Priority Setting Beyond Evidence-based Medicine and Cost-effectiveness Analysis

Priority Setting: Beyond Evidence-based Medicine and Cost-effectiveness Analysis Douglas K. Martin, Ph. D Director, Collaborative Program in Bioethics, Assistant Professor, Department of Health Policy, Management and Evaluation, and the Joint Centre for Bioethics, University of Toronto Career Scientist, Ontario Ministry of Health and Long-Term Care

Outline v Where we have been – the 1980 s & 1990 s v Where we are going – 2000 to 2010 v Improving priority setting

Where we have been v PS: Distribution of goods and services among competing needs v PS occurs at all levels of system Øgovernment, RHAs, disease management organizations, research agencies, PBM, hospitals, clinical programs v rationing resource allocation priority setting sustainability

Evidence-based Medicine & Cost-effectiveness Analysis Dominant tradition; HTA = TAH n Technical problems n – Levels of evidence; types of benefits; availability – WB “The Economics of Priority Setting for Health Care” (2003): problems with economic evaluations; incorporating equity; practical constraints n Pauss. Jensen, Singer, Detsky. Ontario’s Formulary Committee How Recommendations are Made. Pharmacoeconomics (2003). – “Complex economic analyses played a limited role. ” n Helpful but limited; necessary but not sufficient

Let’s be clear: PS decisions are. . . VALUE-BASED DECISIONS NOT information-based decisions Compassion for the Vulnerable Rule-of-Rescue Evidence Equity Risk Equality Solidarity Access Benefit Individual Responsibility Democratic deliberation Efficiency Need AND THESE VALUES OFTEN CONFLICT

Gaps in knowledge Goodbye to simple solutions (Holm, BMJ 2000) v Normative approaches (e. g. philosophy, health economics) v Ø help identify values Ø but conflict, no consensus, too abstract v Empirical approaches Ø Ø v what is done what can be done but not what should be done International experience shows difficulty agreement on what decision made (Ham, Coulter, JHSRP 2001) Martin, Singer 2000 reaching should be

Can agree on how : Fair process But, what is fair?

‘Accountability for reasonableness’ based on reasons upon which stakeholders can agree in the circumstances v Relevance: v Publicity: accessible reasons publicly v Revision/Appeals: mechanism for challenging/revising reasons v Enforcement: conditions met Daniels & Sabin, 1997 to ensure 3

Where we are going n “Simple solutions” on one hand “muddling through” on the other, or substantive versus procedural criteria, represent dialectically opposite extremes. A synthesized conceptual model or framework, grounded in real experience and taking account of various discipline-specific perspectives, represents the next phase of priority setting. Martin, Singer, 2000

Criteria & Process: Parameters of Success Competing goals and multiple stakeholder relationships n Efficiency considerations or technical solutions limited influence, not sufficient n An evaluation of the normative 'rightness' [of ps criteria] depends on the specific institutional circumstances, the stakeholders who are affected, and the strategic goals that are being pursued. n Underscores the importance of procedural fairness to secure socially acceptable priority setting decisions and to ensure public accountability. n Gibson, Martin, Singer. BMCHS, 2004

Informal Networks of Deliberation n n n n Beyond formal institutional structures Emphasizes ‘public good’ over ‘private interests’ Context where claims must be justified; actions shaped by requirements of justification [Chaves, 1974] Provides more information about others’ preferences Engages inherent human ability to assess different reasons [Manin, 1987] Renders decision legitimate in the eyes of participants; Groups can pool their experience and creativity Enhances ‘buy-in’

Improving Priority Setting v Describe v. Case study methods v. What groups actually do v Evaluate Ø ‘Accountability for reasonableness’ Ø What groups should do Ø Correspondence: good practices Ø Gaps: opportunities for improvement v Improve Ø Implement strategies to close gaps Martin, Singer, Health Care Analysis 2003

Benefits of describe/evaluate/improve v Institution: Ø quality improvement Ø political involvement Ø learning organization Ø leadership v Other health care organizations: Ø share good practices

Example #1: PS and Hospital Strategic Planning v Relevance Ø ensure info captures impact on academic programs and hospital’s community Ø optimize inclusivity / exclusivity Ø revise agreement mechanism v Publicity v Appeals v Enforcement Ø comprehensive communication plan Ø clarify op and strategic plan Ø develop appeals grounds / process Ø start data consultation & data collection earlier Ø describe, evaluate, and improve again! Martin, Shulman, Santiago-Sorrel, Singer, JHSRP 2003

Other examples Ø Health System Ø Provincial Drug Formulary Ø Hospital Drug Formulary Ø Cancer Drugs Ø ICU Ø Martin, Singer “Canada” in Ham & Roberts (eds) Reasonable Rationing. 2003 Ø Pauss. Jensen, Detsky, Singer Pharmacoeconomics 2002 Ø Martin, Hollenberg, Mac. Rae, Madden, Singer Health Policy 2003 Ø Martin, Pater, Singer Lancet 2001 Ø Mielke, Martin, Singer Critical Care Medicine 2003 Ø Martin, Bernstein, Singer J Neur, Neurosurg, Psych 2003

Database of Learning Relevance Health system Mo. H PBM Disease Manag. Orgs RHAs Hosp Strat Plan Hosp Oper Plan Hosp drug formulary Clinical Programs Publicity Appeals Enforce

Social Policy Learning v Make ‘private’ decisions public v Educative function v Body of ‘case law’; institutional reflective equilibrium ty v Iterative - improves riori P g ettin S over time

Beyond and Forward n Synthesis: Criteria & Process – Value-based decisions about which there is much conflict – EBM & CEA necessary but insufficient – Fair process enhances legitimacy & accountability n Informal networks of deliberation – creates climate of ‘public good’, assessment of reasons; enhanced problem-solving; increased ‘buy-in’ Describe-evaluate-improve approach n Ongoing process of social policy learning n

Acknowledgements v The JCB PS Research Team: Ø Mark Bernstein, Scott Berry, Jennifer Gibson, Heather Gordon, Lydia Kapiriri, Shannon Madden, David Reeleder, Zahava Rosenberg-Yunger, Peter A. Singer, Ross Upshur, Nancy Walton v Norman Daniels has contributed enormously to our understanding Funded by grants from CIHR v www. canadianprioritysetting. ca