- Email: [email protected]
THE OREGON HEALTH INITIATIVE
106
THE OREGON HEALTH INITIATIVE
setting priorities for state-funded health services when money is limited.
SIR,-Dr Duggan, in his April 8 (p 772) article on resource allocation, made passing reference to the State of Oregon. Duggan
accurately identifies the fact that medical technology has outstripped our ability to pay for it, thus forcing difficult choices. Assuming that simply adding more money to the system is not an option, Duggan describes an economic/political solution and a
medical/scientific solution. In the economic/political solution use of is limited through the application of incentives such as prospective payment schemes (eg, health maintenance organisations) and bed reductions. Duggan points out that this solution "presupposes that all medical interventions are equally justified or equally cost effective and doctors have no role... to set priorities in the utilisation of scarce resources". In the medical/ scientific solution "resource allocation and its priorities are founded on an unemotional analysis of the cost, benefit, and likely outcome of medical intervention". The article cites the 1987 action by the Oregon State legislature on soft-organ transplants. Faced with demands far exceeding our ability to pay for them we discontinued funding for soft-organ transplants, potentially affecting 34 individuals over a two-year period. Instead, we used the money to provide, over the same time period, basic health care services, including prenatal care, for 1200 women and 1800 children. While I agree with Duggan’s definitions and with his contention that we cannot buy our way out of this problem, I disagree with his characterisation of Oregon’s approach as a "striking example of an economic/political solution". On the contrary, Oregon’s actions in 1987 and since then represent a medical/scientific solution. In 1987 we did not assume that "all medical interventions are equally justified or equally cost effective". Our experience with soft-organ transplants was exactly the opposite. Of the 19 Medicaid transplant recipients (bone marrow, heart, liver and pancreas) funded by Oregon between 1985 and 1987, 10 died. On the other hand, prenatal care and basic services for children are of proven efficacy. We felt it better to provide services that were clearly cost-effective to a large number of people rather than to provide high-tech services of questionable benefit to a few. The main criticism of that decision is that it was discriminatory to single out transplants. We agree. On the other hand, it would have been discriminatory to have denied prenatal care and basic care to 3000 women and children to fund transplants for perhaps 34 individuals, especially when those 34 individuals already had access to a very rich benefit package under Medicaid. With a limited health-care budget there will always be winners and losers. The challenge is to develop a framework in which these choices can be made in a way that reflects sound clinical data and social values. Since the controversial decision in 1987, Oregon has been working quietly to develop such a framework. The plan was introduced into the Oregon State Senate in January, 1989, as Senate Bill 27. It passed the Senate by a vote of 24-2 and the House of Representatives by 58-2, and became law with the governor’s
resources
signature. A centrepiece of this proposal is a health services commission made up primarily of providers but also with consumei representation. It is charged with setting priorities in services and procedures based on the benefit each will have on the population, starting with services and procedures that are most important anc moving down to less important ones. Decisions will be based or solid clinical information and the knowledge of physicians. Once th( commission has completed its work, the legislature will provid( these services to the entire needy population, starting at the top o the priority list and working down within the constraints oflimitec revenue.
This approach separates the medical/scientific aspects from th economic/political ones. The priority choosing process is objective
and non-political, whereas the legislature is involved in fundinj decisions which are, by their very nature, political. The priority decisions are based on clinical information and made by clinicians not politicians. The Oregon Health Initiative offers a way c achieving social and political consensus on a definition of "adequat care", and it clearly recognises the role physicians must have i
Oregon State Senate, State Capitol, Salem, Oregon 97310, USA
JOHN KITZHABER, Senate President
CUBA’S HEALTH RECORD
SIR,-Dr Summerfield (April 15, p 834), reporting on an open letter on health in Cuba, does not challenge any official Cuban record. The letter itself does but it was not published, leaving your readers in ignorance. If Summerfield had challenged the official record he would have commented on Cuba’s abortion rate (1-3 abortions per live birth), on the country’s suicide and violent death rate (109 per 100 000), and on the despicable hygienic conditions in the Cuban capitaL! Most of this information is available, but can be confirmed outside Cuba only through the testimony of physicians who have recently escaped; many of them signed the open letter. AIDS in Cuba was dismissed by Summerfield because the 75 doctors signing the letter "offer no evidence". Cuba first recognised HIV infection in the island in April, 1987.2 However, it was prevalent in 1980, as shown by a study on newly arrived immigrants.3 In its extent the HIV epidemic in Cuba is more like that of New York City than of Oklahoma, as Castro would have the world believe.3,5A study on a representative sample of immigrants, which had rates of diabetes, hypertension, and hepatitis B comparable with those reported by Cuba (as can readily be verified from official Cuban data), showed that Cuba’s HIV load in 1980 was the highest in the American.3-1 Of the many disturbing issues raised by Cuba’s approach to AIDS, one is the fact that lifelong isolation of the sick is based on a "micro-ELISA" test developed in Cuba and not, to our knowledge, validated elsewhere.1,8 We can agree that "AIDS is not a health problem in Cuba"’ only in the sense that it is overwhelmingly a political problem since the whole of the AIDS campaign is under the direction of the state security (Cuban KGB) not the Ministry of Health. Cuba is not free from poverty, inequality, and a disorganised health network, as Summerfield claims. When Cuban youths exchange sexual favours for a pair of blue jeans, that is a sign of poverty. When tourists and high-ranking communist officials have access to beaches, hotels, and stores but workers, students, and housewives do not, that is a sign of inequality. When control of an infectious venereal disease is managed by the police and not by public health, that is a sign of a bizarre and disjointed health care network. Finlay Society, 344 W 65 Street, No 204, Hialeah, Florida 33012, USA
