2.2 methods in priority setting (t)

Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 1

Methods in priority setting


The goal in resource allocation decisions

•Decision-makers need to determine:

• what health care services to provide

• for whom to provide services

• how to provide services

• where services should be provided

… in order to meet local and/ or system level objectives including access, health gain…


How is that typically done?Resource allocation decisions are typically based on:

•Historical patterns with incremental adjustment

•Politics and the ‘squeaky wheel’

•Needs assessment

•Core services

•economic evaluation (limited)


What is required?

A pragmatic decision-making approach that….– Aligns resources strategically with system goals and

community needs – Leads to publicly defensible decisions based on available

evidence and community values– Facilitates stakeholder engagement around improving benefit

with limited resources– Supports the public accountability of health care decision-

makers


This leads us in the direction of Program Budgeting and Marginal Analysis (PBMA)

•Formal framework to assist decision-makers in making resource allocations decisions

•Combines medicine, economics and ethics

•Used since the 1970’s in health care


1. What resources are available in total?2. In what ways are these resources currently spent? 3. What are the main candidates for more resources and

what would be their effectiveness?4. Are there any areas of care which could be provided to the

same level of effectiveness but with less resources, so releasing resources to fund candidates in (3)?

5. Are there areas of care which, despite being effective, should have less resources because a proposal in (3) is more effective (per $ spent)?

Basic thinking behind PBMA


PBMA: Practical Steps•Determine aim and scope of activity

•Identify and map resource use

•Form an advisory panel

•Define and weight decision making criteria

•Identify options for service growth and resource release

•Evaluate proposed investments and disinvestment

•Validate results, recommendations for (re)-allocation, communicate decisions

•Evaluation, refinement and ongoing revision

Peacock et al. 2006


Determine aim and scope of activity

• Is the aim to bridge a deficit situation, to allocate new funding, to consider possible re-allocations of existing funding…

•What parts of the organization are included in the process implementation?


Mapping resource use

•Objective is to have an accurate summary of information about services provided across the continuum of care

- Costs and benefits

May not have a clear picture of how many services are provided and by whom

Splitting costs in different ways


The Advisory Panel•Multi-disciplinary mix of stakeholders

• Decision-makers, policy-makers, clinician leaders• Finance/information personnel• Consumer/community representatives

•Key responsibilities are: -Establishing assessment criteria (process to do this critical for buy-in) - Identify and assess service growth and resource release options


Benefit measurement•Multi-attribute decision analysis (MCDA)

• Limited ‘real’ health care examples published

• Reflects multiple objectives

•Score service options for investment and disinvestment in terms of benefits for patients against pre-defined set of criteria

•To get a single measure of each service’s benefit need to combine the scores

Mitton and Donaldson 2004


Assessment Criteria•Basis for priority setting decisions

•Should be specified at outset of process in explicit manner

•Operational enough to assess services against

•Should not overlap (mutually exclusive)

•Need to clearly define

•Embody organizational values


Use of ‘evidence’

DeterminingOperational Priorities:

Identifying Marginsfor Change

Population Needs

Provincial Requirements /

Targets

Rating options against pre-defined criteria

Stakeholder InputThe CommunityStaff / Doctors

Board

Financial DataService Utilization

Output / Outcomes Data

Business Plan Priorities

Practice Guidelines &

Standards


Validation•Prior to final decisions, recommendations should be

taken to various stakeholders

• More than ‘face validity’ feedback

• Don’t go unless willing to re-assess

•Seek stakeholder feedback on recommendations using a formal decision review process

• New data/information; errors

• Failure of due process


Physician roles•Advocacy vs. system perspective

•Critical appraisal of competing evidence from a range of sources and settings

•Assessment of clinical evidence from systematic reviews

•Expert judgment when ‘good evidence’ lacking

Ruta et al. 2005


Board roles

•Endorsement and support of the process

•Policy approval – direction and monitoring

•Assure alignment with organizational priorities

•Explicit fiscal framework

• Involved and engaged stakeholders

•Buy in for investment and disinvestment


Public role

•Only go there if really want input!

•Values in relation health care objectives

•Possible input on assessment criteria

•Possible participation on advisory panels

•Focus groups to provide viewpoint on clinical areas


Expected Outcomes Primary benefit of PBMA

• Achieving real resource shifts that are consistent with strategic decision-making objectives

Secondary benefits of PBMA

• Ownership of planning process

• Evidence driven decisions

• Transparent and defensible decision making

• Clinician engagement and partnershipGibson et al. JHSRP 2006Ruta et al. BMJ 2005


Lessons from experience-key success factors

Shared vision

• Stakeholder buy-in

• Transparency

Credible commitment

• Resources for process (training, ongoing support, time freed up)

• Incentives to encourage participation

Follow-through (execution)

• Facilitating change process

Learning/ quality improvement


Canadian examplesChinook Health Region (Alberta)

• Surgery, chronic disease

Headwaters Health Authority (Alberta)

• Surgery, long term care

Calgary Health Region (Alberta)

• Macro, children’s services

Vancouver Island Health Authority (BC)

• Macro, within portfolios

Interior Health Authority (BC)

• Community care services

Northern Health Authority (BC)

• Home and community care

Menno Home and Hospital (BC)

• Seniors’ care

BC Cancer Agency (BC)

• Screening, select drug therapies

St. Joseph’s Health Centre (Toronto)

• All clinical service areas

North West, Central West and Champlain LHINs

• Urgent priorities, Aging at Home, Alternative levels of care


Summary

• Health care environment is politically charged and complex

• Need a pragmatic framework that can introduce evidence based decision making

• PBMA is one way to take on an explicit approach to priority setting


What’s in a name?Point is not ‘PBMA’ or ‘no PBMA’. It is about:

• Use of explicit criteria (e.g., MCDA)

• Fit within a broader process of decision making

Priority setting committee

Evidence based

Transparent

Appeals mechanism

• Ownership of recommendations

2.2 methods in priority setting (t)

Health & Medicine

resource releaseevaluate

scores mitton

map resource useform

mapping resource useobjective

health care services

areas of care

releasing resources

thecontinuum of care