Priority Setting: Priority Setting: Beyond Evidence-based Beyond Evidence-based

Medicine and Cost-Medicine and Cost-effectiveness Analysis effectiveness Analysis

Priority Setting: Priority Setting: Beyond Evidence-based Beyond Evidence-based

Medicine and Cost-Medicine and Cost-effectiveness Analysis effectiveness Analysis

Douglas K. Martin, PhDDouglas K. Martin, PhDDirector, Collaborative Program in Bioethics,Director, Collaborative Program in Bioethics,

Assistant Professor, Department of Health Policy, Management and Evaluation, Assistant Professor, Department of Health Policy, Management and Evaluation, and the Joint Centre for Bioethics, University of Torontoand the Joint Centre for Bioethics, University of Toronto

Career Scientist, Ontario Ministry of Health and Long-Term CareCareer Scientist, Ontario Ministry of Health and Long-Term Care

OutlineOutline

Where we have been – the 1980s & Where we have been – the 1980s & 1990s1990s

Where we are going – 2000 to 2010Where we are going – 2000 to 2010 Improving priority setting Improving priority setting

PS: Distribution of goods and services PS: Distribution of goods and services among competing needsamong competing needs

PS occurs at all levels of systemPS occurs at all levels of systemgovernment, RHAs, disease management government, RHAs, disease management

organizations, research agencies, PBM, organizations, research agencies, PBM, hospitals, clinical programshospitals, clinical programs

rationing rationing resource allocation resource allocation

priority setting priority setting

sustainabilitysustainability

Where we have beenWhere we have been

Evidence-based Medicine & Evidence-based Medicine & Cost-effectiveness AnalysisCost-effectiveness Analysis

Dominant tradition; Dominant tradition; HTA = TAHHTA = TAH Technical problemsTechnical problems

– Levels of evidence; types of benefits; availabilityLevels of evidence; types of benefits; availability– WB “The Economics of Priority Setting for Health WB “The Economics of Priority Setting for Health

Care” (2003): problems with economic evaluations; Care” (2003): problems with economic evaluations; incorporating equity; practical constraintsincorporating equity; practical constraints

PaussJensen, Singer, Detsky. Ontario’s PaussJensen, Singer, Detsky. Ontario’s Formulary Committee How Recommendations Formulary Committee How Recommendations are Made. are Made. PharmacoeconomicsPharmacoeconomics (2003). (2003). – ““Complex economic analyses played a limited role.”Complex economic analyses played a limited role.”

Helpful but limited; necessary but not sufficientHelpful but limited; necessary but not sufficient

Let’s be clear: PS decisions Let’s be clear: PS decisions are . . . are . . .

NOT information-based decisionsVALUE-BASED DECISIONS

AND THESE VALUES OFTEN CONFLICT

Evidence

Benefit

Risk Equity

Equality

Access

Rule-of-Rescue

Efficiency

Individual ResponsibilityNeed

Solidarity

Compassion for the Vulnerable

Democratic deliberation

Martin, Singer 2000Martin, Singer 2000

Gaps in knowledgeGaps in knowledge

Goodbye to simple solutions Goodbye to simple solutions (Holm, BMJ 2000)(Holm, BMJ 2000)

Normative approaches Normative approaches (e.g. philosophy, health (e.g. philosophy, health economics)economics)

help identify values help identify values but conflict, no consensus, too abstractbut conflict, no consensus, too abstract

Empirical approachesEmpirical approaches what is done \ what can be donewhat is done \ what can be done but not what should be done but not what should be done

International experience shows difficulty International experience shows difficulty reaching agreement on reaching agreement on whatwhat decision decision should be made should be made (Ham, Coulter, JHSRP 2001) (Ham, Coulter, JHSRP 2001)

Can agree on Can agree on howhow : Fair process: Fair process

But, But,

what is what is fairfair??

