Involving Consumers in Health Care Decision Making

Involving Consumers in Health Care Decision Making

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HEALTHCAREANALYSIS VOL. 3:196-204 (1995) c Phil Shackleyand Mandy Ryan Health Economics Research Unit, University of Aberdeen, Scotland Abstract This paper considers ways of involving consumers in decisions regarding the allocation of scarce health service resources. Specifically, two levels of consumer participation are highlighted and discussed.

These are: (1) at the level of deciding whether or not a particular service should be introduced or its scale changed; and (2) at the level of deciding how best to provide a service once it has been decided that the service will be provided.The limitations of the current methods of involving consumers are outlined and two alternative approaches discussed. These are willingness to pay and conjoint analysis.

Introduction Limited resources coupled with unlimited d e m a n d for health care mean that decisions have to be m a d e regarding the allocation of scarce resources across competing health care interventions. Traditionally, the extent of consumer (patient) involvement in this decision making process has been minimal. However, with the advent of the recent reforms of the UK National Health Service (NHS), greater consumer involvement has been advocated. -3 A policy emphasis on increasing patient choice and the implication that this is a good thing indicates that the UK government envisages consumers in the ‘new’ NHS as having a m u c h more active role in health care decision making. Although the background to this paper is the recent reforms of the UK National Health Service, the concepts discussed are relevant to any health care system in which community values a n d / o r patient preferences are elicited. In this p a p e r w e consider ways of involving consumers in decisions regarding the use of scarce health care resources.

Consumer involvement is considered at two distinct levels. The first concerns decisions about w h e t h e r or not a particular service should be introduced or its scale changed (extended or contracted). In economics terminology, this level of decision making is concerned with allocative 9yiciency. The second level is concerned with the best w a y of providing a particular service once it has been decided that the service will be provided.

In the terminology of economics, this level of decision making is concerned with technical efficiency. Each of these decision making levels will be discussed in turn.In doing so, the limitations of existing methods of involving consumers are outlined and alternative innovative approaches are suggested which not only educate and inform consumers, but also m a k e clear the trade-offs that exist.

Should A Service Be Provided (Or Its Scale Changed)? The NHS Management Executive with the publication of its d o c u m e n t Local Voices has stimulated purchasers to take more account of the wants of local people w h e n setting health care priorities. 4 The M a n a g e m e n t Executive’s initiative has forced purchasing authorities toPhil Shackley and Mandy Ryan, Health Economics Research Unit, Department of Public Health, University of Aberdeen, University Medical Buildings, Foresterhill, Aberdeen, AB9 2ZD, Scotland CCC

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1065-3058/95/030196-09 9 1995 by John Wiley & Sons, Ltd. INVOLVINGCONSUMERS 197 consider the opinions of the local community in their purchasing decisions.

They have been directed to purchase more services on the basis of wants rather than needs, implying less weight being given to results of needs assessment exercises vis-? z-vis community values.In principle, the elicitation of community values represents a big step forward in terms of enhancing consumer participation in health care. However, for the exercise to be a useful one, purchasers have to be able to use the values. Whether or not they will be able to will depend upon the method used to elicit the values. The emphasis of Local Voices is on market research techniques, such as opinion polls.

One example of such an approach is the recent British Medical Association (BMA) survey reported in the British Medical Journal s Another is the study carried out in City and Hackney. The BMA sample comprised 265 managers from purchaser and provider organisations, 800 doctors representing the national distribution of specialties, including general practitioners, and 2012 members of the public. The sample was asked to rank ten health service interventions in order of priority for spending. The results were as in Table 1. Leaving aside for now the differences and similarities in the rankings among the three groups (these will be discussed later), let us consider the advantages and limitations of surveys of this type with respect to their usefulness to purchasers.The one obvious advantage of opinion polls is that they are relatively quick and simple to carry out. In this respect opinion polls can be useful.

