Co-payment for medical treatment by ikevantrounk



Co-payment for medical treatment
Anne Slowther
Institute of Clinical Education, Warwick Medical School, UK

In 2004, the then Minister of State for Health in the UK,                package, so that a co-payment (of varying value) is
John Hutton, stated:                                                     required for every hospital outpatient appointment or
    ‘We strongly believe that the introduction of vouchers, pass-
                                                                         GP consultation.7 Or it might be for specific treatments,
    ports, co-payment, or extra charges to patients will have a          for example in Germany patients undergoing in vitro fer-
    regressive impact on the health of our people – as all of            tilization treatment are required to pay 50% of the treat-
    the international evidence confirms. That is why a patient’s          ment costs for each cycle.8 Co-payments also occur
    passport to personal health should not be dependent on a             within the UK NHS although these have tended to be
    patient’s personal wealth.’1                                         implicit rather than explicit. Thus, GPs will provide
This unequivocal position now appears to be less secure in               private prescriptions for malaria prophylaxis medication
2008 due to a number of factors including:                               while providing some travel immunizations as part of
                                                                         NHS care, or a patient may pay for a private magnetic res-
† The continued increase in the number of innovative                     onance imaging scan rather than wait for the NHS scan
      (but expensive) treatments available in the health-care            that her consultant has requested. One could argue that
      market;                                                            prescription charges per se are a form of co-payment.
†     Several high-profile challenges to decisions by the                 The role of NICE in assessing new technologies and
      National Institute of Health and Clinical Excellence               issuing directives on whether specific treatments should
      (NICE) with regard to funding for new treatments,                  be funded by the NHS has thrown the question of
      for example drugs for Alzheimer’s disease and certain              co-payment into sharp relief. The focus of the public
      forms of cancer;2,3                                                debate, and the government policy review, is the specific
†     Specific case reports precipitating a public debate                 issue of payment by patients for treatment that is not
      about the permissibility of patients paying for treat-             funded by the NHS (often following a NICE recommen-
      ments not funded by the National Health Service                    dation) within the context of a NHS treatment pro-
      (NHS) as part of their NHS care.4                                  gramme. Current policy states that patients wishing to
    The specific issue of co-payment for drugs not funded by              do this should pay for their whole treatment programme
the NHS is now the subject of a Government-commissioned                  privately. It is this specific model of co-payment which
review of policy in this area, chaired by Professor Mike                 we will consider here although the ethical values dis-
Richards and expected to report in October 2008. The                     cussed will be relevant to other models.
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           Individual autonomy and the right
option have been discussed previously in this journal and else-
where.5,6 It is also a problem that is brought to clinical ethics        to choose specific treatments
committees and one which challenges us to reflect on the core             A strong argument in favour of allowing co-payments rests
values of the NHS. In this FMF we will consider the ethical              on respect for the autonomy of an individual patient to
values and arguments underpinning the debate.                            make treatment decisions, including decisions about
                                                                         whether the cost of a specific treatment is worth paying
                                                                         for the potential benefit gained. Decisions about whether
What is co-payment?                                                      to pay for a treatment will be informed by both evidence
Co-payment for medical care is a feature of many health-                 of clinical effectiveness (it provides some benefit in
care systems. This may be part of the standard health-care               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
Anne Slowther is Associate Professor in Clinical Ethics at Warwick       may be very different depending on who is making the jud-
Medical School, and a practising general practitioner (GP). She joined   gement. Thus, NICE may consider a treatment too costly
Warwick in 2006 having previously worked at Ethox. Before moving into    in relation to its benefit for the NHS to afford within its
academia, she was a full-time GP in Manchester. Anne oversees the        budget constraints, but, as Mohindra has pointed out, an
National Clinical Ethics Network support programme, which develops
                                                                         individual patient does not make value judgements from
and provides support for clinical ethics committees in National
Health Service Trusts. Her current work involves teaching medical
                                                                         the perspective of the NHS as a whole.5 For her the
undergraduates, developing and running educational workshops for         price may be worth paying. To prevent a patient from
members of clinical ethics committees, and supporting the work of        making that choice would be seen as an infringement of
priority-setting groups in PCTs.                                         her autonomy.