ANTONIO GORDON REINALDO PAYA
1. World Health Organisation. Annual Epidemiology Vital Statistics. Geneva, WHO, 1979: 94. 2. Cordoves R. Contra el flagelo mortal. Bohemia Magazine 1989: 20-24. 3. de Medina M, Fletcher MA, Valledor MD, Ashman M, Gordon AM, Schiff ER Serologic evidence of HIV infection in Cuba. Lancet 1987; ii: 166. 4. Gordon AM. HIV infection in Cuba, JAMA 1987; 258: 3387. 5. Gordon AM. Nutritional and health status of Cuban refugees. Am J Clin Nutr 1982; 35: 582-90. 6. de Medina M, Cancio-Bello TP, Curtein E, Schiff ER. Serological survey of liver disease among recent Cuban immigrants to US. Clin Res 1980; 28: 820A. 7. Castallanos R, Farinas M, Gonzalez P. Antigeno Australia y su anticuero correspondiente (Santiago de Cuba). Rev Cub Med Trop 1982; 21: 592-98. 8. Bayer R, Healton C. Controlling AIDS in Cuba: the logic of quarantine. N Engl J Med
1989; 320: 1022-24.
TOBACCO AND THE KAROLINSKA
SiR,—The tobacco industry spends large amounts of money on public relations and other ploys to convince the public that it cares about the individual and that tobacco is a harmless product. Thus they foster sporting and cultural events, and they also sponsor medical research to create an image of being trustworthy and socially aware. The Swedish Tobacco Group has offered 20 million Skr to the Karolinska Institute in Stockholm to establish a chair in medical tobacco research (neurobiology, toxicology, biochemistry, or cell biology). This offer is not a gesture of interest in medical science-even though that is what the unsuspecting scientists at the Karolinska believe.
THE OREGON HEALTH INITIATIVE
setting priorities for state-funded health services when money is limited.
SIR,-Dr Duggan, in his April 8 (p 772) article on resource allocation, made passing reference to the State of Oregon. Duggan
accurately identifies the fact that medical technology has outstripped our ability to pay for it, thus forcing difficult choices. Assuming that simply adding more money to the system is not an option, Duggan describes an economic/political solution and a
medical/scientific solution. In the economic/political solution use of is limited through the application of incentives such as prospective payment schemes (eg, health maintenance organisations) and bed reductions. Duggan points out that this solution "presupposes that all medical interventions are equally justified or equally cost effective and doctors have no role... to set priorities in the utilisation of scarce resources". In the medical/ scientific solution "resource allocation and its priorities are founded on an unemotional analysis of the cost, benefit, and likely outcome of medical intervention". The article cites the 1987 action by the Oregon State legislature on soft-organ transplants. Faced with demands far exceeding our ability to pay for them we discontinued funding for soft-organ transplants, potentially affecting 34 individuals over a two-year period. Instead, we used the money to provide, over the same time period, basic health care services, including prenatal care, for 1200 women and 1800 children. While I agree with Duggan’s definitions and with his contention that we cannot buy our way out of this problem, I disagree with his characterisation of Oregon’s approach as a "striking example of an economic/political solution". On the contrary, Oregon’s actions in 1987 and since then represent a medical/scientific solution. In 1987 we did not assume that "all medical interventions are equally justified or equally cost effective". Our experience with soft-organ transplants was exactly the opposite. Of the 19 Medicaid transplant recipients (bone marrow, heart, liver and pancreas) funded by Oregon between 1985 and 1987, 10 died. On the other hand, prenatal care and basic services for children are of proven efficacy. We felt it better to provide services that were clearly cost-effective to a large number of people rather than to provide high-tech services of questionable benefit to a few. The main criticism of that decision is that it was discriminatory to single out transplants. We agree. On the other hand, it would have been discriminatory to have denied prenatal care and basic care to 3000 women and children to fund transplants for perhaps 34 individuals, especially when those 34 individuals already had access to a very rich benefit package under Medicaid. With a limited health-care budget there will always be winners and losers. The challenge is to develop a framework in which these choices can be made in a way that reflects sound clinical data and social values. Since the controversial decision in 1987, Oregon has been working quietly to develop such a framework. The plan was introduced into the Oregon State Senate in January, 1989, as Senate Bill 27. It passed the Senate by a vote of 24-2 and the House of Representatives by 58-2, and became law with the governor’s
resources
signature. A centrepiece of this proposal is a health services commission made up primarily of providers but also with consumei representation. It is charged with setting priorities in services and procedures based on the benefit each will have on the population, starting with services and procedures that are most important anc moving down to less important ones. Decisions will be based or solid clinical information and the knowledge of physicians. Once th( commission has completed its work, the legislature will provid( these services to the entire needy population, starting at the top o the priority list and working down within the constraints oflimitec revenue.
