Clin Ethics 2008;3:168-170
doi:10.1258/ce.2008.008039
© 2008 Royal Society of Medicine Press
Co-payment for medical treatment
Anne Slowther
Institute of Clinical Education, Warwick Medical School, UK
E-mail: a-m.slowther{at}warwick.ac.uk
In 2004, the then Minister of State for Health in the UK, John Hutton, stated:
‘We strongly believe that the introduction of vouchers, passports, co-payment, or extra charges to patients will have a regressive impact on the health of our people – as all of the international evidence confirms. That is why a patient's passport to personal health should not be dependent on a patient's personal wealth.’1
This unequivocal position now appears to be less secure in 2008 due to a number of factors including:
- The continued increase in the number of innovative (but expensive) treatments available in the health-care market;
- Several high-profile challenges to decisions by the National Institute of Health and Clinical Excellence (NICE) with regard to funding for new treatments, for example drugs for Alzheimer's disease and certain forms of cancer;2,3
- Specific case reports precipitating a public debate about the permissibility of patients paying for treatments not funded by the National Health Service (NHS) as part of their NHS care.4
The specific issue of co-payment for drugs not funded by the NHS is now the subject of a Government-commissioned review of policy in this area, chaired by Professor Mike Richards and expected to report in October 2008. The ethical dilemmas raised by requests from patients to be able to pay for a treatment currently not funded by the NHS but which the patient and clinician consider a desirable treatment option have been discussed previously in this journal and elsewhere.5,6 It is also a problem that is brought to clinical ethics committees and one which challenges us to reflect on the core values of the NHS. In this FMF we will consider the ethical values and arguments underpinning the debate.
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What is co-payment?
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Co-payment for medical care is a feature of many health-care
systems. This may be part of the standard health-care package,
so that a co-payment (of varying value) is required for every
hospital outpatient appointment or GP consultation.
7 Or it might
be for specific treatments, for example in Germany patients
undergoing
in vitro fertilization treatment are required to
pay 50% of the treatment costs for each cycle.
8 Co-payments
also occur within the UK NHS although these have tended to be
implicit rather than explicit. Thus, GPs will provide private
prescriptions for malaria prophylaxis medication while providing
some travel immunizations as part of NHS care, or a patient
may pay for a private magnetic resonance imaging scan rather
than wait for the NHS scan that her consultant has requested.
One could argue that prescription charges
per se are a form
of co-payment. The role of NICE in assessing new technologies
and issuing directives on whether specific treatments should
be funded by the NHS has thrown the question of co-payment into
sharp relief. The focus of the public debate, and the government
policy review, is the specific issue of payment by patients
for treatment that is not funded by the NHS (often following
a NICE recommendation)
within the context of a NHS treatment
programme. Current policy states that patients wishing to do
this should pay for their whole treatment programme privately.
It is this specific model of co-payment which we will consider
here although the ethical values discussed will be relevant
to other models.
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Individual autonomy and the right to choose specific treatments
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A strong argument in favour of allowing co-payments rests on
respect for the autonomy of an individual patient to make treatment
decisions, including decisions about whether the cost of a specific
treatment is worth paying for the potential benefit gained.
Decisions about whether to pay for a treatment will be informed
by both evidence of clinical effectiveness (it provides some
benefit in terms of increased quality or length of life) and
cost. However, the value placed on the treatment in terms of
how much one is willing to pay for the benefit gained may be
very different depending on who is making the judgement. Thus,
NICE may consider a treatment too costly in relation to its
benefit for the NHS to afford within its budget constraints,
but, as Mohindra has pointed out, an individual patient does
not make value judgements from the perspective of the NHS as
a whole.
5 For her the price may be worth paying. To prevent
a patient from making that choice would be seen as an infringement
of her autonomy.
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Duty of care and the doctor–patient relationship
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The primary duty of a doctor is to make the care of his or her
patient their first concern.