Clinical Ethics 2008; 3: 168 –170                                                                          DOI: 10.1258/ce.2008.008039
Co-payment for medical treatment                                                                                                 169

Duty of care and the doctor – patient                            will not be able to benefit from treatments available only
relationship                                                     through co-payment. Evidence from other countries
                                                                 where co-payment systems have been introduced would
The primary duty of a doctor is to make the care of his or       suggest that they result in a reduction in health-care util-
her patient their first concern.9 If a doctor considers that a    ization that differentially affects those of low socio-
particular treatment would be in his or her patient’s best       economic status.12,13 In light of the recent publication of
interests, refusal to provide the treatment could be seen        the World Health Organization report on health
as a breach of this duty. It is generally accepted that exter-   inequity,14 this is a cause for concern. However, in the
nal constraints, which could include NICE directives,            context of co-payments for specific treatments on the
NHS contractual obligations or limited resources, will           margin of a comprehensive and publicly-funded health-
mitigate this duty to some extent.10 The current debate          care system such as the NHS, the inequity argument may
on co-payments raises the question of whether government         be less forceful. In this context, co-payment would
policy should constrain a doctor’s duty of care to his or her    only be considered for treatments that are not funded as
patient in this context.                                         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
Utilitarian arguments for and                                    diverted from that service, the current equity of access to
against co-payment                                               treatment would be maintained. Indeed, some would
Utilitarianism requires that for decisions to be morally         argue that it would be more equitable because the extra
acceptable they should maximize overall benefit. A criti-         treatments would be available to a greater number of
cism that is often levelled at NICE is that it takes a           people than would otherwise be the case.
purely utilitarian view when making its recommendations,
considering only the cost-effectiveness of treatments at a
population level and ignoring the level of individual            Long-term consequences and
need and suffering of patients and their carers.11 This          slippery slopes
appears to be the crux of the objection to co-payments           Two ethical concerns regarding co-payments relate to
made by John Hutton in the speech quoted above.1 A cri-          possible long-term consequences for both individual
tique of the ethics of resource allocation and utilitarianism    patients and the system as a whole. First, there is a
in general is beyond the scope of this article, but most         concern that relaxing the rules on paying for non-NICE
critics of utilitarianism would concede that when making         recommended treatments could result in vulnerable
decisions at a population level within a limited budget,         patients being persuaded by pharmaceutical companies to
it is desirable to ensure efficient use of resources to           pay for treatments that may not be in their best interests
benefit the maximum number of people. This may mean               or may even cause them harm. Many patients for whom
that some less cost-effective treatments are not funded.         co-payment may be an option will have serious or terminal
However, supporters of co-payments have argued that              disease for which other treatments have failed. These
they increase efficiency by increasing the number of              patients may be particularly vulnerable to undue persua-
patients who will benefit from the effective but expensive        sion. A second concern is the possibility that the accep-
treatment at no extra cost to the NHS. Thus, the overall         tance of the principle of co-payments will lead to a shift
benefit will be increased by co-payments.5                        from a universal highest quality possible service with
     The argument for increased efficiency and therefore          co-payments for marginal treatments to a universal
increased overall benefit from co-payments is based on            minimum acceptable quality service with co-payments
the assumption that there is no corresponding loss of            for all other treatments. This scenario would lead to
benefit to patients who do not or cannot choose the               much greater inequities in health-care provision.
co-payment option. If this is not the case, then an assess-          The debate on co-payments within a publicly-funded
ment of overall harms and benefits would have to be made.         health-care system is ethically challenging. There is a
For example, if the co-payment treatment required extra          need to balance respect for individual patients’ right to
resources to be administered or to monitor for toxicity          make informed choices about their health care, mainten-
and treat side-effects, then other patients may be harmed        ance of the principle of equitable access to high quality
by the diversion of resources from their care.                   health care based on need rather than ability to pay, pre-
                                                                 vention of diversion of NHS resources to support
                                                                 co-payment treatments and protection of vulnerable
Consideration of equity in the                                   patients from undue persuasion to purchase treatments of
co-payment debate                                                questionable benefit. The Institute for Public Policy
A key argument against co-payments in the UK health              Research (commissioned by the NHS Confederation) has
system is that they run counter to the NHS founding prin-        published a discussion document which considers these
ciple of equal access to treatment based on need and not         and other questions around co-payment. They have made
ability to pay. Permitting co-payments would mean that           a number of recommendations which include:
patients with equal need would be treated differently and        † Considering top-up payments for a specific range of
thus inequitably. While co-payments will not be restricted          treatments under explicit circumstances;
to the most affluent in society (some people have been            † Requiring a second opinion to ensure that patients
known to sell their house in order to pay for innovative            have adequate and independent information before
cancer treatments), it is likely that the poorest in society        making a decision;

