Post on 19-May-2015
transcript
Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 1
Methods in priority setting
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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…
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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)
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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
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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
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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
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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
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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?
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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