[Priority setting and rationing of pharmaceuticals - an experimental analysis of discussion processes]

BACKGROUND/OBJECTIVE: In the face of rising expenditure among statutory sickness funds in Germany it is necessary to start a discussion about priority setting in the healthcare system. For a long time this issue was avoided in healthcare debates. As a result, normative directives are still missing, which can lead to priority setting among healthcare providers in daily healthcare practice. A discussion on priority setting can be conducted at three different levels: at the government (macro), the institutional (meso), and the patient (micro) level. Surveys about societal preferences for different criteria exist, but the weighting of these criteria in the situation of approval and reimbursement of pharmaceuticals (meso) is lacking. For this reason, the present study analyzed the implementation and weighting of the criteria for priority setting at the meso level taking values and experiences of the participants into account. METHOD: Six qualitative focus groups were carried out with representatives from the fields of medicine, ethics, public health and economics. During the discussions four fictitious drugs for the treatment of different lung diseases were prioritized based on guidelines. The discussion processes were analyzed according to Bohnsack's documentary method. RESULTS: The criteria "quality of life", "life expectancy" and "other patient-relevant outcomes" were discussed in relation to each other. The evaluation of change in patient-relevant outcomes was difficult to perform for non-medical participants. The second argument concerned the cost of the criteria, the severity, and the number of patients. Costs were given less weight, but were often used to support other criteria. Other challenges in reaching a consensus included emerging role conflicts between profession and personal opinion, and the transfer of the discussion to a different level of decision-making. DISCUSSION: In the discussions the problem of priority setting was not based on different preferences for prioritization criteria, but on the weighting of the criteria. The operationalization of the criteria seems to depend on the decision-making situation, the participants' personal connection with the disease in question and on the correspondence between evidence and personal experiences.

• Aumann, I.; Litzkendorf, S.; Damm, K.; von der Schulenburg, J. M. G.