circumstances only one ("the best") treatment per condition is reimbursed per patient. Even if unlimited resources were available, this would not mean to apply all available treatments assessed in a comparing HTA at once. Prioritizing is a ranking of items which cannot replace one another e.g. diseases or forms of health care. Curative medicine cannot be substituted by preventive medicine. Assuming limited resources and a ranking of disease importance, prioritizing means accepting to deprive a patient of a curative treatment, when other patients' diseases are more important. The same scenario with unlimited resources would lead to administering a treatment to everyone, independently from the rank of the disease.

Prioritized lists of health care measures are helpful

In order to make a decision on the importance of a treatment in a given situation a listing according to widely accepted criteria would be helpful. The criteria applied would be transparent. This list would be a good base for discussing and regulating the health care system.

Prioritizing does not mean rationing

Raspe and his team stress that ranking does not necessarily mean rationing. This is because an existing ranking list on the importance of treatments does not automatically mean to take resources away from "unimportant" treatments, as this is an additional decision.

Nevertheless: Low Acceptance of Prioritizing

It is supposed that prioritizing treatments is not welcomed by citizens, although in the fields of triage and organ donation it is accepted to set priorities. Yet, this is because these resources are effectively limited, while resources in health care could theoretically grow by augmented spending.

Main points

Main objectives

Finding principles for the ranking of health care measures (prioritizing).

Type of incentives

The possibility of public participation.

Groups affected

Citizens, stakeholders in the health care system

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual highly controversial highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low low very high
Transferability strongly system-dependent strongly system-dependent system-neutral

The approach is innovative. As it was a short and small project the visibility was given but rather low.

Political and economic background

As widely known, the German health care system faces serious financial problems. Root causes are seen in the aging society, increasing costs for medical innovations and sinking revenues of statutory health insurance funds, as a result of a diminishing percentage of wage earners. Besides financial issues, it is sometimes said that there are long waiting times for doctor´s appointments. Various approaches have been undertaken to address these problems.

Prioritizing is often seen as a measure to avoid increased spending by allocating scarce resources in an equitable way. Prioritizing is also often supposed to imply a controlled rationing of health care services although this is not neccesarily the case, even if one treatment is seen as more important than another. As already mentioned above, this contradicts existing law and ethical convictions on health care. Political authorities aggressively refuse the option of using priority setting. Political proposals, such as the exclusion of the elderly from orthopedical surgery, are seen as a provocation.

Physicians often stress that they are already facing a situation of prioritizing, even if this is not politically recognized, as they are obliged to operate within fixed budgets. Due to the impression that the budget often does not seem to be sufficient, the doctors have got the feeling they have to decide about priorities on their own. As the chairman of the Federal Physicians Chamber said, doctors feel a lot of pressure, as they have the impression that they must make decisions without legitimate support. German physicians have a practical need for prioritizing criteria.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes yes no no no no no

Origins of health policy idea

Priority setting has been neglected for a long time by physicians

While other countries tried to control resource problems by priority setting, this has never been a popular idea in Germany. Heiner Raspe's lonely attempt in 2000, as a member of the commission on ethics of the Federal Physicians Chamber, evoked no reaction. Political provocations as the aforementioned call for the exclusion of the elderly from certain health care were always condemned as disrespecting human dignity, especially by physicians and their representing organizations. Since the introduction of fixed physicians' budgets, they have to prioritize unofficially on their own. Later, the political agenda of the physicians' organizations changed, and now the Federal Physician Chamber argues for priority setting in order to legitimize the decisions physicians have to make.

Physicians asking for a legal prioritizing-foundation

One argument is that physicians should be relieved from feelings of guilt that arise when they have to deny treatment. Hoppe, chairman of the Federal Physicians Chamber, proposed to establish a commission for prioritizing which should belong to the Federal Joint Committee consisting of physician delegates. The approach of the commission should be similar to the Swedish prioritizing method with "horizontal" and "vertical prioritizing". "Vertical prioritizing" means a ranking of treatments (for certain conditions) within one branche of surgery. Vice versa, "horizontal prioritizing" means prioritizing of (all) other heterogeneous competing classes of health care related factors, e.g. forms of care or regions to activate. The proposed commission would create a catalogue in which treatments and diseases are assigned a certain rank and importance. Disregarding these claims, politicians still do not acknowledge the fact that physicians are forced to unofficial prioritizing due to resource constraints.