Daniels & Sabin, 1997Daniels & Sabin, 1997

‘‘Accountability for Accountability for reasonableness’reasonableness’

RelevanceRelevance: : based on based on reasonsreasons upon which stakeholders can upon which stakeholders can agree in the agree in the circumstancescircumstances

PublicityPublicity: : reasonsreasons publicly publicly accessibleaccessible

Revision/AppealsRevision/Appeals: : mechanism for mechanism for challenging/revising challenging/revising reasonsreasons

EnforcementEnforcement: : to ensure 3 to ensure 3 conditions metconditions met

Martin, Singer, 2000Martin, Singer, 2000

Where we are goingWhere we are going ““Simple solutions” on one hand Simple solutions” on one hand

and “muddling through” on the and “muddling through” on the other, or substantive versus other, or substantive versus procedural criteria, represent procedural criteria, represent dialectically opposite dialectically opposite extremes. A synthesized extremes. A synthesized conceptual model or conceptual model or framework, grounded in real framework, grounded in real experience and taking account experience and taking account of various discipline-specific of various discipline-specific perspectives, represents perspectives, represents the next phase of priority the next phase of priority setting.setting.

Gibson, Martin, Singer. BMCHS, 20Gibson, Martin, Singer. BMCHS, 200404

Criteria & Process: Criteria & Process: Parameters of SuccessParameters of Success

Competing goals and multiple stakeholder Competing goals and multiple stakeholder relationshipsrelationships

Efficiency considerations or technical solutions Efficiency considerations or technical solutions limited influence, not sufficient limited influence, not sufficient

An evaluation of the normative 'rightness' [of An evaluation of the normative 'rightness' [of ps criteria] depends on the specific ps criteria] depends on the specific institutional circumstances, the stakeholders institutional circumstances, the stakeholders who are affected, and the strategic goals that who are affected, and the strategic goals that are being pursued.are being pursued.

Underscores the importance of procedural Underscores the importance of procedural fairness to secure socially acceptable priority fairness to secure socially acceptable priority setting decisions and to ensure public setting decisions and to ensure public accountability.accountability.

Informal Networks of Informal Networks of DeliberationDeliberation

Beyond formal institutional structuresBeyond formal institutional structures Emphasizes ‘public good’ over ‘private Emphasizes ‘public good’ over ‘private

interests’interests’ Context where claims must be justified; Context where claims must be justified;

actions shaped by requirements of actions shaped by requirements of justification justification [Chaves, 1974][Chaves, 1974]

Provides more information about Provides more information about others’ preferences others’ preferences

Engages inherent human ability to Engages inherent human ability to assess different reasons assess different reasons [[ManinManin, 1987], 1987]

Renders decision legitimate in the Renders decision legitimate in the eyes of participants; eyes of participants;

Groups can pool their experience Groups can pool their experience and creativity and creativity

Enhances ‘buy-in’ Enhances ‘buy-in’

Martin, Singer, Health Care AnalysiMartin, Singer, Health Care Analysis 2003s 2003

Improving Priority SettingImproving Priority Setting DescribeDescribe

Case study methodsCase study methodsWhat groups actually doWhat groups actually do

EvaluateEvaluate ‘‘Accountability for reasonableness’Accountability for reasonableness’ What groups should doWhat groups should do Correspondence: good practicesCorrespondence: good practices Gaps: opportunities for Gaps: opportunities for

improvementimprovement

ImproveImprove Implement strategies to close gapsImplement strategies to close gaps

Benefits of Benefits of describe/evaluate/improvedescribe/evaluate/improve

Institution:Institution: quality improvementquality improvement political involvement political involvement learning organizationlearning organization leadershipleadership

Other health care organizationsOther health care organizations: : share good practicesshare good practices

Martin, Shulman, Santiago-Sorrel, SMartin, Shulman, Santiago-Sorrel, Singer, JHSRP 2003inger, JHSRP 2003

Example #1: Example #1: PS and Hospital Strategic PlanningPS and Hospital Strategic Planning

Relevance Relevance ensure info captures impact on academic ensure info captures impact on academic

programs and hospital’s communityprograms and hospital’s community optimize inclusivity / exclusivityoptimize inclusivity / exclusivity revise agreement mechanismrevise agreement mechanism

PublicityPublicity comprehensive communication plancomprehensive communication plan clarify op and strategic planclarify op and strategic plan

AppealsAppeals develop appeals grounds / processdevelop appeals grounds / process

EnforcementEnforcementstart data consultation & data collection start data consultation & data collection

earlierearlierdescribe, evaluate, and improve again!describe, evaluate, and improve again!