However, we feel that in terms of providing useful information to policy-makers they do not go far enough. Table 1. Treatment Childhood immunisation GP care for everyday illness Screening for breast cancer Intensive care for premature babies Heart transplant operations Support for carers of elderly people Hip replacements for elderly people Anti-smoking education for children Treatmentfor schizophrenia Cancer treatment for smokers Resultsof the BMA SurveyThe Limitations of Opinion Polls The survey revealed some general limitations of opinion polls. First, the results of the survey indicate the direction of people’s preferences but not their strength of preference. The survey does not (indeed cannot) distinguish between someone who has a weak preference for childhood immunisation over GP care for everyday illness, say, and someone who has a strong preference over the same two interventions.

Second, the results provide little help in addressing policy questions.For example, the choices offered are so broad as to be meaningless. Assuming a low rank reflects a candidate for reduction (and this is by no means obvious) then if cancer treatment for smokers were to be reduced would this apply solely to cancers directly related to smoking, such as lung cancer, or would it also apply to cancers not normally implicated to smoking? The survey also fails to address the issue of whether there are net costs associated with reduction or expansion.

For example, if cancer treatment for smokers were reduced would ore resources need to be devoted to palliative and terminal care for smokers? These, and other related issues, are not

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addressed by the poll, thus rendering the results virtually useless to policy-makers. Third, the results of opinion poll surveys do not address the real life situation facing purchasers. Health boards/authorities are faced with an existing mix of expenditure on health care services and have to make decisions about how much more to spend on some types of care and how much less to spend on others. It is marginal choices (i. .

changes) such as these that Public 1 2 3 4 Doctors 1 2 7 8 Managers 1 2 5 8 5 6 9 4 9 4 7 8 9 5 3 6 6 3 7 10 10 10 198 R SHACKLEYANDM. RYAN community values should address. For instance, opinion polls do not give any indication of how much more (if anything) should be spent on childhood immunisations, or from which programme the funds should come. Fourth, and arguably most important, there is no concept of scarcity and nor is there any indication that there may be a need to make sacrifices in the ranking process.Asking people simply to rank interventions in order of priority for spending is a reasonable starting point, but it is somewhat unrealistic in that no resource constraints are imposed. Obviously, in setting priorities, the purchasing authority is constrained by limited resources. Every purchasing decision involves some notion of sacrifice-in the language of economics, there is an opportunity cost.

In order to reflect more fully the situation facing purchasing authorities, the elicitation of community values should ideally incorporate the concepts of scarcity and opportunity cost, i. e. decision making under resource constraints.

Summarising the above points, exercises in eliciting community values should have the following characteristics: 9 they should provide information which reflects people’s intensity of preference; 9 they should address specific choices reflecting local health board/authority problems; 9 values should be elicited in the correct marginal context, i. e. the scale of change should be realistic; 9 the questions should incorporate some notion of sacrifice. The ‘Willingness to Pay’ Technique An alternative method of eliciting community values which reflects intensity of preference and incorporates the notions of the margin, scarcity and pportunity cost is the economic technique of maximum willingness to pay.

This method has the disadvantage that it is more complex than opinion polls. However, any results will be more useful for policy-makers. The concept of asking people how much they would be prepared to pay for a new product as part of the market research process is wellestablished. However, its application to health care has been limited. 7 This may reflect the fact that health care is effectively free at the point of consumption and as such there are problems in asking people to value health care services in this way.Applying the concept of willingness to pay to health care is an extremely sensitive area and great care must be taken not to arouse public concern. That said, if due care is taken then willingness to pay may offer a legitimate means of eliciting community values which can be used by policy-makers.

The key is to ask people to imagine themselves in situations where they have to value a service but in doing so, they have to give something up. This might be in terms of extra taxation or reductions in another service.

