Making priority setting and resource allocation decisions from principles to practices

Transcription

1 Making priority setting and resource allocation decisions from principles to practices Craig Mitton and Howard Waldner University of British Columbia New Caledonia Solutions Prioritize Consulting

2 Case of bariatric surgery in BC Costs and benefits in terms of QALYs recently assessed from BC Ministry of Health perspective Came up with a favorable cost-per QALY (i.e., <$20K per QALY gained for almost all scenarios) MoH had hoped for a dominant result to make their decision more straightforward Question remains: to fund or not to fund? 2

3 Session outline Background on priority setting Economic/ ethics approach Criteria and practical steps Lessons from the real world 3

4 Current expenditure in Canada $200B+ in total health care spending in 2012 On average over $5500 per person Canada ranked in top 5 of OECD countries 30% after inflation increase since 1993 $37 billion in spent in 1984 Greatest increases in drugs Translates to 10.7% of GDP and in some provinces over 40% of provincial expenditure 4

5 But yet resources are still scarce! (and decision makers are often stuck) Allocation of health care funds according to defined populations is a global phenomenon Basic notion within health authorities is that of a limited funding envelope Not enough resources to meet all needs Surveys have reported uncertainty amongst decision makers on how best to set priorities and allocate resources 5

6 What is typically done? Historical/ political allocation: funding based on last year s budget with some adjustments Often becomes: whoever yells the loudest Continual growth in budgets year on year Other approaches: Needs assessment Economic evaluation 6

7 Aspects of Formalization Dedicated technical support Explicit internal communication plan Numeric system for weighting criteria and comparing scores System to inform public and external stakeholders Quantitative measures of costs and benefits Based on published framework or research evidence Clearly defined benefit criteria Written procedural manual Appeal mechanism Formal process or outcome evaluation 4 QALYs or similar Formal Other 2012 Canadian survey, n=90 Smith et al

8 Historical vs. formal process Poor or very Poor Fair Good or very Good Historical or Political Process 18% 50% 32% Formal/Rational Process 2% 25% 73% Those who stated their organization used a formal/rational process tended to be more satisfied with the priority setting process than those without. 8

9 Economics and ethics Literature on priority setting has economics and ethics contributions Useful to see these disciplines as complementary Value for money Fair process Develop and implement an approach to priority setting which incorporates both perspectives Gibson et al

10 Economics and ethics in practice Define aim and scope Evaluate and improve Form Advisory Panel PBMA Decision review process Establish program budget MCDA Decisions and rationale Identify and rank options Develop decision criteria Mitton and Donaldson 2004 Gibson and Mitton

11 Key Concepts Ethical conditions alongside economic principles Assess options for change against multiple criteria Clinicians and managers working together Stakeholder engagement --- public input Link to Health Technology Assessment agencies 11

12 Criteria Operationalize organizational objectives Link to strategic priorities Clearly defined at the outset Mutually exclusive Weight to reflect relative importance Involvement of relevant stakeholders 12

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14 Benefit measurement Multi-attribute decision analysis (MCDA) Widely used in other sectors 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 linear or multiplicative functions Baltussen et al

15 Managing evidence Education on process and expectations on using evidentiary base Business case proposal template Targets on investments and disinvestments Process guidelines explicit submission process New electronic platform: 15

16 Prioritize screen shot 16

17 Expected Outcomes Primary benefits of explicit approach Achieving real resource shifts consistent with strategic decision making objectives Bending the cost curve and investing in areas where we will get the greatest gains Clinical engagement and opportunity for public involvement Greater transparency and accountability 17

18 International applications Wide range of program areas, majority at micro/ meso levels; more recently macro level applications 150+ exercises primarily in UK, NZ, Australia, Canada Distinct shift from focus on efficiency to more of a management process aimed at meeting range of organizational objectives Majority of organizations that institute process tend to continue with it and see positive impact: new way of thinking re-allocation to better meet system objectives 18

19 What can we be certain of? Demand will continue to exceed available resources System is complex and operates in silos Challenges with physician and staff engagement Small p and big p politics Robust coherent process can help 19

20 Einstein s Definition of Insanity Doing the same thing over and over again and expecting different results

21 Required behaviors for success Moving from knowing to doing Engage and involve the team Open and transparent discussions Set challenging targets accept givens Get stakeholder and board buy in Effective leadership 21