Other examplesOther examples Health SystemHealth System

Martin, Singer “Canada” in Ham & Roberts (eds) Martin, Singer “Canada” in Ham & Roberts (eds) Reasonable Rationing.Reasonable Rationing. 2003 2003

Provincial Drug Formulary Provincial Drug Formulary PaussJensen, Detsky, Singer PaussJensen, Detsky, Singer Pharmacoeconomics Pharmacoeconomics 20022002

Hospital Drug FormularyHospital Drug Formulary Martin, Hollenberg, MacRae, Madden, Singer Martin, Hollenberg, MacRae, Madden, Singer Health Health

Policy 2003Policy 2003 Cancer DrugsCancer Drugs

Martin, Pater, Singer Martin, Pater, Singer LancetLancet 2001 2001 ICUICU

Mielke, Martin, Singer Mielke, Martin, Singer Critical Care Medicine Critical Care Medicine 20032003 Martin, Bernstein, Singer Martin, Bernstein, Singer J Neur, Neurosurg, Psych J Neur, Neurosurg, Psych 20032003

Database of LearningDatabase of LearningRelevanceRelevance PublicityPublicity AppealAppeal

ssEnforceEnforce

Health systemHealth system

MoHMoH

PBMPBM

Disease Manag. Disease Manag. OrgsOrgs

RHAsRHAs

Hosp Strat PlanHosp Strat Plan

Hosp Oper PlanHosp Oper Plan

Hosp drug Hosp drug formularyformulary

Clinical Clinical ProgramsPrograms

Social Policy LearningSocial Policy Learning

Make ‘private’ decisions Make ‘private’ decisions publicpublic

Educative functionEducative function Body of ‘case law’; Body of ‘case law’;

institutional reflective institutional reflective equilibriumequilibrium

Iterative - improves Iterative - improves over timeover time

Priority

Setting

Beyond and ForwardBeyond and Forward Synthesis: Criteria & ProcessSynthesis: Criteria & Process

– Value-based decisions about which Value-based decisions about which there is much conflictthere is much conflict

– EBM & CEA necessary but insufficientEBM & CEA necessary but insufficient– Fair process enhances legitimacy & Fair process enhances legitimacy &

accountabilityaccountability Informal networks of deliberationInformal networks of deliberation

– creates climate of ‘public good’, creates climate of ‘public good’, assessment of reasons; enhanced assessment of reasons; enhanced problem-solving; increased ‘buy-in’problem-solving; increased ‘buy-in’

Describe-evaluate-improve approachDescribe-evaluate-improve approach Ongoing process of social policy Ongoing process of social policy

learninglearning

AcknowledgementsAcknowledgements The JCB PS Research Team:The JCB PS Research Team:

Mark Bernstein, Scott Berry, Jennifer Mark Bernstein, Scott Berry, Jennifer Gibson, Heather Gordon, Lydia Gibson, Heather Gordon, Lydia Kapiriri, Shannon Madden, David Kapiriri, Shannon Madden, David Reeleder, Zahava Rosenberg-Reeleder, Zahava Rosenberg-Yunger, Peter A. Singer, Ross Yunger, Peter A. Singer, Ross Upshur, Nancy WaltonUpshur, Nancy Walton

Norman Daniels has contributed Norman Daniels has contributed enormously to our understandingenormously to our understanding

www.canadianprioritysettingwww.canadianprioritysetting.ca.ca

Funded by grants from CIHR