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The following two examples illustrate how the technique of willingness to pay can be used to establish consumer preferences.The first example used the willingness to pay approach to elicit community values for child health services in Grampian Region in Scotland. 8 Specifically, community values were elicited for three aspects of child health services: routine elective surgery, the location of routine outpatient clinics, and the organisation of the school health service. A sample of parents were interviewed in the valuation exercise and were asked to express not just the direction of their preferences on each option, but also the intensity of their preference through a valuation exercise.For example, one aspect of the interview was to elicit the preferences of parents between day case surgery and a two-night stay in hospital for tonsillectomy.

At the time, day case surgery was not available for tonsillectomy. Those who expressed a preference for day case surgery were asked how much they would be willing to pay for day case surgery to be available for their child instead of a two-night stay. Similarly, those who expressed a preference for the two-night stay in hospital were asked how much they would be willing to pay to retain that service for their child rather than having day case surgery.

The parents were asked to express their willingness to pay as a one off extra taxation payment. The mean willingness to pay of those preferring day surgery was s while the corresponding value for those preferring inpatient stay was s The difference between the means was not statistically significant. It was INVOLVING CONSUMERS 199 found that for both day case surgery and inpatient stay, those living in wealthier areas were willing to pay significantly more than those living in less-well-off areas.Similarly, women were prepared to pay significantly more than men. The willingness to pay data from this study provided information about how strongly people felt about their preferences, i. e. Grampian Health Board was presented with information on intensity of preference as well as direction of preference.

The second example of how the willingness to pay technique can be used to elicit community values is the evaluation of public sector health care programrnes in Northern Norway. Members of the public were asked their willingness to pay in extra taxation for each of the following: the introduction of a helicopter ambulance service to serve remote communities; an expansion in the number of heart operations performed; and an expansion in the number of hip operations performed. The programmes were described in some detail and respondents were told that each of the three programmes would cost the same to implement and that only one could be implemented.

Respondents were also asked the reasons for their valuations. Mean willingness to pay for the ambulance service was 316 Norwegian Kroner (NOK) per year.The corresponding values for hearts and hips were 306NOK and 232NOK respectively.

The mean willingness to pay for hips was significantly different from the mean willingness to pay values for the ambulance service and hearts. Women were willing to pay significantly more than men for hip operations, whilst older people

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were willing to pay significantly less than younger people for hips. Women were also willing to pay significantly more for the ambulance service, as were those with a higher level of education. The results of this study not only provided information on the relative intensity of people’s preferences for the three rogrammes, but also indicated that people are concerned with more than just health gain from health care.

This was evidenced by respondents’ concern for access to care for other people. It appeared that people were prepared to express this concern in the values they ascribed to the helicopter ambulance service vis-? ~-vis the other programmes. We do not claim that the use of willingness to pay is the method to be used to elicit community values. Such a claim could only ever be made after much testing of the method and further research.Such an approach will undoubtedly encounter problems. However, the identification of such problems should allow further refinement and development of the method.

Before moving on from community values, it is worth raising two additional general issues. From the ranking of interventions in the BMA survey above it can be seen that there are some quite marked differences between the public’s ordering and those of doctors and managers. For example, the public give a low ranking to antismoking education for children, yet the same intervention is given a high ranking by doctors and managers.This highlights the issue of what to do with community values that policy-makers find unacceptable. The very process of eliciting such values raises the expectation among the community that their values will be used. If community values are ignored, the whole process is at risk of being undermined.

Related to this is the issue of whether the values of the community should be elicited and used in the first place. A further, and more fundamental, related point is the question of whether or not the community wants its values to be used in health care policy.There seems to be an implication in the aforementioned policy documents that involving the community in the purchasing process is a good thing. The results of the BMA study indicated that over half of the managers thought the public should have some say in the purchasing process. However, only one in five doctors and one in three of the public were of a similar view. Is it right to involve the public in this process if they do not want to be involved? It is no easy task to obtain people’s views on these complex issues-but that does not mean that attempts should not be made to do so.How Should Services Be Provided? Once it has been decided that a programme is to be provided, policy-makers must then decide how to provide the service.