Scientific research on the topic

In the noughties the large interdisciplinary science project "Priorisierung in der Medizin" (prioritizing in medicine) commenced, but its adoption is limited to the scientific field.

The Lübeck approach is more fundamental

The approach of the citizens' round table in Lübeck is more fundamental than the physicians' claims, as its target is to find a consensus on values or principles in health care. Citizens are seen as individuals responsible for political progress. The goal of the initiators of the citizens' round table was to openly discuss prioritizing given that resources are always limited. In addition, the questions "What is important to us in health care?" and "How could we decide on priorities?" were to be answered. To discuss principles for prioritizing means rethinking political goals in health care. The pilot project described brings the fundamental targets of health care, that go beyond the negotiations of stakeholder groups on financially optimizing the system, back into discussion. A final statement was published by the citizens' round table. The results of the survey have not yet been published. The round table agreed on most criteria used nowadays for making treatment decisions: efficiency, quality of life, cost effectiveness, etc. Other criteria, such as need to care for a family, risky behaviour and restoring the ability to work provoked controversion. Yet, those are not relevant criteria for health care treatment allocation in the German system.

Citizens' round tables inspire politics

A citizens' round table is a way of the civil society to contribute of  the forming of the political will. Although this process takes place within the political parties, grassroot movements played an important role during mayor political changes, e.g. for the ecological turn of German politics in the eighties. Grassroot movements enjoy the advantage of not being dependent from party political restraints. So the statement of the citizens' round table could be seen as a rather independent suggestion to responsible politicians.  Likewise it could serve as a stimulus for  further public discussions.

Initiators of idea/main actors

  • Civil Society
  • Scientific Community: The Lübeck

Approach of idea

The approach of the idea is described as:
new: Similar projects took place in other countries but not yet in Germany.

Innovation or pilot project

Pilot project - A survey and a citizens' round table were organized to discuss prioritizing in health care.

Stakeholder positions

The citizens' round table published its results as a "citizens' vote"("Bürgervotum"). The survey's results have not been published yet.

Actors and positions

Description of actors and their positions
Civil Society
survey's participantsvery supportivevery supportive strongly opposed
round table's participantsvery supportivevery supportive strongly opposed
Scientific Community
Lübeckvery supportiveneutral strongly opposed

Actors and influence

Description of actors and their influence

Civil Society
survey's participantsvery strongnone none
round table's participantsvery strongnone none
Scientific Community
Lübeckvery strongneutral none
survey's participants, round table's participantsLübeck

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

 No further adoption has been foreseen yet.

Expected outcome

Even after many health reforms were implemented, prioritizing has not yet been a serious subject of public discussions, nor was this true for the question of principles of health care in the German health system. For a long time the debate is restricted to discussions on the allocation of financial resources to different stakeholders.

The idea of the citizens' poll and round table is convincing as it asks the direct beneficiaries of health care about their opinion, or in other words the electorate who determine the political direction of the health care system. Asking citizens about health care priorities could launch a public debate on health policy, which is different from the one of the past years. Discussing the values and principles of health policy might be a chance to develop new models in a grassroots approach. This would empower political parties to implement new accepted models in order to solve the system´s problems without too much consideration for existing structures. In addition, political parties could analyse the system, considering its goals and not only its stakeholders. A new discussion on the goals of health care opens a chance for a substantial debate without practical constraints.

Would it be sufficient to limit the discussion to the "value" or "principle"-subject independently from their importance? As most principles are known, accepted and even fixed in the social law this is not an option. Obviously, resources are limited nowadays. The problem is how one should act when legally fixed principles, such as efficiency and guaranteed treatment rights, interfere. On the one hand, the discussion on prioritizing in order to produce a ranking of principles is useful for understanding that the newest treatment a patient might desire is so expensive that it will inhibit treatment for other patients. On the other hand: Of what use is a pharmaceutical, which is not efficient, even when it is cheaper than another one? A growing public debate on those questions would return political responsibility for the German health care system to the citizens.

Impact of this policy

Quality of Health Care Services marginal marginal fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low neutral very high

The model project was rather small, there is no high impact.

References

Sources of Information

Author/s and/or contributors to this survey

Hoffmann, Christine and Busse, Reinhard

Suggested citation for this online article

Hoffmann, Christine and Busse, Reinhard. "Bottom-up priority setting: The Lübeck project". Health Policy Monitor, December 2010. Available at http://www.hpm.org/survey/de/a16/1