9 If a doctor considers that a particular
treatment would be in his or her patient's best interests, refusal
to provide the treatment could be seen as a breach of this duty.
It is generally accepted that external constraints, which could
include NICE directives, NHS contractual obligations or limited
resources, will mitigate this duty to some extent.
10 The current
debate on co-payments raises the question of whether government
policy should constrain a doctor's duty of care to his or her
patient in this context.
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Utilitarian arguments for and against co-payment
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Utilitarianism requires that for decisions to be morally acceptable
they should maximize overall benefit. A criticism that is often
levelled at NICE is that it takes a purely utilitarian view
when making its recommendations, considering only the cost-effectiveness
of treatments at a population level and ignoring the level of
individual need and suffering of patients and their carers.
11 This appears to be the crux of the objection to co-payments
made by John Hutton in the speech quoted above.
1 A critique
of the ethics of resource allocation and utilitarianism in general
is beyond the scope of this article, but most critics of utilitarianism
would concede that when making decisions at a population level
within a limited budget, it is desirable to ensure efficient
use of resources to benefit the maximum number of people. This
may mean that some less cost-effective treatments are not funded.
However, supporters of co-payments have argued that they increase
efficiency by increasing the number of patients who will benefit
from the effective but expensive treatment at no extra cost
to the NHS. Thus, the overall benefit will be increased by co-payments.
5
The argument for increased efficiency and therefore increased overall benefit from co-payments is based on the assumption that there is no corresponding loss of benefit to patients who do not or cannot choose the co-payment option. If this is not the case, then an assessment of overall harms and benefits would have to be made. For example, if the co-payment treatment required extra resources to be administered or to monitor for toxicity and treat side-effects, then other patients may be harmed by the diversion of resources from their care.
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Consideration of equity in the co-payment debate
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A key argument against co-payments in the UK health system is
that they run counter to the NHS founding principle of equal
access to treatment based on need and not ability to pay. Permitting
co-payments would mean that patients with equal need would be
treated differently and thus inequitably. While co-payments
will not be restricted to the most affluent in society (some
people have been known to sell their house in order to pay for
innovative cancer treatments), it is likely that the poorest
in society will not be able to benefit from treatments available
only through co-payment. Evidence from other countries where
co-payment systems have been introduced would suggest that they
result in a reduction in health-care utilization that differentially
affects those of low socioeconomic status.
12,13 In light of
the recent publication of the World Health Organization report
on health inequity,
14 this is a cause for concern. However,
in the context of co-payments for specific treatments on the
margin of a comprehensive and publicly-funded health-care system
such as the NHS, the inequity argument may be less forceful.
In this context, co-payment would only be considered for treatments
that are not funded as part of the universal package of care
available to all patients. If a high quality service is available
to everyone and co-payments do not result in resources being
diverted from that service, the current equity of access to
treatment would be maintained. Indeed, some would argue that
it would be more equitable because the extra treatments would
be available to a greater number of people than would otherwise
be the case.
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Long-term consequences and slippery slopes
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Two ethical concerns regarding co-payments relate to possible
long-term consequences for both individual patients and the
system as a whole. First, there is a concern that relaxing the
rules on paying for non-NICE recommended treatments could result
in vulnerable patients being persuaded by pharmaceutical companies
to pay for treatments that may not be in their best interests
or may even cause them harm. Many patients for whom co-payment
may be an option will have serious or terminal disease for which
other treatments have failed. These patients may be particularly
vulnerable to undue persuasion. A second concern is the possibility
that the acceptance of the principle of co-payments will lead
to a shift from a universal highest quality possible service
with co-payments for marginal treatments to a universal minimum
acceptable quality service with co-payments for all other treatments.
This scenario would lead to much greater inequities in health-care
provision.