Only when planners and evaluators know what factors are important 200 P. SHACKLEYAND M RYAN to users in their assessment of health care, and whether or not they are satisfied with these factors, will they be able to plan a service that meets the demands of users. Current

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methods of involving consumers in health care decision making at this level largely involve the use of patient satisfaction surveys.These studies generally produce similar findings, i. e.

patients are concerned with such factors as access, waiting times, continuity of staff, attitudes of the medical profession, information, and involvement in the decision making process. 1~ Such surveys provide little useful information to policy-makers and have recently been criticised. 12 The main advantage of such studies is that they provide information on what is important to consumers in the provision of health care, and how satisfied they are with such factors. However, satisfaction surveys have similar problems to opinion polls.That is: they ignore crucial issues such as the intensity of consumers’ preferences for the various factors that are identified as important in the satisfaction studies; they provide little help in addressing policy questions; the results of such surveys do not address the real marginal issues that policymakers face, e. g.

by how much should waiting times be reduced; and again, arguably the most important limitation, they incorporate no concept of opportunity cost. Asking people simply to state their level of satisfaction ignores scarcity of resources.Given limited resources and the fact that for most factors identified above, consumers would prefer more of all of them, preferred levels of all factors cannot be provided.

The important policy question then becomes what are the relative weights of the dimensions of satisfaction identified as important, and how do individuals trade-off these dimensions? Conjoint Analysis One technique that can be used to address this question is conjoint analysis, which has its origin in mathematical psychology. Market researchers first used this technique to establish the relative importance of attributes in the provision of goods and services. 3 The technique has also been used extensively in transport economics to establish the importance of such attributes as fare, time, comfort, speed, etc., in choices concerning alternative modes of transport. 14 It is also gaining widespread support in environmental economics, and the use of the technique to establish users’ valuations of quality in the provision of public services was recently recommended by the Treasury. is However, the application of conjoint analysis to health care has, to date, been very limited.

The technique involves presenting individuals with hypothetical scenarios comprising different levels of various attributes that have been identified as being important, and asking respondents to either rank, rate or make ‘pairwise’ choices between these hypothetical scenarios. From these data it is possible to establish the relative importance of different attributes in the provision of a good or service; the optimal w a y of providing a good or service; and the change in utility (or satisfaction) from moving from one type of good or service to another.For a more detailed review of the technique see Ryan. 16 One of the few examples of conjoint analysis being applied to health care was the recent study in the Grampian Region of Scotland which attempted to establish the trade-offs that individuals make with regard to location of treatment and waiting time in the provision of orthodontic services. 17 Three attributes were included: location of first

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appointment (specified as local or central); location of second appointment (specified as local or central); and waiting time (specified in months).Individuals attending three orthodontic clinics in Grampian were presented with 15 ‘pairwise’ choices and asked to state their preference within each choice. All 15 choices involved the individual comparing the current situation (central clinic for both first and second appointment, and a waiting time of 8 months) with alternatives that varied with respect to these three attributes.

Possible responses for each choice were: ‘definitely prefer current’; ‘probably prefer current’; “no preference’; ‘probably prefer alternative’; and ‘definitely prefer alternative’. The results are shown in Table 2.Waiting time was found to be significant, suggesting that patients consider this an INVOLVING CONSUMERS T a b l e 2, Regression analysis results. Results Variable Constant Waiting time Location of first appointment (1 = central, 2 = local) Location of second appointment (1 = central, 2 = local) Ease of travelling to clinic-1 to 5 scale where 1 = easy and 5 – difficult Experience with clinic-continuous variable representing number of appointments at clinic Education level-1 to 5 scale where 1 – secondary school and 5 = university R2 Coefficient – 1. 22 – 0.

09 0. 36 p-value 0. 001 0. 001 0. 489 0. 03 0. 001 0.

024 0. 008 201 important attribute in the provision of orthodontic services. The negative sign indicates that the higher the waiting time in the alternative style of care relative to the current, the less likely individuals are to choose the alternative.