                                                                                        Clinical Ethics   2008   Volume 3   Number 4
170                                                                                                                                   Slowther

† Additional treatment costs including treatment of                    3 See
      side-effects and NHS overheads must be met by the                  (last checked 30 August 2008)
                                                                       4 See (last checked
      patient (or insurer).15
                                                                         30 August 2008)
   The report of Professor Richards will provide a further             5 Mohindra RK, Hall JA. Desmond’s non-NICE choice: dilemmas
impetus for public debate on this important subject.                     from drug eluting stents in the affordability gap. Clin Ethics
                                                                       6 Richards C, Dingwall R, Watson A. Should NHS patients be
                                                                         allowed to contribute extra money to their care? BMJ 2001;
Summary points                                                           323:563–5
                                                                       7 Holm S, Lis PE, Fritioff-Norheim O. Access to health care in
† Increasing cost of health care means that some treat-                  the Scandinavian countries: ethical analysis. Health Care Anal
      ments may not be affordable in a public health-care                1999;7:321–30
      system such as the NHS;                                          8 Griesinger G, Diedrich IK, Altgassen C. Stronger reduction of
†     This can lead to conflicts for doctors in their duty to             assisted reproduction technique treatment cycle numbers in econ-
      act in an individual patient’s best interests;                     omically weak geographical regions following the German healthcare
                                                                         modernization law in 2004. Hum Reprod 2007;22:3027– 30
†     Permitting patients to pay for some treatments within a
                                                                       9 General Medical Council. Good Medical Practice. London: GMC,
      publicly-funded care programme would respect their                 2006. See
      autonomy to make choices about their health care;                  tice/duties_of_a_doctor.asp (last checked 30 August 2008)
†     Co-payments are likely to increase inequity as the most         10 Weinstein MC. Should physicians be gatekeepers of medical
      disadvantaged in society are less likely to be able to pay         resources? J Med Ethics 2001;27:268– 74
      for them;                                                       11 A recent example is the reaction to the NICE recommendation on
†     Careful assessment of costs and benefits need to be                 drugs for renal cancer in August 2008
                                                                      12 Lostaoa L, Regidorb E, Geyerc S, Aıachd P. Patient cost sharing
      made to determine whether co-payments will increase
                                                                         and social inequalities in access to health care in three western
      or reduce overall health benefit to society.                        European countries. Soc Sci Med 2007;65:367– 76
                                                                      13 Vardy DA, Freud T, Shvartzman P, et al. Introducing co-payment
                                                                         for consultant specialist services. Isr Med Assoc J 2006;8:558–62
References and notes                                                  14 World Health Organization Commission on Social Determinants of
 1 Speech by Rt Hon John Hutton MP, Minister of State (Health), 26       Health. Closing the Gap in a Generation: Health Equity through Action
   May 2004: The Government and the Private Sector. See http://www.      on the Social Determinants of Health. Geneva: WHO, 2008. See (last checked
   1 August 2008)                                                        (last checked 30 August 2008)
 2 See      15 Institute for Public Policy Research. Topping Up: Should it be Allowed
   OutcomeofJR.jsp (last checked 30 August 2008)                         in the NHS? London: NHS Confederation, 2008

Clinical Ethics   2008   Volume 3   Number 4

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