Principles versus procedures in making health care coverage decisions: addressing inevitable conflicts

It has been suggested that focusing on procedures when setting priorities for health care avoids the conflicts that arise when attempting to agree on principles. A prominent example of this approach is “accountability for reasonableness.” We will argue that the same problem arises with procedural accounts; reasonable people will disagree about central elements in the process. We consider the procedural condition of appeal process and three examples of conflicts over coverage decisions: a patients’ rights law in Norway, health technologies coverage recommendations in the UK, and care withheld by HMOs in the US. In each case a process is at the center of controversy, illustrating the difficulties in establishing procedures that are widely accepted as legitimate. Further work must be done in developing procedural frameworks. The opinions expressed are the authors’ own. They do not reflect any position or policy of the National Institutes of Health, US Public Health Service, or Department of Health and Human Services. This research was supported by the Intramural Research Program of the NIH Clinical Center.