Location of first appointment was not found to be significant, while location of second appointment was. The positive sign suggests that if the clinic for the second appointment was located locally, respondents would be more willing to choose it.Ease of travel was found to be a significant predictor of preferences, with the positive sign indicating that respondents who found it difficult to travel to the appointment were more likely to value the alternative location. Individuals who had more experience with the service were more likely to value the current style of care, whilst those with a higher level of education were more likely to value the alternative style of care.

From the regression coefficients it is also possible to estimate utility (or satisfaction) scores for various possible ways of providing orthodontic care.These utility scores can then be used to rank alternative ways of providing orthodontic services (Table 3). The most preferred alternative is choice 9, which was local clinics for first and second appointment and a waiting time of 4 months. Other choices which lead to greater satisfaction than that enjoyed from the current service provision are those shown in the table as having positive utility scores. For these choices, a move from the current provision to that presented in the questionnaire would lead to an increase in satisfaction.Similarly, those choices with negative values indicate the current provision yields greater satisfaction than the alternative.

Therefore, the only choices that should be considered for change are those that result in a positive change in utility, i. e. those in the top part of Table 3. In summary, this study found that there are differences between the location coefficient and waiting time coefficient. The analysis shows that waiting time has a greater influence over satisfaction from orthodontic services than does the location of the clinic.Although users of the service

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would generally prefer both shorter waiting times and local clinics, if they had to make a choice, waiting times are more important to them.

Table 3, Effects of changing location of clinic and waiting time on utility: choice presented in the questionnaire. Utility (Satisfaction) Score 1. 31 1. 27 1.

34 Choice Choice 9 Choice 8 Choice 7 Choice 10 Choice 6 Choice 15 Choice 4 Choice 1 Choice 5 Choice 11 Choice 2 Choice 13 Choice 3 Choice 14 Choice 12Ranking 1st 2nd 3rd 4th 5th 6th 7th 8th 9th lOth 11th 11th 13th 14th 15th 202 R SHACKLEYAND M RYAN Discussion and Conclusion The focus of this paper has been consumer involvement in health care decision making. It has been argued that current methods for establishing consumer preferences for health care are inadequate. In view of these inadequacies, two alternative techniques have been suggested, viz. willingness to pay and conjoint analysis.

In principle, both techniques are very powerful. However, as indicated above, in practice neither technique is without its problems.One of the main concerns with willingness to pay is that it is inevitably a function of ability to pay, which, it is argued, could have implications for equity. The argument is as follows.

Because the ability to pay of rich people is greater than that of poor people, other things being equal, the willingness to pay values of the former will carry more weight in a priority setting exercise than those of the latter. This may be regarded as unfair if health care resource allocation is supposed to be based on some notion of ‘need’ rather than ability to pay.However, it has been pointed out by Donaldson is that such an argument is not as straightforward as it first seems. He argues that it is important to take into account the distribution of preferences across the alternatives being evaluated. In the evaluation of two alternative treatments A and B, for example, if the preferences of both rich and poor people are split equally between A and B, then the “purchasing power’ of the two groups will be equally split. In such circumstances, any comparison of average willingness to pay for A over B with that for B over A will reflect a difference in strength of preference rather than ability to pay.Another issue to bear in mind when considering the effect of ability to pay on willingness to pay is whether ability to pay affects relative willingness to pay.

Continuing the above example of evaluating two treatments A and B, suppose a rich person is willing to pay s for A and s for B, but that a poor person (because of a lower ability to pay) is only willing to pay s for A and s for B. Although ability to pay has affected absolute willingness to pay, because it has not affected relative willingness to pay we can say that the relative strength of preference of both the rich person and the poor person for A over B is the same, i.. they are both willing to pay twice as much for A as for B. If ability to pay does not affect relative willingness to pay (and there is some evidence to suggest

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that this is indeed the case), 19 then the relationship between ability to pay and willingness to pay may not be a problem in the context of priority setting as described above. Other concerns which may be raised in connection with willingness to pay and conjoint analysis relate to the response rates achieved from such studies, how easy respondents find it to answer the questions, and the issue of onsistency of preferences.