The debate on co-payments within a publicly-funded health-care system is ethically challenging. There is a need to balance respect for individual patients' right to make informed choices about their health care, maintenance of the principle of equitable access to high quality health care based on need rather than ability to pay, prevention of diversion of NHS resources to support co-payment treatments and protection of vulnerable patients from undue persuasion to purchase treatments of questionable benefit. The Institute for Public Policy Research (commissioned by the NHS Confederation) has published a discussion document which considers these and other questions around co-payment. They have made a number of recommendations which include:
- Considering top-up payments for a specific range of treatments under explicit circumstances;
- Requiring a second opinion to ensure that patients have adequate and independent information before making a decision;
- Additional treatment costs including treatment of side-effects and NHS overheads must be met by the patient (or insurer).15
The report of Professor Richards will provide a further impetus for public debate on this important subject.
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Summary points
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- Increasing cost of health care means that some treatments may not be affordable in a public health-care system such as the NHS;
- This can lead to conflicts for doctors in their duty to act in an individual patient's best interests;
- Permitting patients to pay for some treatments within a publicly-funded care programme would respect their autonomy to make choices about their health care;
- Co-payments are likely to increase inequity as the most disadvantaged in society are less likely to be able to pay for them;
- Careful assessment of costs and benefits need to be made to determine whether co-payments will increase or reduce overall health benefit to society.
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Footnotes
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Anne Slowther is Associate Professor in Clinical Ethics at Warwick
Medical School, and a practising general practitioner (GP).
She joined Warwick in 2006 having previously worked at Ethox.
Before moving into academia, she was a full-time GP in Manchester.
Anne oversees the National Clinical Ethics Network support programme,
which develops and provides support for clinical ethics committees
in National Health Service Trusts. Her current work involves
teaching medical undergraduates, developing and running educational
workshops for members of clinical ethics committees, and supporting
the work of priority-setting groups in PCTs.
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References and notes
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- Speech by Rt Hon John Hutton MP, Minister of State (Health), 26 May 2004: The Government and the Private Sector. See http://www.dh.gov.uk/en/News/Speeches/Speecheslist/DH_4083816 (last checked 1 August 2008)
- See http://www.nice.org.uk/newsevents/infocus/infocusarchive/OutcomeofJR.jsp (last checked 30 August 2008)
- See http://www.guardian.co.uk/society/2008/aug/25/nhs.cancer (last checked 30 August 2008)
- See http://news.bbc.co.uk/1/hi/health/7495971.stm (last checked 30 August 2008)
- Mohindra RK, Hall JA. Desmond's non-NICE choice: dilemmas from drug eluting stents in the affordability gap. Clin Ethics 2006;1:105–8[Abstract/Free Full Text]
- Richards C, Dingwall R, Watson A. Should NHS patients be allowed to contribute extra money to their care? BMJ 2001;323:563–5[Free Full Text]
- Holm S, Lis PE, Fritioff-Norheim O. Access to health care in the Scandinavian countries: ethical analysis. Health Care Anal 1999;7:321–30[Medline]
- Griesinger G, Diedrich IK, Altgassen C. Stronger reduction of assisted reproduction technique treatment cycle numbers in economically weak geographical regions following the German healthcare modernization law in 2004. Hum Reprod 2007;22:3027–30[Abstract/Free Full Text]
- General Medical Council. Good Medical Practice. London: GMC, 2006. See http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp (last checked 30 August 2008)
- Weinstein MC. Should physicians be gatekeepers of medical resources? J Med Ethics 2001;27:268–74[Abstract/Free Full Text]
- A recent example is the reaction to the NICE recommendation on drugs for renal cancer in August 2008
- Lostaoa L, Regidorb E, Geyerc S, Aïachd P. Patient cost sharing and social inequalities in access to health care in three western European countries. Soc Sci Med 2007;65:367–76[Medline]
- Vardy DA, Freud T, Shvartzman P, et al. Introducing co-payment for consultant specialist services. Isr Med Assoc J 2006;8:558–62[Medline]
- World Health Organization Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: WHO, 2008. See http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (last checked 30 August 2008)
- Institute for Public Policy Research. Topping Up: Should it be Allowed in the NHS? London: NHS Confederation, 2008
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