INDIVIDUAL UTILITIES ARE INCONSISTENT WITH RATIONING CHOICES - A PARTIAL EXPLANATION OF WHY OREGON COST-EFFECTIVENESS LIST FAILED

Objective. To test whether cost-effectiveness analysis and present met hods of eliciting health condition ''utilities'' capture the public's values for health care rationing. Design. Two surveys of economics stu dents. The first survey measured their utilities for three states of h ealth, using either analog scale, standard gamble, or time tradeoff. T he second survey measured their preferences, in paired rationing choic es of the health states from the first survey and also compared with t reatment of acutely fatal appendicitis. The rationing choices each sub ject faced were individualized according to his or her utility respons es, so that the subject should have been indifferent between the two c onditions in each rationing choice. Results. The analog-scale elicitat ion method produced significantly lower utilities than the time-tradeo ff and standard-gamble methods for two of the three conditions (p < 0. 001). Compared with the rationing choices, all three utility-elicitati on methods placed less value on the importance of saving lives and tre ating more severely ill people compared with less severely ill ones (p < 0.0001). The subjects' rationing choices indicated that they placed values on treating severely ill people that were tenfold to one-hundr ed-thousand-fold greater than would have been predicted by their utili ty responses. However, the subjects' rationing choices showed internal inconsistency, as, for example, treatments that were indicated to be ten times more beneficial in one scenario were valued as one hundred t imes more beneficial in other scenarios. Conclusions. The subjects sou ndly rejected the rationing choices derived from their utility respons es. This suggests that people's answers to utility elicitations cannot be easily translated into social policy. However, person-tradeoff eli citations, like those given in our rationing survey, cannot be substit uted for established methods of utility elicitation until they can be performed in ways that yield acceptable internal consistency.