In the Northern Norway study, individuals from 285 households were approached and asked if they would be willing to take part in an interview. Of these, 135 refused to participate (a response rate of 53%). Of the 150 completed interviews, seven individuals were not prepared to give a willingness to pay value nor would they priorifise. No tests of consistency of preferences were reported in the paper.

In the child health services study, a sample of 300 parents were approached to participate in an interview.Of these, 82 were interviewed (a response rate of 27%). Sixty-four of those interviewed (78%) claimed that they had found the questions easy to answer. Ninety-two per cent felt that the questions were relevant to the real world. Regarding consistency of preferences, the results suggest that the majority of respondents were consistent in their answers to the willingness to pay questions. In the conjoint analysis study of orthodontic care, all patients attending three orthodontic clinics were approached to take part in the study.

Nobody refused, and only three questionnaires were unusable. Ease of response and consistency of preferences were both addressed in the study. Respondents were asked to rate the ease of answering the conjoint analysis questions on a scale from I to 5, where 1 represented extremely easy and 5 extremely difficult. Only 15% of respondents gave a response of 4 or 5, indicating that respondents had little difficulty with the questionnaire. Tests of consistency comprised two choices being included where the respondent should definitely prefer the current clinic over theINVOLVINGCONSUMERS 203 alternative, and one choice where the respondent should definitely prefer the alternative style of care. The results indicated that the majority of respondents completed the questionnaire with a high degree of consistency. Another more general concern with willingness to pay and conjoint analysis is the issue of whose values to elicit.

This concern relates to the phenomenon of different groups valuing the same thing differently. One example of this is the rankings by the public, doctors and managers above. 5Other examples can be found in the health status measurement literature where different groups in society value the same health states differently.

2~ In the field of health status measurement, at least, there is no overall consensus regarding whose values are most relevant. The question of whose values to elicit when using willingness to pay and conjoint analysis to aid priority setting is, we would argue, more straightforward. At the heart of the issue is the identification of the true opportunity cost context of any decision to allocate resources to/within health care programmes.When using willingness to pay to establish preferences for a number of competing alternative uses of resources, as in the Northern Norway example above (an allocative efficiency question), then it is the views of

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the community which are relevant. The true opportunity cost of devoting resources to a helicopter ambulance service, say, are the benefits forgone by not using those resources to perform hip or heart operations. The decision to invest in the ambulance service is a community decision and therefore it is the values of the community which should be elicited.When using conjoint analysis to establish preferences for how a particular service should be provided (a technical efficiency question), the amount of resources devoted to the particular service has already been decided.

The decision is no longer a community decision. Rather, the relevant question is how best to provide the service given the resources allocated to it. The opportunity cost of providing a particular attribute of the service is the benefit forgone from not being able to provide another attribute of the same service.In this case it is the preferences of users of the service which are the relevant values to elicit. The application of willingness to pay and conjoint analysis to health care is relatively new. As a consequence, it is inevitable that there will be certain problems to overcome.

However, the crucial point about willingness to pay and conjoint analysis is that the way in which choice problems are presented to consumers reflects the real life choice problems facing purchasers. That is, they make explicit the concepts of scarce resources and choices at the margin.The two techniques can be applied to many of the choice problems facing the NHS and other health care systems and their application to health care is to be encouraged. Acknowledgements We would like to thank Cam Donaldson and John Cairns of HERU, Andrew Walker of Greater Glasgow Health Board and three anonymous referees for comments on an earlier draft of this paper.

The Health Economics Research Unit is funded by the Chief Scientist Office of the Scottish Office Home and Health Department (SOHHD): however, the opinions expressed in this document are those of the authors, not SOHHD. References. Secretaries of State for Health, Wales, Northern Ireland and Scotland (1989). Working for Patients, HMSO, London. 2.

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