This approach separates the medical/scientific aspects from th economic/political ones. The priority choosing process is objective
and non-political, whereas the legislature is involved in fundinj decisions which are, by their very nature, political. The priority decisions are based on clinical information and made by clinicians not politicians. The Oregon Health Initiative offers a way c achieving social and political consensus on a definition of "adequat care", and it clearly recognises the role physicians must have i
Oregon State Senate, State Capitol, Salem, Oregon 97310, USA
JOHN KITZHABER, Senate President
CUBA’S HEALTH RECORD
SIR,-Dr Summerfield (April 15, p 834), reporting on an open letter on health in Cuba, does not challenge any official Cuban record. The letter itself does but it was not published, leaving your readers in ignorance. If Summerfield had challenged the official record he would have commented on Cuba’s abortion rate (1-3 abortions per live birth), on the country’s suicide and violent death rate (109 per 100 000), and on the despicable hygienic conditions in the Cuban capitaL! Most of this information is available, but can be confirmed outside Cuba only through the testimony of physicians who have recently escaped; many of them signed the open letter. AIDS in Cuba was dismissed by Summerfield because the 75 doctors signing the letter "offer no evidence". Cuba first recognised HIV infection in the island in April, 1987.2 However, it was prevalent in 1980, as shown by a study on newly arrived immigrants.3 In its extent the HIV epidemic in Cuba is more like that of New York City than of Oklahoma, as Castro would have the world believe.3,5A study on a representative sample of immigrants, which had rates of diabetes, hypertension, and hepatitis B comparable with those reported by Cuba (as can readily be verified from official Cuban data), showed that Cuba’s HIV load in 1980 was the highest in the American.3-1 Of the many disturbing issues raised by Cuba’s approach to AIDS, one is the fact that lifelong isolation of the sick is based on a "micro-ELISA" test developed in Cuba and not, to our knowledge, validated elsewhere.1,8 We can agree that "AIDS is not a health problem in Cuba"’ only in the sense that it is overwhelmingly a political problem since the whole of the AIDS campaign is under the direction of the state security (Cuban KGB) not the Ministry of Health. Cuba is not free from poverty, inequality, and a disorganised health network, as Summerfield claims. When Cuban youths exchange sexual favours for a pair of blue jeans, that is a sign of poverty. When tourists and high-ranking communist officials have access to beaches, hotels, and stores but workers, students, and housewives do not, that is a sign of inequality. When control of an infectious venereal disease is managed by the police and not by public health, that is a sign of a bizarre and disjointed health care network. Finlay Society, 344 W 65 Street, No 204, Hialeah, Florida 33012, USA
ANTONIO GORDON REINALDO PAYA
1. World Health Organisation. Annual Epidemiology Vital Statistics. Geneva, WHO, 1979: 94. 2. Cordoves R. Contra el flagelo mortal. Bohemia Magazine 1989: 20-24. 3. de Medina M, Fletcher MA, Valledor MD, Ashman M, Gordon AM, Schiff ER Serologic evidence of HIV infection in Cuba. Lancet 1987; ii: 166. 4. Gordon AM. HIV infection in Cuba, JAMA 1987; 258: 3387. 5. Gordon AM. Nutritional and health status of Cuban refugees. Am J Clin Nutr 1982; 35: 582-90. 6. de Medina M, Cancio-Bello TP, Curtein E, Schiff ER. Serological survey of liver disease among recent Cuban immigrants to US. Clin Res 1980; 28: 820A. 7. Castallanos R, Farinas M, Gonzalez P. Antigeno Australia y su anticuero correspondiente (Santiago de Cuba). Rev Cub Med Trop 1982; 21: 592-98. 8. Bayer R, Healton C. Controlling AIDS in Cuba: the logic of quarantine. N Engl J Med
1989; 320: 1022-24.
TOBACCO AND THE KAROLINSKA
SiR,—The tobacco industry spends large amounts of money on public relations and other ploys to convince the public that it cares about the individual and that tobacco is a harmless product. Thus they foster sporting and cultural events, and they also sponsor medical research to create an image of being trustworthy and socially aware. The Swedish Tobacco Group has offered 20 million Skr to the Karolinska Institute in Stockholm to establish a chair in medical tobacco research (neurobiology, toxicology, biochemistry, or cell biology). This offer is not a gesture of interest in medical science-even though that is what the unsuspecting scientists at the Karolinska believe.