The past and future of health care priority setting in Canada

Craig Mitton, PhD

Associate ProfessorCentre for Clinical Epidemiology and EvaluationSchool of Population and Public Health, UBC

Michael Smith Foundation for Health Research Scholar

craig.mitton@ubc.ca

Co-presenters

� Stuart Peacock, UBC/ BCCA

� Francois Dionne, C2E2

� Neale Smith, C2E2

� Evelyn Cornelissen, UBC Okanagan

� Jennifer Gibson, University of Toronto

� Cam Donaldson, Glasgow Caledonian University

Resource scarcity

� Claims on resources exceed available resources… choices must be made

� Decision makers have expressed uncertainty on tools available to support allocation

� Historical/ political processes: funding based on last year’s budget with some adjustments� Can become: ‘whoever yells the loudest’

� Incremental growth or across the board cuts

Key advances to date

� Benefit measurement

� Public involvement

� Organizational behavior

� Measuring ‘success’

� Ethics and economics

Economics and ethics

� Literature on priority setting has economics and ethics contributions

� Need to see these disciplines as complementary

� Value for money

� Fair process

� Develop and implement an approach to priority setting which incorporates both perspectives

Resource Allocation Framework

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1. Determine aim & scopeof decision making.

4. Develop decision criteriawith stakeholder input.

3. Clarify existing resource mix.

5. Identify & rank funding options.

7. Provide formal decision review process.

8. Evaluate & improve.

6. Communicate decisionsand rationale.

2. Identify priority settingcommittee.

Key Concepts

� Shifting or re-allocating resources based on comparison against pre-defined criteria

� Incentives to encourage participation

� Clinicians and managers working together

� Ethical conditions built in

� Tool that supports decision making

� Clear link to HTA

Expected Outcomes

� Primary benefit of explicit approach

• Achieving real resource shifts that are consistent

with strategic decision-making objectives

� Secondary benefits

• Evidence driven decisions

• Ownership of planning process

• Transparent and defensible decision making

• Clinician engagement and partnership

Gibson et al. JHSRP 2006Ruta et al. BMJ 2005

Case studies

� Basic approach used well over 150 times across multiple countries

� We have been involved in about 50 of these

� Five cases presented here:� BC Cancer Agency� Menno Home and Hospital� Vancouver Coastal Health, Home and Community Care� St. Joseph’s Hospital, Toronto� NW Local Health Integration Network

� Lessons learned and future research

Vancouver Coastal Health

� Community Care Division - $250M of $600M total resources included

� Plan to address forecasted deficit of $4.65M for 2010/11

� Working group, advisory panel, senior executive

� 3 month process – criteria, templates, scoring tool, proposals, rating, recommendations

� 45 disinvestments = $4.9M; possible investment options also considered

St. Joseph’s Hospital

� Community teaching hospital, $230M

� Focus on re-allocation for 2009/10 budget

� Aim to improve rigor and transparency

� Layered committees reporting to sr mngt

� Relative value of disinvestment and investment proposals assessed against explicit criteria, about $1M shifted

� Wide spread support and buy-in

BC Cancer Agency

� Focus on cancer control priorities; direct involvement of senior management

� Local cost and outcomes data and published QALY evidence to conduct local HTAs

� Herceptin, screening mammography, PET/ CT scans in non-small cell lung cancer

� Multi-disciplinary committees applying broad criteria including CEA with results directly informing decisions

Menno Home and Hospital

� Long term care facility in Abbotsford, total budget of just under $25M

� Initially used process to address deficit but became tool for re-allocation (now into year 4)

� Broad representation on priority setting committee, explicit criteria, formal scoring tool, short and long form proposals

� Relative value trade-offs, multi-million re-allocation to date

NW Local Health Integration Network

� Urgent funding priorities for 2009, focus on alternative levels of care

� Priority setting committee including 4 public members, recommendations to sr mngt

� Public input for criteria, formal scoring tool, ranked list of options, $800K allocated

� Transparency and engagement main elements

� Framework now supported across the LHINs

Lessons learned

� Committed and supportive leadership

� External support and strong project management

� Explicit criteria and formal proposal scoring tool

� Importance of transparency of process and decisions

� Physician engagement in all aspects of the process

� Credible commitment takes time - organizational trust

� Recognition of political overlay

Areas for future research

� Head to head comparison of approaches

� More examples of MCDA within priority setting; different weighting mechanisms

� Stronger/ broader evidence base

� Disinvestment at the margin

� High performance in priority setting

Practical plan

� Decision to move away from historical/ political allocation and across the board cuts

� Training on principles and process, establish working group, develop criteria and templates

� Investment and/ or disinvestment proposals submitted and assessed

� Recommendations for re-allocation

� Implementation and evaluation

Comments/ questions